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Health Care

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.

Jane Bryant Quinn:

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.

On the other hand,

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.

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  1. A Canadian Reader  •  Jun 15, 2006 @12:58 pm


    An excellent article on the dangers to health of the American system appeared in the New Yorker a few months ago. I’m sorry I can’t remember either the author or the date, but it’s a must read.

    BTW, I got my MRI in just a few days by agreeing to have it done at 1:30 a.m. It’s not a perfect system here in Canada, but I wouldn’t trade it for a fancy job and a big house in the States!

  2. Ian  •  Jun 15, 2006 @1:35 pm

    It’s really too bad that the French seem to have one of the best national health systems in the world.

    The irrational hatred of France on the right would tend to make them dismiss anything france does as bad and without merit.

    By the way, any idea where this hatred of France actually comes from? It just seems bizarre to me…


  3. Julie O.  •  Jun 15, 2006 @3:33 pm

    Also, those who oppose universal healthcare ignore the obvious fact that ERs are acting as universal healthcare already. We need to do it smarter and more efficiently.

  4. fshk  •  Jun 15, 2006 @3:46 pm

    They covered this story on the evening news last night, and NBC did, in fact, point out that a lot of ER visits were by people without insurance. They interviewed one poor ER doc who said he was pretty sure things would have to get a lot worse before anyone would do anything. Also, the big reason a lot of ERs closed is that the hospitals couldn’t afford (or didn’t want to deal with) the uninsured or the crowds, meaning there’s a bigger burden on the hospitals that do maintain ERs.

    Of course, the solution some lawmakers are proposing is to throw more money at the problem without fixing the root cause of the problem.

  5. AnnieCat  •  Jun 15, 2006 @6:39 pm

    Universal health care might BE tort reform.


    Let me explain that. I work in a law firm that handles personal injury cases, Many of our clients are catastrophically injured — paraplegia, severe brain damage, amputated limbs. Quite frequently one reason these people sue is that even if they have health insurance and some savings, it’s not enough to cover the cost of the treatment they need, now or in the future, or the loss of income they suffer if they can’t return to their job. Not to mention the trap of losing your health insurance if you lose your job, thereby having no money to pay premiums even on a COBRA conversion insurance policy. Right now all they can do is hope they have grounds for a lawsuit and hope the other parties have enough insurance or assets to pay their damages.

    If we had national healthcare in some form or another, and people didn’t have to lie awake at night worrying about how they would pay for their new prosthetic leg in ten years, they might have less incentive to get what they need via lawsuits.

  6. khughes1963  •  Jun 15, 2006 @9:26 pm

    William Greider commented in his 1992 book “Who will Tell the People” that it takes a “seismic event for Congress to go after the rich folks.” I think Mr. Greider’s comment is appropriate in this context as well. Likewise, I agree with the ER doctor interviewed that it will get a lot worse before it gets better. I’m not so sure we’ll see universal care in my lifetime-I’m 43, but I think the only way we’ll see it happen is if we have some massive economic catastrophe along the lines of the Great Depression. Judging by what I’m seeing these days in our political and economic systems, I would not be surprised to see the 21st century equivalent of the Great Depression in a few years.

  7. Swami  •  Jun 15, 2006 @11:55 pm

    It’s depressing to read about health care. I got the same coverage as Lewis and Clark or Christopher Columbus had, so I consider it a traditional coverage. At least I don’t feel a sense of being deprived with 46 million others in the same boat as I am. One thought that does cross my mind is the 6 to 10 billion dollars a month being spent in Iraq and wondering how better spent that money could be if used in some fashion toward basic health care for all Americans.. But we don’t want somebody to get something for nothing, especially those health gluttons who don’t contribute to society

    Something that Maha didn’t include in this post, which I’ve read somewhere, but can’t /won’t bother to substantiate, is that in the recent Credit Reform Act (scam) the leading factor in defaulting on credit was due to overwhelming medical expenses and not deadbeat credit card holders buying frivolous goodies and then sticking it to the rest of us to pick up the tab.

  8. Swami  •  Jun 16, 2006 @12:09 am

    Oh, that was the Bankruptcy Reform Act and not the Credit Reform Act .. you all know what I mean.. If they had named it the Indentured Servant Act, we’d all be clear on what we’re talking about.

  9. Francophile  •  Jun 16, 2006 @1:39 am

    I’m an American but I’ve lived in Paris. French health care is wonderful. Doctors come to you – you dial SOS-medicin and they come to your house. Or you can go see them. Oddly enough, The American Hospital (established post WWII) is a wonderful facility – its quite easy to get an appointment same day.

    I have a program now through a large company that is considered “posh” by current standards, but its still nowhere near as good as I can get in France for much less money.

    This really ought to be a much higher priority than the nonsense that went on in the house today.

  10. Mary Kay Pinnick  •  Jun 16, 2006 @10:28 am

    I want to respond to your post about health care. I have been a RN for 30 yrs. (recently retired) & an acupuncturist for 20 yrs. Since I have worked in the system I have my own insights & opinions about the problems. They may not be right but they are shared by quite a few of my co-workers.

