Within the System of No-System
JAMA Vol. 286 No. 20, November 28, 2001
by Robert L. Ferrer, MD, MPH
"My waiting room is bigger than yours. It seats 228 and by mid-afternoon it is usually packed. On a good day patients will wait two to three hours to see me or one of the other clinicians who work here. On a bad day the wait can reach five or six hours. Not as many patients complain as you might think. Almost all are uninsured, and they have nowhere else to go. Our 'acute care' clinic is a large county-hospital walk-in clinic -- portal of entry to the public health care system in a county in which 360,000 of the 1.3 million inhabitants are uninsured. The numbers are alarming, but the stories underlying them are even worse."
(Dr. Ferrer then describes the shocking realities of ten patients seen at the clinic. A description of one follows in the next paragraph.)
"A man in his early 20s with a worsening dental infection who was unable to afford a dentist. He finally saw a physician who prescribed an antibiotic, but the patient was unable to pay for the prescription. He presented to our clinic with sepsis and spread of the infection to his mediastinum. He died soon after admission."
"I wish this was a top-ten list of lamentable stories, but it is not. The egregious is commonplace in our setting. My colleagues and I are part of what is widely known as the health care 'safety net' for the uninsured, but to work here is to realize that, for many, the safety net does not provide a soft landing, nor are its failures the random 'accidents' implied by the image of missing a net.
"In actuality, events such as these are the product of a system, an increasingly coherent system of exclusion that denies care to the uninsured: the system of no-system. The system of no-system's components are the fragmented resources locally available to the uninsured, embedded within the national nonsystem of health care. It is a netherworld of closed doors and shrinking services. The paradox of the system of no-system is that it is becoming increasingly systematized. Unintended consequences of changes in health care organization and financing, positive feedback loops enabled by the nonsystem, and maladaptations to the health care market are solidifying the barriers to care for the uninsured."
(Dr. Ferrer then explains the features of the system of no-system: inversion, concentration, fragmentation, evasion, degradation, resignation, amplification, and maladaptation. The descriptions of these features will alarm you. As one example, the process of evasion is described in the next paragraph.)
"Despite legislation to prohibit patient 'dumping,' it still occurs. To survive, it has mutated into a less visible form. Private hospitals are no longer shipping indigent patients off to public EDs in a taxicab. Instead, they now offer perfunctory treatment, forego any diagnostic procedures, and discharge patients with instructions to 'follow up tomorrow with your primary care physician.' They might as well be advised to see their personal banker."
(And, concluding... )
"It is time to rescue the 39 million Americans who are forced to seek care within the system of no-system. If there is to be universal health care, we cannot keep having the same dialogues about the government vs. the market, equality vs. liberty, efficiency vs. bureaucracy. Stripped of all the ideology, the need and the suffering are there, now, plain for all to see. Stop by my waiting room sometime and I'll show you."
Robert L. Ferrer, MD, MPH San Antonio, Tex
<http://jama.ama-assn.org/issues/current/ffull/jpo10168-1.html#aainfo>http://jama.ama-assn.org/issues/current/ffull/jpo10168-1.html#aainfo
Comment: Download and save this one. The next person that tells you that the uninsured still receive care, hand them a copy of this and insist that they read it.