SPECIAL CONTRIBUTION indigent health care
Indigent Health Care in Emergency Medicine: An Academic Perspective [Lowe RA, Young GP, Reinke B, White JD, Auerbach PS: Indigent health care in emergency medicine: An academic perspective. Ann Emerg Med July 1991;20:790-794.] INTRODUCTION After several decades of setting the standards in medical science throughout the globe, the United States is only now appreciating that it trails many developed countries in a number of health care indexes. This paradox stems in large part from the lack of access to health care by the uninsured and underinsured. Emergency physicians are ethically and legally required to see all patients regardless of ability to pay and hence have more exposure to the health care crisis than many office-based practitioners.l-4 During 1989 and 1990, the Government Affairs Committee of the Society for Academic Emergency Medicine (SAEM) reviewed the indigent health care crisis as it affects patients, the health care system, and emergency physicians in general. More specifically, the committee considered how the crisis threatens teaching and research in emergency medicine, thereby jeopardizing the future of our specialty. This position paper is designed to stimulate discussion among readers, encouraging responses in the medical literature and the political arena. MEDICALLY I N D I G E N T AMERICANS: EXTENT OF THE PROBLEM Approximately 100 million US citizens, 40% of the population, lack adequate financial protection from medical expenses, s-lo The 1986 population survey by the US Census Bureau found that approximately 37 million citizens (more than 17% of the total US population) are completely without health insurance, reflecting an increase of more than 33% from the mid-1970s. As many as 80 million additional citizens may have limited health insurance, placing them at risk for out-of-pocket expenses exceeding 10% of their annual income. Furthermore, most major medical policies do not provide coverage for prenatal care, preventive health care, extended nursing home Stays, and home care services, and approximately half of the elderly are not covered for long-term care needs. 8 Not all of the uninsured are poor or unemployed;6,7,T M nearly two thirds are members of families with incomes above the poverty level, and more than two thirds of uninsured adults belong to the labor force all or part of the year.5,6,9,10,12,13 Although the United States spends the greatest amount per capita of any nation on health care, 16 of the 33 "developed countries" studied by the World Health Organization report higher life expectancies at birth. 14 Socioeconomic status is a crucial influence on access to medical services;9,1°,l~, ls-~7 a major cause for the discrepancy between expenditures and health indexes is the number of US citizens who lack access to comprehensive health care.
Robert A Lowe, MD, FACER FACP*# San Francisco, California Gary P Young, MD, FACER FACPt# Portland, Oregon Brad Reinke, MD$# Santa Rosa, California J Douglas White, MD, MPH, FACER FACP§# Washington, DC Paul S Auerbach, MD, MSI!# Nashville, Tennessee From the Division of Emergency Medicine, University of California, San Francisco;* Department of Emergency Medicine, Portland Veterans Administration Medical Center, Portland, Oregon;t Santa Rosa Community Hospital, Santa Rosa, California;:~ Departments of Emergency Medicine and Internal Medicine, Georgetown University, Washington, DC;§ Division of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee;II and the Society for Academic Emergency Medicine Government Affairs Committee. # Received for publication October 15, 1990. Accepted for publication November 19, 1990. Address for reprints: Robert A Lowe, MD, FACER FACP, Society for Academic Emergency Medicine, 900 West Ottawa Street, Lansing, Michigan 48915-1794.
