Emptying crowded ERs will take more than just insurance
A few years ago, an insurance industry executive spoke at a local event focused on health care disparities. While he expressed support for broadening access to insurance, he took pains to point out that “being insured doesn’t fix everything.” Many in the crowd interpreted this to mean that he wasn’t really all that supportive of broader access, and the event became considerably less fun for him after that point.
In fact, he was making a critically important point about the limits of insurance in improving health. He noted that the members of his health plan had excellent access to annual physical exams – out-of-pocket costs were low and the plan had a huge network of primary care physicians. Yet a paltry one in ten members was actually getting a physical each and every year. Clearly, there were complicated cultural issues around lifestyle and individual responsibility that were very important in keeping people healthy. The audience that day wasn’t ready to hear him, but his point bears repeating.
I was reminded of that exchange today when I read news coverage of CDC research showing that the uninsured are no more likely to use the ER than insured patients. According to the CDC’s data, the heaviest users of ERs are not the uninsured, but African Americans and Medicaid patients. Having insurance, in and of itself, doesn’t keep you out of the ER.
This dovetails neatly with findings from a recent Capstrat poll showing that African American respondents rated doctors lower and Google higher in relative rankings of “reliable” sources of information.
I have to wonder if there isn’t a bigger story here about how we need to come to grips with fundamental differences in how diverse populations access the health care system. If broadening access to insurance coverage won’t necessarily reduce traffic at emergency rooms, what will?
Perhaps we need to look more closely at access to primary care. According to the CDC study, Medicaid patients weren’t more likely than other groups to show up at an ER for a non-urgent problem, but they were more likely to have made multiple trips to the ER in a 12-month period. Perhaps repeated visits aren't an abuse of the system, but a reflection on the lack of alternatives. Could our nation’s biggest ER problem be more a lack of primary care clinics in low-income and minority neighborhoods than spotty insurance coverage?
It makes perfect sense for Congress to try to rein in health care costs by moving people out of emergency rooms, where care is terribly expensive. But the CDC data suggests that making coverage available will be only a small step in the right direction. It seems to me that pairing that coverage with a “medical home” where people get regular access to personalized, affordable care is what's really needed.
Here in North Carolina, the Medicaid program and partners such as Community Care of North Carolina have made considerable progress in building such local systems. But as health reform drastically increases the number of patients with insurance, both public and private, will there be medical homes for all? Probably not.
I worry that all the insurer-bashing rhetoric that helped get health care reform through Congress may lead to unreasonably high expectations in terms of cost control. Slaying the insurance dragon makes for great political theater. But the CDC study shows it will take more than that to fix what ails our health care system.
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