Tuesday, June 14, 2011

Health Reform and the ER

Many years ago, I developed a sore throat and a cough at the tail end of recovering from a cold. The sore throat became worse and worse each day, so I called my primary care doctor. But her office refused to see me. They were swamped with patients, it was flu season, and "you just have the flu," the receptionist told me.

Ultimately, sick and fed up, I dragged myself to my local emergency room. There, the professional and refreshingly compassionate nurses evaluated me and gave me a prescription for antibiotics to treat a raging sinus infection. When I recovered, I found a new primary care provider.

The problem I had was what many uninsured patients face every day: no access to a primary care provider. Without this access, they, like me, end up in the emergency room for urgent but non-emergency problems. This frustrates emergency room doctors and nurses, but they also understand that some patients don't have other choices for care. A pediatric emergency room doctor once explained to me that there was a tacit understanding between some uninsured parents and ER staff that many visits were not true medical emergencies, but their children had an urgent medical problem and the ER was the only place they could go.

Massachusetts legislators hoped to mitigate this and other problems with the health care system by mandating insurance coverage for all state residents, who must be insured through private or government plans. This grand experiment, initiated in 2006, has not turned out exactly as they had planned. But a recent study in the Annals of Emergency Medicine found that, although ER visits increased in Massachusetts after 2006, the number of "low-severity visits" decreased slightly ("Emergency Department Utilization After the Implementation of Massachusetts Health Reform").

Ideally, Massachusetts health care reform should have more dramatically decreased emergency room use. Increasing insurance coverage, however, also increases the need for primary care providers, and these providers are in short supply in both Massachusetts and elsewhere. The state's subsidies to expand health care coverage "do nothing to increase the supply of medical services in a market suffering from shortages of everything from family doctors to nurses to hospital beds," writes Shawn Tully in an article about health care reform for CNN Money ("5 painful health-care lessons from Massachusetts").

The CNN article, and a recent article on the LA Times ("One in three employers may drop health benefits, report says"), also point out that as health care reform is rolled out nationally, many employers might drop insurance coverage for their employees and choose to pay a non-compliance fine instead. This would increase the government's fiscal burden of health care.

There are a lot of challenges ahead for health care reform, and I hope the state and federal governments can work all this out. Although there's work to be done, I'm glad that Massachusetts is making some progress with reform, because I know how frustrating, costly, and inefficient it is to be forced to use the ER when you can't get care elsewhere.

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