ROLE OF G O V E R N M E N T IN HEALTH CARE Through Medicare and Medicaid, the federal government assists with the health care costs of approximately 20% of the US population. Medicare has improved access to care for the elderly. 28 Medicaid provides medical
20:7 July 1991
Annals of Emergency Medicine
790/129
INDIGENT HEALTH CARE Lowe et al
a s s i s t a n c e to 25 m i l l i o n l o w income elderly persons, 9 million poor children, 5 million disabled persons, and 4 million u n m a r r i e d low-income parents. ~z It was established as a federal and state program for medical care for the poor under which the federal g o v e r n m e n t matches from 50% to 78% of total program expenditures, depending on the per capita income of the individual state. 7,gA°,lz,zS,29 In addition, health care now accounts for one fifth of h u m a n welfare outlays by state governments, z The Medicaid program suffers from many erroneous perceptions. It is often alleged that Medicaid provides support primarily for potentially employable adults and members of minorities, but less than 30% of Medicaid funds provide services to minorities, and only a few unemployed adults are covered by Medicaid. 7 As noted above, poor children and the elderly c o m p r i s e the two largest groups of Medicaid beneficiaries. Interestingly, the federal government pays more toward health care to the middle class and wealthy, through tax deductions for providing employee h e a l t h insurance, t h a n it spends on health care for the poor. 25 Medicaid is said to be inflationary primarily because of fraud, abuse, and misuse. 7 Medicaid's cost per recipient is similar to the cost of private care. 7,9A°,25 Medicaid costs have increased faster than total health expenditures, in part because the number of persons receiving Medicaid benefits doubled from 11.5 to 21.5 million between 1968 and 1979. 7 Although Medicaid's impact on the health of recipients has been questioned, Medicaid has been far more valuable than is generally realized. Since its inception in 1965, Medicaid has improved the health status of its recipients by increasing their access to health care. 7 Between 1968 and 1980, mortality in the United States decreased substantially for a number of diseases for which access to health care is a key determinate of prognosis, including maternal deaths during childbirth (72% decrease), influenza and pneumonia (53%), tuberculosis (52%), and diabetes (31%) (National Center for Health Care Statistics, unpublished data, 1982). However, many states have never appropriated sufficient sums to obtain the maximum federal contribu130/791
tion; therefore, in many states, the eligibility criteria are restrictive and the services included are limited. In 1989, a family of three could have an income of up to $9,798 and still receive Medicaid in Alaska; in Alabama, the i n c o m e t h r e s h o l d was $1,416. 30 In 1987, only 53% of the poor and near-poor (those with incomes of as m u c h as 125% of the poverty line) were on Medicaid, leaving more than 20 million poor and near-poor uncovered. 3o Furthermore, fiscal pressures in the 1980s led the federal government to limit Medicaid expenditures. Federal reductions in indigent health care began with the Tax Equity and Fiscal Responsibility Act of 1982. Since then, 26 states have increased Medicaid cost-sharing requirements. 31 Tightening of states' enrollment criteria between 1975 and 1983 reduced the proportion of low-income US citizens receiving Medicaid from 63% to 46%. 27,32 Another response of state and federal governments to the federal cutbacks has been to decrease physician reimbursement, either by failing to authorize rate increases to match inflation or, in some cases, by actually cutting fee schedules. The meager provider reimbursement under Medicaid has led most physicians to limit the number of Medicaid patients that they will see. 8 Robert Wood Johnson Foundation surveys showed improvements in access to health care between 1976 and 1982 that reversed in 1986. 26,27,33 The reduction of Medicaid eligibility in California in 1982 demonstrated that health status worsens for patients losing access to Medicaid. 34-36 Coinciding with the cutbacks, the decline in the infant mortality rate that began in the late 1960s has slowed since 1982. 37
ROLE OF T H E PRIVATE SECTOR I N T R E A T I N G THE MEDICALLY I N D I G E N T If the government is unable to provide adequate health care for the uninsured and underinsured, can the private sector be expected to bridge the gap? The private sector's reluctance or inability to provide care for the uninsured is reflected by the disparity between the a m o u n t of uncompensated care provided by private and public hospitals. In 1982, public ("county") hospitals in the 100 Annals of Emergency Medicine
largest US cities contained only 5% of US hospital beds, but they provided 26% of uncompensated care. In contrast, private ( " n o n p r o f i t " and "for-profit") hospitals in these cities contained 30% of US hospital beds but provided only 27% of uncompensated care. 3s Significant cost-shifting from private to p u b l i c h o s p i t a l s o c c u r s through various forms of "patient dumping," defined as "the denial of or limitation in the provision of services to a patient for economic reasons and the referral of that patient elsewhere. ''39 It is estimated that 250,000 patients a year in n e e d of emergency care are transferred for financial reasons, 39 and many of these p a t i e n t s are at increased risk of dying. 40-4z Although regulations and sanctions against financially motivated transfers of unstable patients enacted by the federal government 43 are necessary to protect these unstable patients, 44 regulations fail to remedy the underlying problem of indigent health care funding.
