ER confronts new emergency: too many patients

Dial 911 and you may discover the nation's economically ailing healthcare system is caught in an emergency of its own.

Across the country, from Boston to Seattle, an increasing number of overcrowded, understaffed hospital emergency rooms are turning ambulances away and diverting them to other hospitals, except in the most extreme cases.

Healthcare experts contend the record number of ambulance diversions is the latest symptom of the healthcare system's economic crisis.

"It has become a nationwide issue," says Dr. Robert McNamara, head of the American Academy of Emergency Medicine. "The trouble is that there are patients who the emergency physicians know need to be admitted to the hospital, but there are no inpatient beds available."

While lawmakers in Washington focus on the battle over coverage for prescription drugs for the elderly, some healthcare experts say the emergency-room crisis is even more pressing. One way to alleviate the overcrowding, they contend, would be to find coverage for the more than 42 million uninsured Americans, whose first stop is often the emergency room.

The situation has reached such crisis proportions that some of the sharpest antagonists in the healthcare debate - from the insurance industry to the hospital associations to the advocates for universal coverage - have decided to work together, hoping to transcend their differences to find a workable solution to present to Congress this year.

Each group now says it's willing to give up some of its top priorities to forge a compromise. "We're looking for the opportunity to come together on a 'second favorite' choice," says Ron Pollack, executive director of Families USA, a leading reform advocate. "If we can do that, we could eliminate the contentiousness that has existed each and every time health reform has been on the table."

President George W. Bush's campaign pledge to spend $132 billion over 10 years to help deal with the problem of the uninsured is adding to the optimism a solution can be found this year.

The emergency-room crisis was caused by a combination of factors. For the past decade, the advent of managed care intensified the pressure on hospitals to cut costs. More than a thousand have closed nationwide, and those that remained open have cut back the number of available inpatient beds in order to save money. Add to that a nationwide nursing shortage.

At the same time, the number of uninsured Americans, who often use ERs for primary care, has continued to grow. With the exception of last year, more than 1 million people joined the ranks of the uninsured every year since 1993, when overall healthcare reform foundered in Congress.

There are now more than 42 million Americans without health insurance. Most are working people, like Estelle Meyers, a self-employed nanny who can't afford private insurance. Studies show most put off getting care until their situation becomes acute. Then they head to the emergency room. In fact, the uninsured are four times more likely to use one than the insured.

"The first thing they do is they ask you if you have coverage," says Meyers. "So I told them I'd go get cash from a cash machine, or I could use a credit card, so they took good care of me."

But even if she didn't have any money, the hospital by law would have to take care of her in an emergency situation. Which explains another of the hospital's economic dilemmas. For years, they subsidized the free care given to people who couldn't afford it by increasing the cost of services to people who did have insurance.

That's called cost-shifting, and it's become a thing of the past. Managed-care organizations have forced hospitals to squeeze out any unnecessary expenditure and to justify every price increase.

That's left them with a far less flexible income stream, large amounts of bad debt, and few ways to pay it. "Hospitals have done, perhaps, too good of a job of staying alive in the most difficult of financial situations," says Carolyn Lewis, chairman of the board of the American Hospital Association. "There's almost nowhere left to shift that cost, and uninsured people keep showing up [at emergency rooms]."

Such problems are not new to the healthcare system, but each year they've gone unaddressed, they've gotten worse.

That's why Families USA, a health-reform advocate, and the Health Insurance Association of America (HIAA), a major opponent of Clinton's healthcare plan, have come together on a proposal that both say is neither one's "ideal." But, both say, it would dramatically increase the number of Americans with insurance.

It would expand Medicaid to make it available to more of the working poor, the largest segment of the uninsured. It would also set up tax credits for businesses to encourage them to provide health insurance, particularly for low-wage workers.

If enacted, the two groups contend, the combined proposals would provide coverage for "many millions" of the country's uninsured. That, in turn, would allow them to get primary care at a doctor's office, taking pressure off emergency rooms.

"If you could get more low-income Americans covered, whether it's through public programs or through employment, then everybody benefits," says Charles Kahn, president of HIAA.

(c) Copyright 2001. The Christian Science Publishing Society