    The health care system has been taken over by the insurance companies who make the important decisions. Doctors & the public allowed this because at first it seemed ideal. Doctors were assured of getting paid & people didn’t have to worry about big bills. I do disagree with Maha that people who have insurance don’t care about the cost of something. They will agree to have costly tests because they are not paying for it. In addition, doctors have lost the “art” of medicine & feel they have to depend on all the tests to confirm a diagnosis & to protect themselves from being sued. Having worked with doctors & having to carry out their orders, I know they do not consider the costs when ordering tests. Most of the time, they do not even know how much a test costs. Also, most of their treatment is to write out a prescription. There is little offered in the way of preventive care or a healthy lifestyle.

    As often happens, what seemed like a good idea at the time has mushroomed into a problem that seems unsurmountable. Insurance companies need to keep their costs down, employers are feeling the crunch of offering health care benefits. The benefits go down & the costs go up with each passing year.

    Studies have shown that 50% or more of physical complaints taken to doctors have no physical origin, that is, they are emotionally or psychically caused.

    I have always enjoyed good health. On the other hand, I have always been very careful to take good care of my health & consider it my responsibility. Since I found acupuncture I am able to take care of some minor problems that if taken to a Western doctor would be treated with “drugs”. They only treat the symptom not the cause. The best way to deal with the stress, germs, viruses, etc. is to develop a good immune system & trust in one’s own body’s intelligence. Mother Nature has a better system than any man-made one.

    Finally, I will have to admit it will have to get worse before it gets better. I have been predicting for more than 10 yrs. that the health care system in this country is going to crash. When it does, maybe we can get back to a more natural way of living.


  11. Rick  •  Jun 16, 2006 @12:33 pm

    Hatred of France? Maybe all the talk of how rude the french were to american tourists. Pissed off the self righteous among us whom you just don’t question or condescend to our natural superiority, I’m sure.

  12. Donna  •  Jun 16, 2006 @1:37 pm

    We need to be calling this exactly what it is. There is not ‘health care’ in America. There is a huge, growing ‘health industry’ in America.
    As long as the corporate-minded are making their bucks from citizens’ health dollars and spending those bucks on high-priced lobbyists who are in cahoots with legislators, our Congress will not change the system as it exists. Look at the Medicare drug program…..that tax-payer funded program was created only by kowtowing to the insurers and drug companies to, first and foremost, assure them continued and increased profits…..which is saying that UNLESS something would be added into the ‘health industry’ system to keep the corporate world happy, nuthin’s gonna change.

    Health care providers do care about their patients; corporate types do not care about patients nor the whole class of folks who are uninsured. All the spin about ‘socialism’ and ‘taking away incentives for health shopping’ and ‘tort reform’ are red herrings to keep the focus off the corporate-minded lack of national caring or compassion for the have-nots. But, hey, the profiteers, their lobbyists and their shills in Congress can lie to themselves all they want….I don’t buy their lies, nor should anyone else.

  13. goatherd  •  Jun 16, 2006 @2:38 pm

    I am a former Program Manager for a non-profit rehabilitation facility. I worked with people with a very wide range of physical disabilities. My wife is a Certified Nurse Midwife. So we are both personally familiar with our health care system. I think you have put together a good article that hits the high points nicely. Emergency rooms are certainly taking the brunt of our health care systems failures and there are many ways of saving money with preventive care etc. as some of the commenters have said.

    My wife had a surgery that her insurance would not cover. She did a bit of research and found that both of us could travel to France, spend three weeks there and have the operation for significantly less than having the procedure done in the US.

    One reason is that their service delivery system is very practical. The hospital was very comfortable, but there were no a lot of frills. That suits me just fine. I really don’t have to feel like I am hotel to get health care. The french facility was more like a summer camp, which my wife and I both felt was more comfortable Also, I bet you it was cleaner with fewer lurking infectious bacteria etc. than american hospitals. Because, the hospital was more open and there was a lot less clutter. All in all it was a very pleasant atmosphere, but then I suppose being in Lyon might have something to do with that.

    It is an old leftist joke that “capitalism can produce anything except a living wage.” Unfortunately it looks like decent healthcare may also be on that list along with many other things. The trick that the Right has nearly pulled off is to convince the american public that what the “miracles” of privatization, deregulation and outsourcing can not do are the same things that society SHOULD not do. This is bunk.

    Vive la France!! I’d move there in a New York minute.

  14. Avedon  •  Jun 19, 2006 @6:13 pm

    A friend of mine recently was telling me about his wealthy, activist Republican mother’s sudden lack of interest in the Republicans. She had been complaining to her GP about all the tests the specialists kept wanting to do on her – many of them quite invasive. Her doctor said, “Well, you know, you are very … generously insured….” It suddenly dawned on her that something had gone wrong with the way healthcare is being handled in our country.

  15. JustThinking  •  Jun 21, 2006 @6:14 pm

    As a nurse of 25 years, and having worked in the ED for over 10 years across this country, and overseas, I can appreciate the comments made – all have validity. An excellent, balanced, resource about our current system issues can be found at; particularly the MAR/APR issues. Healthcare is an industry. Healthcare represents 16% of the GDP. Some will argue that stat in or out of 14-18%. Any way you look at it – healthcare is a money maker. Only when we address this key issue can reform be attained. Key to reform will be public education and accountability. Physicians/hospitals/insurers are not “bad” by default, they are what a captalistic society has made them. I do believe I will see some type of universal care in this country in the next 10 years. Personally, I admire the Australian system which is a two tier, public private system – critically, this system holds individuals accountable for their health, while providing the laws and resources to educate.

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