ROLE OF PUBLIC H E A L T H CARE FACILITIES US public hospitals can no longer provide adequate health care for all of the poor. As described above, public hospitals bear a disproportionate share of the burden for the health care of medically indigent persons who are ineligible for Medicaid. 3s Furthermore, increases in the number of uninsured persons have been accompanied by reductions in funding for public programs and facilities. Public hospitals are becoming too overloaded to provide adequate, let alone optimal, health care for the uninsured. Cook County Hospital reports a nine-month wait for clinic appointments. 45 Even public hospitals have begun to erect barriers to health care. 46 Clinics limit their volumes by requiring patients to be seen in the emergency department before they can be referred to a clinic. Some public h o s p i t a l s refuse to see " n o n emergent" patients w i t h o u t insurance, Medicaid, Medicare, or other public funding sources unless the patients provide cash payments in advance. 34 Public hospitals have even begun to divert ambulances to other facilities, a practice labeled "reverse dumping. ''46 One university hospital ED with a heavy indigent caseload 20:7 July 1991
INDIGENT HEALTH CARE Lowe et al
reported turning away 19% of ambulatory patients after a nurse made the determination that the problem was " n o n e m e r g e n t , " removing a vital safety net for the medically indigent. 47
EMERGENCY MEDICINE AND THE INDIGENT HEALTH CARE CRISIS
E m e r g e n c y m e d i c i n e carries a greater burden than most specialties w i t h r e g a r d to i n d i g e n t h e a l t h care. 2-4 Emergency physicians have become the physicians of last resort for the uninsured. Our sense of responsibility as physicians, reinforced by state and federal laws and by medicolegal standards of practice, requires that medically indigent patients presenting to the ED be evaluated. However, the ED is not the optimal source of primary care for patients with chronic illnesses, who would benefit from a continuing relationship with a single health care provider. Furthermore, when a medically indigent patient requires admission or referral for specialty care, the e m e r g e n c y p h y s i c i a n m u s t often spend an extensive period of time locating a physician willing to provide subsequent care. These administrative activities detract from the delivery of e m e r g e n c y care to o t h e r patients. ED problems created by the indigent health care crisis affect the insured as well as the uninsured. Hospitals have come under increased financial pressure to avoid caring for p e r s o n s w h o c a n n o t pay. W h e n trauma center designation leads to financial losses, hospitals withdraw from regional trauma systems. Such withdrawals have jeopardized the trauma systems in Chicago and Los Angeles, decreasing the level of trauma care for all residents in those cities. Uninsured patients, unable to obtain care elsewhere, are drawn to EDs for m i n o r problems, creating overcrowding and prolonged waiting times for all users of the ED. If entire public hospitals fold, uninsured or u n d e r i n s u r e d p a t i e n t s w o u l d be forced to seek care in private physicians' offices and community hospitals, thereby taxing their resources. All of these factors create problems extending beyond the boundaries of individual EDs or public hospital systems. 20:7: July 1991
IMPACT ON ACADEMIC EMERGENCY MEDICINE
This situation affects academic emergency physicians in particular because inadequate funding for indigent health care has a disproportionate impact on emergency medicine training programs in both public and private hospitals. As discussed below, the indigent health care crisis undermines emergency medicine training programs by 1) taxing them financially; 2) burdening emergency medicine residents with custodial, social, and nursing tasks that do not contribute to their education; 3) diverting faculty from teaching and other academic pursuits; 4) exposing physicians-in-training to a suboptimal standard of practice; and 5) shifting excellent teaching cases away from private hospitals' teaching programs. The results threaten the fin a n c i a l v i a b i l i t y of t r a i n i n g programs, skew training venues and resident experience, and undermine the public health orientation of the specialty. Teaching hospitals provide a disproportionate a m o u n t of indigent care. Although the members of the Council on Teaching Hospitals of the Association of A m e r i c a n Medical Colleges operate fewer than 20% of the nation's hospital beds, these hospitals account for almost half of all US hospitals' revenue losses for charity care. 48 This burden of care - reimbursed by neither the patient, private health insurance, nor government agencies - drains the resources of educational programs. 49-54 Residency and faculty positions may be cut or program accreditation may be threatened by lack of financial assets needed to provide proper schedules, appropriate attending coverage, and supportive training environments. When hospitals lack funds for ancillary staff, residents inevitably perform tasks that do not contribute to their education. 49-54 Furthermore, many public hospitals shift the patient care burden from overloaded clinics into their EDs. This practice overloads the ED with subacute and chronic illnesses and disturbs the desired patient mix for a good teaching environment. Also, when a patient presents to the ED with complex psychosocial and medical problems (eg, an uninsured demented patient with inadequate social support to ensure that he will return for an outpaAnnals of Emergency Medicine
