David Brown writes at the Washington Post that the nation’s hospital emergency rooms are hurting.
Emergency medical care in the United States is on the verge of collapse, with the nation’s declining number of emergency rooms dangerously overcrowded and often unable to provide the expertise needed to treat seriously ill people in a safe and efficient manner.
That’s the grim conclusion of three reports released yesterday by the Institute of Medicine, the product of an extensive two-year look at emergency care.
Long waits for treatment are epidemic, the reports said, with ambulances sometimes idling for hours to unload patients. Once in the ER, patients sometimes wait up to two days to be admitted to a hospital bed
The causes of the crisis are not hard to understand. A law passed in 1986 provides that ERs must at least evaluate and stabilize everyone who seeks help from the ER. However, since 1993 the population has grown, and the percentage of Americans seeking health care from ERs has grown even more, but the capacity of emergency rooms has declined. “In that same period,” writes Brown, “425 emergency departments closed, along with about 700 hospitals and nearly 200,000 beds.”
Brown doesn’t say this, but the number of uninsured Americans using emergency rooms for “non-urgent care” is going up, up, up. The rising number of uninsured Americans results in a rising number of patients with nowhere else to go for medical care. This adds to the stress of emergency room care considerably. And because emergency rooms are supposed to maintain expensive technological gizmos (and staff trained to use the gizmos) to treat catastrophic injuries, heart attacks, strokes, etc., ERs are expensive. Sending the poor to ERs for basic health care is probably the least cost-effective way to provide basic health care, which is a big part of why the United States pays more per capita on health care than any other nation on the planet.
As expensive as emergency room treatment is, patients are dying because they have to wait too long to receive treatment. Brown writes:
The number of deaths caused by a delay in treatment or lack of expertise is especially uncertain, though it may not be small. San Diego established a trauma system in 1984 after autopsies of accident victims who died after reaching the ER suggested that 22 percent of the deaths were preventable, said Eastman, one of the Institute of Medicine committee members.
This is terrible. Yet, I am amused. Why? Because once again, righties conform to my expectations. Last February I wrote in a post called “Obliviousness” —
Try to discuss national health care with a rightie, and the first sentence out of his mouth will be, “You mean like in Canada?†Then he will go off on a tirade about the problems with the Canadian system. (Unless you remind them of the underfunded British system, which is the other good “bad†example of a system with problems.)
Today James Joyner comments on the David Brown article, and what does he do but argue that Canada and Britain have problems, too.
As I wrote in “Obliviousness” and other posts on health care, both Canada and the UK face problems with their single-payer systems. In a nutshell, the British system is scraping by on the cheap (see Figure One; the Brits are spending less than one-third per capita on health care than we are). Canada may have to revise its system to permit citizens to purchase private health insurance if they can afford it.
But as I’ve also written elsewhere, study after study of the world’s health care systems point to France as a nation that seems to be getting it right. Ezra Klein wrote about this last year. Very briefly, France provides health insurance that covers everyone in the nation. But unlike most Canadians, the French may purchase private supplemental insurance, and Ezra says that about 85 percent of the French have done so. Whether they have supplemental insurance or not, French citizens can still choose their own doctors, doctors are not government employees but can establish their practices wherever they choose, and patient-client confidentiality is respected. Further, France has more doctors and more hospital beds per capita than the U.S. does. And France spends about half per capita on health care than we do (see Figure One). You can read more about the French health care system here.
So I’m pleased Mr. Joyner writes that France and also Belgium “do ER care better in the aggregate.” According to WHO,
Belgium has a compulsory health care system based on the social health insurance model. Health care is publicly funded and mainly privately provided. The National Institute for Sickness and Disability Insurance oversees the general organization of the health care system, transferring funds to the not-for-profit and privately managed sickness funds. Patients have free choice of provider, hospital and sickness fund.
A comprehensive benefit package is available to 99% of the population through compulsory health insurance. Reimbursement by individual sickness funds depends on the nature of the service, the legal status of the provider and the status of the insured person. A distinction is made between those receiving standard reimbursement and those benefiting from increased reimbursement (vulnerable social groups).
Substitutive health insurance covers 80% of self-employed people for minor risks. Sickness funds offer the insured people complementary health insurance. Private for-profit insurance remains very small in terms of market volume but has also risen steadily as compulsory insurance coverage has declined.
