Impact of UninsuranceImpact of Uninsuranceon Access to on Access to

Emergency CareEmergency CareArthur L. Kellermann, MD, MPH

Emory University School of Medicine

Robert Wood Johnson Health Policy Fellow,

Co-Chair, IOM Committee on the Consequences of Uninsurance (2001– 2004)

Three Myths About the Uninsured

1. “The uninsured get the care they need.”

2. “I’m not affected, so it’s not my problem.”

3. “We can’t afford to cover the uninsured.”

Care without coverageCare without coverage• Uninsured adults receive fewer and less timely

preventive and screening services • Uninsured cancer patients die sooner due to

delayed diagnosis• The uninsured receive less chronic illness care,

poorer hospital care and are more likely to die in the hospital

• The risk of premature death among uninsured Americans is 25% higher than Americans with health insurance – estimated 18,000/year

Community consequences Community consequences of uninsuranceof uninsurance

• Communities with high rates of uninsurance have difficulty recruiting and retaining physicians

• Specialists are less likely to accept referrals or take ER call

Community consequences Community consequences of uninsuranceof uninsurance

In urban communities with high rates of uninsurance, hospitals generally have:

• Fewer beds per capita• fewer services for vulnerable

populations• Less trauma and burn care• Bigger problems with ER

crowding and diversionSource: Gaskin and Needleman, 2002   

New Info on the “Spillover Effects” of Uninsurance

“[the] problems of health services quality and access facing insured people increase when the proportion of uninsured people in their local communities is greater.”

Mark V. Pauly and Jose PaganHealth Affairs, Sept./Oct. 2007

““I mean, people have access I mean, people have access to health care in America.to health care in America.

After all, you just go to an After all, you just go to an emergency room.”emergency room.”

President Bush President Bush Cleveland, Ohio, July 10, 2007Cleveland, Ohio, July 10, 2007

Difficulty Getting Care on Nights, Weekends,Holidays Without Going to the ER

Among Sicker Adults in Six Countries, 2005

25 28

38

5459 61

0

50

100

GER NZ UK CAN AUS US

Percent of adults who sought care reporting “very” or “somewhat” difficult

Source: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. 2005a).

September 10, 2001September 10, 2001

ER Crowding• Half of U.S. hospitals report ER

crowding on a daily basis. In urban areas, the rate is 2/3rds

• Acutely ill and injured patients may wait >12 hours for an inpatient bed

• ½ million inbound ambulances diverted in 2003; avg. 1 per minute

The problem is The problem is notnot due to due tonon-urgent use…non-urgent use…

Inpatient “boarding” is the problem!

• 90% of level 1 TCs and hospitals >300 beds are “at or above” capacity

• Lack of ICU beds is the main cause of ambulance diversions

• Big urban hospitals are most likely to divert ambulances

“Form Follows Finance”• Hospitals face few consequences for ER crowding. Many

benefit from it • Elective admits pay higher margins & keep referring docs

happy• OR “block time” keeps surgeons happy• “boarding” admits in the ER keeps inpatient nurses

happy• “Two admits for the price of one” keep administrators

happy

Crowding & public health

• In 2003, a young man presented to a Toronto ER with “community-acquired pneumonia”

• He spent the night in an ER stretcher waiting for an inpatient bed

• Over course of his ER stay, he infected 2 adjoining patients and several staff members with SARS

• 31 patients and staff fell ill; 3 patients died

The IOM’s Vision

“A Coordinated, Regionalized,

and Accountable Emergency Care System”

The IOM’s Vision

“A Coordinated, Regionalized,

and Accountable HEALTH CARE System”

IOM Recommendation #1

“That the President and Congress develop a strategy to achieve universal insurance coverage and to establish a firm and explicit schedule to reach this goal by 2010.”

IOM Recommendation #2

“That until universal coverage takes effect, federal and state governments provide resources sufficient for Medicaid and SCHIP to cover all persons currently eligible and prevent the erosion of outreach efforts, eligibility, enrollment and coverage.”

4 Generic Strategies

1. Major public program expansion and new tax credit

2. Employer mandate, premium subsidy, and individual mandate

3. Individual mandate and tax credit

4. Single payer

The Bottom Line

1. The uninsured do not get the care they need.

2. Uninsurance is threatening everyone’s access to care

3. We can’t afford NOT to cover the uninsured.

“It is time for our nation to extend coverage to everyone.”

- IOM, 2004

www.iom.edu/uninsured