tient evaluation), consultants are often reluctant to admit the patient. This situation represents a drain on the e m e r g e n c y p h y s i c i a n ' s t i m e without educational benefit to the resident. To maintain competitive faculty incomes, many teaching hospitals are i n s t i t u t i n g faculty practice plans. Under favorable conditions, such plans can increase efficiency and provide an incentive for high-quality medical care. However, in financially stressed facilities, such plans may act as incentives for faculty to preferentially care for the "paying patients" - decreasing time for teaching and other academic pursuits and presenting an explicit model to housestaff of a two-tiered health care system. A more subtle problem is the false impression that physicians-in-training receive of the standard of care for many patient problems. In an overburdened health care system, many illnesses are inevitably treated suboptimally. Residents may come to believe that only a life- or limbthreatening illness justifies hospital admission, that follow-up in several months is appropriate for diabetics, and that the evaluation of chest pain patients concludes "when the cardiac enzymes come back." Although it is facile to condemn these practices as sloppy, they actually represent the crude attempts of health care providers to ration limited resources. When all of the cardiac care unit beds are full and the ward resident has admitted 15 patients, is it essential to obtain an exercise tolerance test before discharging a chest pain patient? When all patients have to wait a month to get a clinic appointment, is it fair to make them wait longer so that diabetic patients can be seen more often? Residents may learn inadequate standards' of care in the overworked indigent health care setting and bring those standards with them into community hospital practice. A related problem faces the academic emergency physician who is based in a private hospital and is asked to transfer indigent patients out of the facility. Indigent patients often have more advanced medical illnesses and sustain more than their share of penetrating trauma, so residents trained exclusively in community hospitals are deprived of valuable learning opportunities. In the 792/131
INDIGENT HEALTH CARE Lowe et al
100 largest US cities, private teaching hospitals provide 32% of medical care, but only 21% of uncompensated care. 4s Residents in private hospital training programs are inadequately exposed to illnesses and injuries common among the indigent. These problems are not merely hypothetical projections. When directors of emergency medicine residencies were surveyed about the impact of various socioeconomic factors on their training programs, 22 of 34 respondents (65%) reported overloaded clinics spilling over into EDs, 56% reported financial problems causing inadequate staffing, 53% reported financially motivated patient dumping, 35% reported financial problems resulting in critical care bed closures, and 29% reported financial problems resulting in residents being forced to perform menial tasks. 5s
PROPOSED SOLUTIONS Several legislative proposals have addressed parts of the problem created by inadequate access to health care by the uninsured. The Comprehensive Omnibus Budget Reconciliation Act (COBRA) of 1986 and the Omnibus Budget Reconciliation Act (OBRA) of 1989 p r o h i b i t p a t i e n t dumping, although some state statutes require hospitals with EDs to maintain lists of on-call consultants who will see and admit patients regardless of ability to pay. These regulations may be necessary in the short term, but they tend to pit emergency physicians against consultants and private hospital physicians against public hospital p h y s i c i a n s r a t h e r than encouraging them to work together to solve the larger problem. Some medical societies have developed proposals to reimburse physicians for treating uninsured patients, t h r o u g h expanding eligibility for Medicaid or other funding pools. Unless these proposals contain cost-containment measures, however, they are unlikely to succeed politically. More comprehensive solutions must be explored.3°,s6, 57 A n u m b e r of plans have been proposed, S,ss-64 as has an excellent framework for evaluating the merits of different proposals. 65 C O N C L U S I O N A N D CALL
FOR ACTION We have discussed five components of the crisis in access to health 132/793
