Public hospitals have become the last thread of the safety net in treating the poor, the uninsured, legal immigrants and undocumented workers. These clinics and emergency rooms struggle to treat a host of illnesses and injuries produced by social and environmental factors that are severe and increasingly concentrated in the poorest urban and rural communities.
Even this fragile thread is in danger of being severed by poor reimbursement and competition from other facilities that aren't facing the same challenges. As local government declares its inability to finance healthcare for the poor, responsibilities are pushed to states and then on to the federal government. This moving bubble of accountability for poverty is akin to a game of musical chairs. The same process occurs between provider systems in local communities. As one hospital fails or closes, the poor move on to the next, causing a cycle of fiscal chaos.
Common sense suggests that we need a viable strategy of adequate insurance coverage, primary and preventive care, health education and systematic care coordination. These essential services should be delivered through well-organized and financed community-based healthcare systems.
Most of the hospitals that are closing their doors these days are in or near lower-income communities that are highly dependent on ER services for basic care. That only worsens the situation for those physicians, clinics and hospitals that remain in impoverished areas.
The federal Centers for Disease Control and Prevention in 2000 issued a report that is revealing about safety net developments. More than one-third of emergency rooms were classified as having a high burden of safety net cases. About 60% of hospitals in the South were likely to have overburdened ERs. Fewer than half of those ERs received disproportionate-share payments and had limited options to subsidize the care provided. The report also suggests the uninsured and poor understand that their diverse and complex needs are best met in sophisticated emergency departments rather than community-based settings.
An additional finding stated safety net ERs have a higher proportion of visits made by children and black patients but a small portion of visits by seniors. This suggests Medicaid and state children's health insurance programs may not be effectively reaching enough low-income children and minority populations.
Other disturbing findings revealed the higher the uninsured burden for ERs, the larger the percentage of uninsured admissions, the longer the waiting times and the greater number of patients leaving without being seen. These factors reflect a set of complex conditions that can stress any healthcare delivery system and are increasingly concentrated in one or two emergency departments in most communities. Those emergency departments with high Medicaid concentrations were more likely to be in impoverished communities with higher unemployment rates, lower incomes and higher ER use.
The conclusions drawn from this report could be perceived in various ways. The findings strongly suggest the demands of uninsured and poor patients affect some ERs more than others depending on location. It points to the reality of an elusive primary-care system for Medicaid beneficiaries, the uninsured and the poor. It also illustrates the importance of health insurance and healthcare resources. Until the proper resources are re-established in many communities, some ERs will continue to be heavily relied on for primary care.
In 2003, the Institute of Medicine issued a major report on the uninsured that found they receive less care than most people and receive it too late; thus, they are sicker and die sooner. The report identified huge disparities in the lack of treatment and outcomes in breast cancer, car accidents and many chronic illnesses that are primarily treated by ERs. In May 2004, the California Health Care Foundation issued a study on access to physicians in public health programs. Its key findings were: consistent insurance coverage enabled access to services and intermittent insurance coverage made it worse. The foundation noted that adult beneficiaries had more access problems than children and beneficiaries with chronic illness requiring specialty care had the most access problems.
These studies and those from previous years point to fundamental solutions. Access to insurance is key, as is access to primary care and a well-organized system to deliver chronic and specialty care. Without these fundamentals the demands on the safety net will con-tinue to adversely affect a wide group of providers. This destructive pattern has the potential to make a community's overall health system weaker and force individual providers into difficult ethical and moral decisions about what type of care they can refuse.
A meaningful solution to the safety net problem will take intelligence, common sense and courage. It will go far beyond short-term tweaks in reimbursement. It will seriously analyze the weaknesses of health delivery in each community and strengthen these systems. It will also identify and address the social determinants of access, disparities in treatment of minorities and variation in public funding. Finally, it will find a systematic way for healthcare providers serving similar underserved populations and sharing the same burden to work effectively with each other by reducing risk, equalizing the disadvantages and creating incentives to improve health outcomes.
Thomas Chapman is president and chief executive officer of the HSC Foundation, Washington.