Last month, we had a disastrous family discussion on health care reform. Our pre-school-aged participant clutched a box of princess Band-Aids and suggested she had the solution. When I told her that we might need to ration those Band-Aids, she asked me if I was a “social-er-list.” Another participant, aged six months, tried to eat my insurance card and then, when I took it away, wailed incessantly. I was discouraged, because what I had hoped would be a thoughtful exploration of how we might keep health care costs from bankrupting our children, turned into a cacophony of distraction.
This scenario, as you might have guessed, was imagined rather than real. But on the national stage the distraction is all too real and it’s threatening to turn an important discussion into a circus. So, in the interest of informing the debate, I’d like to offer several (general) observations from the point of view of an emergency physician.
*Reform, in some form, is necessary. Our current health care expenditures are out of control and are a major economic threat. Even if you are satisfied with your own medical coverage, the bloated health system still puts you at risk in myriad ways. These risks include retiring into a bankrupt Medicare system, across-the-board cuts in social services, and a sluggish economy with sluggish 401Ks. Most people, on all sides of the debate, understand this.
*There is fat to be trimmed. Emergency care is an excellent example – when patients come to the emergency department (ED) for health conditions that could otherwise be treated in a clinic (medical office), the care that they receive is expensive and sometimes unnecessary. When a non-emergency is treated in the ED, there is rarely additional benefit to the patient, just additional cost (to the patient and the system). In my own research into over a million Northern California ED visits, my co-investigators and I found that 48% of ED visits were for conditions that clinic docs could have seen at lower cost, and with less waiting time. As a whole, there may be at least 30% fat (i.e. unnecessary or excessive costs) in the current system.
*All citizens should have access to health care, but also should be active participants in their health and the public health. Residents of Marin County are, generally speaking, knowledgeable about their medical histories and I cannot over-emphasize how this improves their care when they need to come to the ED. Citizens elsewhere are less familiar with theirs – and this is a problem – for them and the system. As for public health, by definition we are all in this together and there are simple things you can do to contribute; practice good hygiene, limit how much you pollute and (as scary as it might be to some), get your children vaccinated.
*Insuring more people will not, in and of itself, decrease the strain on EDs. Research shows that recipients of public insurance are significantly more likely to use EDs than those with no insurance – in the case of Medicaid, nearly four times more likely. This means that we can expect that any reform that insures more patients will most likely also result in more ED visits. This should give policy makers pause – especially given that the nation has seen the closure of over 1,000 EDs in the last fifteen years while visits have increased by over 20% (to 119.2 million in 2006). Already, our community EDs are strained with overcrowding and poorly equipped to handle a public health crisis – like a potential swine flu epidemic. If we add more coverage to patients, we can expect more unnecessary ED visits and further overcrowding. Unless, that is, there is both: 1) a concerted effort to improve access to primary care providers and 2) the inclusion of some incentives that encourage people to choose clinic care over ED care for non-emergent conditions.
*Some sort of tort (medical malpractice) reform is a must. Overuse of medical testing and so called “defensive medicine” may not be as big a part of the problem as some would lead you to believe, but it is definitely part of the problem. Health reform which purports to control costs but doesn’t control torts is not honest health reform. In California, we have a law that caps pain and suffering damages in malpractice suits – such legislation should be in place nationwide. Otherwise, the trend, evident in states such as Florida, wherein certain specialists, like obstetricians, refuse to take call due to risk of litigation will just worsen.
Regardless of what happens this month or next, the health reform discussion is not going away anytime soon. If a bill gets passed, its success or failure will likely lie in the details of implementation. If it doesn’t get passed, we will just be putting this issue off for another four to eight years. Either way, I for one am rooting for a substantive discussion. And maybe a princess Band-Aid too.
*Dr. Dustin Ballard is an emergency physician practicing in Marin County and the author of "The Bullet's Yaw: Reflections on Violence, Healing and an Unforgettable Stranger." His Medically Clear column appears every other Monday. The opinions expressed in this column are his and do not necessarily reflect the views of affiliated organizations or funding agencies.