care: 1) while the U n i t e d States spends more of its gross national p r o d u c t on h e a l t h care t h a n any other nation, the federal and state governments are reducing their support of health care for the poor; 2) the private medical c o m m u n i t y is not prepared to compensate for these cutbacks; 3) public hospitals are overwhelmed, with some closing and the remainder unable to provide adequate health care for the poor; 4) poor people in the United States are experiencing serious, preventable morbidity and mortality because of lack of adequate medical care; and 5) the medical and economic environments created by these inequities endanger education and research in emergency medicine. SAEM believes that inadequate access to medical care jeopardizes the health and survival of the insured as well as of the uninsured. The unique vulnerability of EDs (especially academic EDs) to the health care crisis endangers the future of emergency medicine. A long-term solution to the crisis is essential. The solution will require funding from government and employers, provisions for cost containment, and compromises between diverse political constituencies. Whatever compromises are accepted, it appears inescapable that the solution must provide some form of universal access to comprehensive health care. SAEM and other physician groups must work actively toward this goal. Members can promote awareness of the problem. Many people still think that Medicaid provides coverage to all of the poor (or at least to the "deserving poor"). Few see the catastrophic impact as clearly as emergency physicians. We are in a unique position to educate our communities about the seriousness of the problem, including its potential i m p a c t on middle-class, insured patients who may be hurt by the impact of the "uninsured crisis" on trauma centers, other specialty centers, and medical education. The media may help disseminate information about patients who have suffered from lack of access to care. Because an individual physician's statements can be distorted by legislators or the media (intentionally or not), we must train a multitude of speakers to deal effectively with this challenge in every community. Annals of Emergency Medicine
We must use our strengths as researchers and educators to document the health impact of the access problem. Academic emergency physicians should study the frequency of medical complications resulting from delays in care when patients cannot be seen by clinics or community physicians. We can perform cost analyses of Medicaid patients seeking care in EDs for minor problems after they have been refused care in less expensive settings, addressing the question of w h e t h e r better access to care might actually save money. We can look at the impact of cutbacks in indigent health care funding on the quality of emergency medicine residency training and research, and we can educate the insured middle class regarding how deterioration in today's research and education will affect the emergency medical care that they receive in the future. We can track the impact of the indigent health care crisis on patient care, education, research, and financial stability at our own institutions and use the resources of SAEM to establish a data base with which to analyze i n f o r m a t i o n from m u l t i p l e EDs. SAEM will encourage the study of indigent emergency care and promote solutions; resolution of these problems is essential to the health of our training programs and the specialty. Finally, in our clinical practices, emergency physicians must continue to act in the patient's interest. If we s u c c u m b to e c o n o m i c pressure to compromise patient care based on ability to pay, we will lose our credibility as patient advocates and our distinctiveness as a specialty. The authors gratefully acknowledge the assistance of the Board of Directors of SAEM. They especially appreciate the helpful comments and encouragement of Arthur Sanders, MD, FACEP; Jerris Hedges, MD, MS, FACEP; and Edward Bemstein, MD, FACEP; and the superb administrative support of Mary Ann Schropp and Eric Gupton.
REFERENCES 1. American College of Emergency Physicians: Access to emergency medical care: Emergency physicimls and u n c o m p e n s a t e d care. Ann Emerg Med i 9 8 7 ; 1 6 : 1302-1304. 2.' Koska MT: Indigent care and overcrowding threaten e m e r g e n c y d e p a r t m e n t s . Hospitals January 20, 1989;63:66-70. 3. Melniek GA, Mann J, Golan I: Uncompensated emergency care in hospital markets in Los Angeles
20:7 July 1991
INDIGENT HEALTH CARE Lowe et al
county. A m J Public Health 1989;79:514-516. 4. L0we RA: Academic emergency medicine: Impact of government indigent health care policies. STEMLetter 1988;9:4-8. 5. Enthoven A, Kronick R: A consumer-choice health plan for the 1990s: Universal health insurance in a system designed to promote quality and economy. N Engi J Med 1989;320:29-37,94d01. 6. Himmelstein DU, Woolhandler S: Pitfalls of private medicine: Healthcare in the USA. Lancet 1984;2: 391-394. 7. Rogers DE, Blendon RJ, Moloney TW: Who needs Medicaid? N Engl J Med 1982;307:13-18. 8. Ginzberg E: Medical care for the poor: No magic bullets. JAMA 1988;259:3309-3311. 9. Nutter DO: Medical indigency and the public health care crisis: The need for a definitive solution. N ~ng] J Med 1987;316:1156q158. 10. Wilensky G, Berk ML: DataWatch: Health care, the poor, and the role of Medicaid. Health Affairs 1982; 1:93-100. 11. Sullivan LW: Shattuck lecture - The health care priorities of the Bush administration. N Engi J Med 1989;32h 125-128. 12. Iglehart JK: Medical care of the poor - A growing problem. N EngI J Med 1985;313:59-63. 13. Reagan MD: Health care rationing: What does it mean? N Engi J Med 1988;319:1149-1151. 14. Centers for Disease Control: Mortality in developed countries. M M W R 1990;39:205-209. 15. Braveman P, Oliva G, Miller MG, et ah Adverse outcomes in lack of health insurance among newborns in an eight-county area of California, 1982-1986. N EngI [ Med 1989~321:508-513. 16. Sachs BP, Brown DAJ, Driscoll SG, et ah Maternal mortality of Massachusetts: Trends and prevention. N Engf J Med 1987;316:667-672.
