The emergency room provides a crucial vessel for our community, a place where, at some unexpected moment, each of us might need to pour all of our hopes. Perhaps that is why the video of the unattended waiting room death of Esmin Green, an appalling, preventable tragedy, inspires such anguish and outrage.
As the New York Times reported:
Someone may need to clue Mr. Bloomberg in. This death appears to be a result of systemic failure in two areas in which the mayor is credited with great expertise: public health and public management.
ER delays have become routine in America, even as they prove deadly. We remember Edith Rodriguez, Christopher Jones, Beatrice Vance and recognize that many unknown others have died waiting for emergency care.
Hospital ERs, by law, must welcome all patients who present for treatment. Hence last year’s Presidential quip, “I mean, people have access to health care in America. After all, you just go to an emergency room.” Yet over recent years we have seen our ERs progressively overwhelmed.
The Institute of Medicine reported in 2006 that ER visits climbed more than 25 percent over ten years while the number of hospital emergency departments declined by about 10 percent. No wonder we have overcrowded ERs and longer wait times.
This year, a benchmark study, by Dr. Andrew Wilper and other Harvard researchers, published in Health Affairs, found that heart attack patients admitted to the ER in 1997 typically waited 8 minutes for treatment, but in 2004 waited 20 minutes, a 150 percent increase.
Because hospitals often lack sufficient inpatient beds, as well as nurses, critically ill or mentally ill ER patients “boarding in the ER,” waiting for intensive care or a psychiatric unit can create a bottleneck, leading to a backup for hours, even days, ultimately causing the diversion of ambulances to another hospital and a greater risk of death for those who are critically ill.
Surprisingly, insured Americans crowd the ERs, not the uninsured. This spring the Annals of Emergency Medicine published a study by Dr. Ellen Weber (and others) that shows the proportion of the uninsured who go to the emergency room declined modestly over a 7 year period, a time when the proportion of uninsured in America rose steadily.
Private health insurance has erected financial disincentives that convince patients to avoid care, for the costs of premiums, co-pays, deductibles and other out-of-pocket expenses have outstripped wages. These days far too many, insured and uninsured, wait to seek medical attention until they are simply too sick to avoid the emergency room. And far too many lack primary and preventive care.
If patients who leave the ER are likely to find themselves bewildered about their treatment, what it means to have insurance “coverage” can be more confusing. A visit to the ER can bring on the up-front co-pay, the daunting deductible (listed on the bill as the “patient responsibility”), as well as other unaffordable out-of-pocket costs, all of which combine to clobber our families financially.
Crowding in the ER weighs upon caregivers too. To be sure those who work in the ER witness terrible human suffering, often bravely, with an an expected psychological toll. Yet confronting wholly unjustified tragedies, products of the system itself, threaten “burnout” – and these frustrations mount along recurring themes like too many patients whose emergency might have been prevented if they had a primary care provider, too few staff, too few beds or a lack of specialty services for sick patients.
With grim consequences for patients, some specialists and primary care doctors no longer take call to back up the ER. For example the St. Petersburg Times reports: “If you sever your fingers in Florida, Tampa may be the only place to get them sewn back on.” (What happens to patients with such injuries at the other 200+ Florida hospitals with ERs?!)
Ambulatory surgical centers, encouraged by private health insurance payments, compete with hospitals for insured patients, thus diverting patients, specialists and revenue away from hospitals. (In contrast, specialist on call to the emergency room find unpredictable off-hours demands, where patients are likely to be high risk and possibly underinsured or uninsured.) Market forces thus undermine our ERs.
Where the percentage of low-income patients tends to be great, specialists tend to be scarce, increasing the likelihood that a severely ill patient (from a hospital that serves a low-income area) may need to go on to another hospital for inpatient care. Health disparities, by race and by region, have grown worse, not better, in recent years. While American life expectancy overall has increased, “the life expectancy of a significant segment of the population is actually declining or at best stagnating.” How is this possible when health spending, per person, is more than 50% more in the United States than any other nation?
The indignities of the emergency room worsen as disparities in American health care grow. We must not allow our front-line colleagues, ER nurses and doctors, in whose hands we place the hopes of our community, to struggle in isolation. Local solutions will not be found to solve systemic, nationwide problems.
Swamped with patients, many of whom have already delayed seeking medical attention, and starved of resources and specialists, our ERs are ailing. The perverse incentives that drag down our ERs – and thus all of us – are the product of the American system of health care financing: private health insurance.
“Systemic failure” led to Esmin Green’s death. These words in the New York Times reflect public awareness of the nationwide crisis in American health care.
Private health insurance, with its unaffordable costs and its billing games, with its intolerable intrusions into personal and professional decisions, undermines both patients and caregivers. Private health insurance must be replaced by public financing.
Single-payer reform of the American health system offers the minimum incremental change needed to improve the care of patients, lessen inequalities and disparities in care, defend and expand patient choice and autonomy, redistribute resources toward care, toward our emergency rooms, and away from bureaucratic waste, profit-making, personal gain and thus reign in costs.
For the health of our nation, for the sake of our emergency room patients and caregivers, we need single payer now.
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