The federal government regulates and supervises all sectors of the social security system, including health insurance. However, responsibility for almost all preventive care and health promotion has been transferred to the communities and regions.
The United States is the only industrialized nation on the planet that does not have some kind of universal health care provision for its citizens. The thirty-something (or more) nations with universal health care have come up with many different ways of delivering that care, and some nations are doing a better job than others. Single-payer is one way, but not the only way. It appears that the most successful health care systems allow for private insurance to supplement the public system. This can create inequities — people with supplemental insurance may have a wider range of treatment options than those without, for example — but these inequities are minor compared to the inequities that exist in the United States.
America’s health-care “system” looks more like a lottery every year. The winners: the healthy and well insured, with good corporate coverage or Medicare. When they’re ill, they get—as the cliche goes—”the best health care in the world.” The losers: those who rely on shrinking public insurance, such as Medicaid (nearly 45 million of us), or go uninsured (46 million and rising).
To slip from the winners’ circle into the losers’ ranks is a cultural, emotional and financial shock. You discover a world of patchy, minimal health care that feels almost Third World. The uninsured get less primary or preventive care, find it hard to see cardiologists, surgeons and other specialists (waiting times can run up to a year), receive treatment in emergencies, but are more apt to die from chronic or other illnesses than people who pay. That’s your lot if you lose your corporate job and can’t afford a health policy of your own.
I think a mixed public/private system like France’s would be a lot easier to sell to the American public than a pure single-payer system like Canada’s, or a National Health Service as in Britain. This is true even though economists seem to like the British system for its cost-control measures. I think it’s counterproductive to get hung up on creating a purely egalitarian system. In the real world, people with money will always find a way to get better stuff than people without. The important thing is to be sure everyone has access to decent health care, regardless of income.
One other thing — Mr. Joyner writes,
The fact that someone else pays most of our medical costs takes away any incentive to cut costs, especially when combined with a tort system that further distorts the economics.
Frankly, I don’t buy the idea that giving people insurance takes away incentive to cut costs. Very few people seek health care treatment for the fun of it, and few of us demand tests and treatments that our doctors didn’t suggest first. And who does cost comparisons for, say, open heart surgery? Who gets on the phone to various hospitals and doctors to get quotes for an appendectomy? The insurance companies themselves act as arbiters of cost, often refusing to pay for treatments they deem inappropriate (even if nine out of ten doctors disagree) or putting a cap on what they will pay for some procedures. This results in a system in which clerks, not doctors, decide course of treatment.
As for tort reform — the Right’s panacea for all health care system problems — in spite of the mighty efforts of conservative think tanks to crank out studies “proving” that rising health care costs are mostly the fault of greedy ambulance-chasing lawyers, the actual impact of litigation on overall health care costs is minor. According to a study published in the May 11, 2006, issue of the New England Journal of Medicine — “Claims, Errors, and Compensation Payments in Medical Malpractice Litigation” (not available online to non-subscribers) — only 3 percent of malpractice claims were found to be completely frivolous — involving no verifiable medical injuries. Claims that turned out not to involve errors accounted for 13 to 16 percent of the malpractice system’s total monetary costs, and plaintants rarely receive compensation in these cases. Rightie claims that the courts are flooded with frivolous claims are way overblown.
The primary myth in the medical malpractice debate that needs to be exposed is the myth regarding the effect of those costs on the health care system. Tort reform proponents have bamboozled the public and many legislators into believing that the cost of medical malpractice lawsuits is a significant factor in driving up the cost of health care. In 2003, the U.S. spent $215 million on liability insurance premiums, and doctors, hospitals and other health professionals paid only $11 billion in medical malpractice insurance premiums. That same year, the U.S. spent more than $1.5 trillion on health care. Something that costs less than 1 percent of total health care costs simply doesn’t have any meaningful effect on access to health care. If we want to address the real problems with the cost of health care, we should start with the evidence, not the myth.
“Tort reform” or health savings accounts or other little tweaks are not going to put a dent in our health care problems. What we need is a total overhaul of the system. But until we can get past the righties screaming about “socialized medicine” or fixating on Canada’s or Britain’s systems as the only models for universal health care on the planet, not much will be done.