Distribution of Infant Mortality and Low Birthweight in the United States, 1978-82. Washington, DC, Food Research and Action Center, 1984.
46. Friedman A: Problems plaguing public hospitals: Uninsured patient transfers, tight funds, mismanagement, and mispemeption. JAMA 1987;257:1850-i857.
25. Mundinger MO: Health service funding cuts and the declining health of the poor. N Engl [ Med 1985; 313:44-47.
47. Derlet RW, Nishio DA: Refusing care to patients who present to an emergency department. Ann Emerg Med 1990;19:262-267.
26. Aday LA, Anderson RM: The national profile of access to medical care: Where do we stand? A m J Public Health 1984;74:1131-1139.
48. Vanselow NA: Academic health centers: Can they survive? Issues 8ci Tech 1986;summer:55-64.
27. Special Report 2. Princeton, New Jersey, The Robert Wood Iohnson Foundation, 1987, p 3-11. 28. Woolhandler S, H i m m e l s t e i n DU: A national health program: Northern light at the end of the tunnel. lAMA 1989;262:2136-2137. 29. Mnnoz E: Care for the Hispanic poor: A growing s e g m e n t of the A m e r i c a n society, l A M A 1988~ 260:2711-2712. 30. American College of Physicians: Access to health care. Ann Intern Med 1990~112:641-660. 31. "Seniors' health tab up a third." Fresno Bee April 14, 1987, p A6. 32. Blendon RJ: Health policy choices for the 1990s. Issues Sci Tech 1986:summer; 65-73. 33. Freedman HE, Blendon RJ, Aiken LH, et ah Ameri ~ cans report on their access to health care. Health Affairs 1987;6:5-18. 34. Lurie N, Ward NB, Shapiro MF, et al: Termination from Medi-Cah Does it'affect health? N Engi J M e d 1984;311:480-484. 35. Lurie N, Ward NB, Shapiro MF, et al: Termination from Medi-Cal benefits: A follow-up study one year later. N Engl ] Med 1986;314:1266-1268.
49. Cameron JM: The indirect cost of graduate medical education. N EngI J Med 1985;312:1233-1238. 50. Gerbert B, Showstack JA, Chapman SA, et ah The changing dynamics of graduate medical education: Implications for decision-making. West f Med 1987; 146:368-373. 51. Iglehart JK: Federal support of graduate medical education. N Engl J Med 1985;312:1000-1004. 52. Iglehart JK: Difficult times ahead for graduate medical education. N Engl J Med 1985;312:1400-1404. 53. Iglehart JK: Federal support of health manpower ed ucation. N E~gl f Med 1986;314:324-328. 54. Rieselbach RE, Jackson TC: In support of a linkage between the funding of graduate medical education and care of the indigent. N Engi J Med 1986;314:32-35. 55. Bernstein E, Lowe RA: A survey of public health and health policy issues addressed in emergency medicine t r a i n i n g programs: 1988. A c a d Emerg M e d 1990;2:7,10. 56. Greenberger NJ, Davies NE, Maynard EP, et ah Universal access to health care in America: A moral and medical imperative. Ann Intern Med 1990;112:637-639. 57. Auerbach PS: Toward a national health care policy in the United States. South Med ] 1989;82:1389-1396.
36. Brook RH, Ware JE, Rogers WH, et ah Does free care improve adults' health? Results from a randomized controlled trial. N EngI J Med 1983;309:1426-1434.
58. Himmelstein DU, Woolhandler S: A national health program for the United States: A physicians' proposal. N Engl J Med 1989;320:102-108.
37. Korenbrot CC: Risk reduction in pregnancies of low-income women. Mobius 1984;1:35--43.
59. National Leadership Commission on Health Care IUS): For the Health of a N~tion: A Shared Responsibility. Ann Arbor, Michigan, Health Administration Press, 1989.
17. Fisher ES, LoGerfo JP, Daling JR: Prenatal care and outcomes during the recession: The Washington State experience. A m J Public Health 1985)75:866-869.
38. Demkovich LE: Hospitals that provide for the poor are reeling from uncompensated costs. Nat J 1984~16: 2245-2249.
18. Gould JB, Davey B, Stafford RS: Socioeconomic differences in rates of cesarean section. N Engi J Med 1989;321:233-239;
39. Ansell DA, Schiff RL: Patient dumping: Status, imp l i c a t i o n s , and policy r e c o m m e n d a t i o n s . JAMA 1987;257:1500-1502.
