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.

Emergency!

It happened so quickly, I hardly had time to understand it. At my daughter’s swim lesson this week, as I sat across the pool and waved at her, one of the other children in the class lost her grip on the side of the pool and began bobbing up and down in the water. Just as I thought, “wait a minute - what’s that kid doing?” the lifeguard ran over and pulled her out. The instructor was just a few feet away in the water; the girl’s mother was about 10 feet away on the side of the pool, and a posse of parents were watching their children swim in different classes – and yet the girl lost her grip and went under, almost unnoticed.

The speed at which emergencies happen still shocks me. The day my daughter fell on the playground several years ago, I was standing right next to her but had looked away for a moment. When I looked back, I found her crying and bleeding, the skin split under her chin. How quickly can I stop what I’m doing and thinking, understand what just happened, and react the right way when I need to? Smoke pours out of a house window, a woman collapses on a train, a car lies upside down on the road, its wheels still spinning – I have witnessed all of these.

An emergency requires you to stop and focus, and that can be hard to do because we’re so unfocused much of the time. We’re often multitasking, visually bombarded with print and video images, and thinking of the next thing we have to do – not what’s in front of us. I think that we might be worse at handling emergencies now than we were in the past, when it was easier to see if something seemed out of place, easier to hear if someone cried out.