60. Freedman SA, Klepper BR, Kuncan RP, et ah Coverage of the uninsured and underinsured: A proposal for school enrollment-based family health insurance. N EngI J Med 1988;318:843-847.
19. Hubbell FA, Waitzkin H, Rucker L, et ah Financial barriers to medical care: A prospective study in a university-affiliated c o m m u n i t y clinic. A m J M e d Sci 1989;297:158-162.
40. Schiff RL, Ansell DA, Schlosser JE, et ah Transfers to a public hospital: A prospective study of 467 patients. N Engl f Med 1986;314:552-557.
61. Butler SM: Assuring affordable health care for all Americans. The Heritage Lectures. Washington, DC, Heritage Foundation, 1989,218.
4t. Himmelstein DU, Woolhandler S, Harnly M, et al: Patient transfers: Medical practice as social triage. A m J Public Health 1984;74:494-497.
62. American Medical Association: The American Health Care System: Its Strengths, Its Weaknesses, and a Plan by Physicians to Improve It. Chicago, AMA, 1989.
20. Hubbell FA, Waitzkin H, Mishra SI, et ah Evaluating the health-care needs of the poor: A communityoriented approach. A m J Med 1989;87:127q31. 21. Woolhandler S, Himmelstein DU, Silber R, et ah Medical care and mortality: Racial differences in preventable deaths. Int J Health Serv 1985;15:1-22. 22. Berwick DM, Hiatt HH: Who pays? N Engl f Med 1989;21:841-542. 23. Wise PH, Eisenberg L: What do regional variations in the rates of hospitalization of children really mean? N EngI J Med 1989;320:1209-1211. 24. Sanders A: The Widening Gap: The Incidence and
20:7: July 1991
42. Kerr HD, Byrd JC: Community hospital transfers to a VA medical center. JAMA 1989;262:70-73. 43. New patient transfer laws take effect. ACEP News June i990;9: i, I4-i5,18.
63. American Medical Association: Health Access America: The A M A Proposal to Improve Access to Affordable, Quality Health Care. Chicago, AMA, 1990.
44. American College of Emergency Physicians: Principles of appropriate patient transfer. A n n Emerg Med 1990;19:337-338.
64. American Medical Association: Health Access America: Challenge for America: Background for the A M A Proposal to Improve Access to Affordable, Quality Health Care. Chicago, AMA, 1990.
45. Young Q: Physicians for Social Responsibility Panel Discussion: The Arms Race and the Health of Chicago, the Nation, and the World. Chicago, March 1987.
65. Brown ER: Principles for a national health program: A framework for analysis and development. Milbank Q 1988;66:573-617.
Annals of Emergency Medicine
794/133
Indigent Health Care in Emergency Medicine: An Academic Perspective [Lowe RA, Young GP, Reinke B, White JD, Auerbach PS: Indigent health care in emergency medicine: An academic perspective. Ann Emerg Med July 1991;20:790-794.] INTRODUCTION After several decades of setting the standards in medical science throughout the globe, the United States is only now appreciating that it trails many developed countries in a number of health care indexes. This paradox stems in large part from the lack of access to health care by the uninsured and underinsured. Emergency physicians are ethically and legally required to see all patients regardless of ability to pay and hence have more exposure to the health care crisis than many office-based practitioners.l-4 During 1989 and 1990, the Government Affairs Committee of the Society for Academic Emergency Medicine (SAEM) reviewed the indigent health care crisis as it affects patients, the health care system, and emergency physicians in general. More specifically, the committee considered how the crisis threatens teaching and research in emergency medicine, thereby jeopardizing the future of our specialty. This position paper is designed to stimulate discussion among readers, encouraging responses in the medical literature and the political arena. MEDICALLY I N D I G E N T AMERICANS: EXTENT OF THE PROBLEM Approximately 100 million US citizens, 40% of the population, lack adequate financial protection from medical expenses, s-lo The 1986 population survey by the US Census Bureau found that approximately 37 million citizens (more than 17% of the total US population) are completely without health insurance, reflecting an increase of more than 33% from the mid-1970s. As many as 80 million additional citizens may have limited health insurance, placing them at risk for out-of-pocket expenses exceeding 10% of their annual income. Furthermore, most major medical policies do not provide coverage for prenatal care, preventive health care, extended nursing home Stays, and home care services, and approximately half of the elderly are not covered for long-term care needs. 8 Not all of the uninsured are poor or unemployed;6,7,T M nearly two thirds are members of families with incomes above the poverty level, and more than two thirds of uninsured adults belong to the labor force all or part of the year.5,6,9,10,12,13 Although the United States spends the greatest amount per capita of any nation on health care, 16 of the 33 "developed countries" studied by the World Health Organization report higher life expectancies at birth. 14 Socioeconomic status is a crucial influence on access to medical services;9,1°,l~, ls-~7 a major cause for the discrepancy between expenditures and health indexes is the number of US citizens who lack access to comprehensive health care.
Robert A Lowe, MD, FACER FACP*# San Francisco, California Gary P Young, MD, FACER FACPt# Portland, Oregon Brad Reinke, MD$# Santa Rosa, California J Douglas White, MD, MPH, FACER FACP§# Washington, DC Paul S Auerbach, MD, MSI!# Nashville, Tennessee From the Division of Emergency Medicine, University of California, San Francisco;* Department of Emergency Medicine, Portland Veterans Administration Medical Center, Portland, Oregon;t Santa Rosa Community Hospital, Santa Rosa, California;:~ Departments of Emergency Medicine and Internal Medicine, Georgetown University, Washington, DC;§ Division of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee;II and the Society for Academic Emergency Medicine Government Affairs Committee. # Received for publication October 15, 1990. Accepted for publication November 19, 1990. Address for reprints: Robert A Lowe, MD, FACER FACP, Society for Academic Emergency Medicine, 900 West Ottawa Street, Lansing, Michigan 48915-1794.
ROLE OF G O V E R N M E N T IN HEALTH CARE Through Medicare and Medicaid, the federal government assists with the health care costs of approximately 20% of the US population. Medicare has improved access to care for the elderly. 28 Medicaid provides medical
20:7 July 1991
Annals of Emergency Medicine
790/129
INDIGENT HEALTH CARE Lowe et al
a s s i s t a n c e to 25 m i l l i o n l o w income elderly persons, 9 million poor children, 5 million disabled persons, and 4 million u n m a r r i e d low-income parents. ~z It was established as a federal and state program for medical care for the poor under which the federal g o v e r n m e n t matches from 50% to 78% of total program expenditures, depending on the per capita income of the individual state. 7,gA°,lz,zS,29 In addition, health care now accounts for one fifth of h u m a n welfare outlays by state governments, z The Medicaid program suffers from many erroneous perceptions. It is often alleged that Medicaid provides support primarily for potentially employable adults and members of minorities, but less than 30% of Medicaid funds provide services to minorities, and only a few unemployed adults are covered by Medicaid. 7 As noted above, poor children and the elderly c o m p r i s e the two largest groups of Medicaid beneficiaries. Interestingly, the federal government pays more toward health care to the middle class and wealthy, through tax deductions for providing employee h e a l t h insurance, t h a n it spends on health care for the poor. 25 Medicaid is said to be inflationary primarily because of fraud, abuse, and misuse. 7 Medicaid's cost per recipient is similar to the cost of private care. 7,9A°,25 Medicaid costs have increased faster than total health expenditures, in part because the number of persons receiving Medicaid benefits doubled from 11.5 to 21.5 million between 1968 and 1979. 7 Although Medicaid's impact on the health of recipients has been questioned, Medicaid has been far more valuable than is generally realized. Since its inception in 1965, Medicaid has improved the health status of its recipients by increasing their access to health care. 7 Between 1968 and 1980, mortality in the United States decreased substantially for a number of diseases for which access to health care is a key determinate of prognosis, including maternal deaths during childbirth (72% decrease), influenza and pneumonia (53%), tuberculosis (52%), and diabetes (31%) (National Center for Health Care Statistics, unpublished data, 1982). However, many states have never appropriated sufficient sums to obtain the maximum federal contribu130/791
tion; therefore, in many states, the eligibility criteria are restrictive and the services included are limited. In 1989, a family of three could have an income of up to $9,798 and still receive Medicaid in Alaska; in Alabama, the i n c o m e t h r e s h o l d was $1,416. 30 In 1987, only 53% of the poor and near-poor (those with incomes of as m u c h as 125% of the poverty line) were on Medicaid, leaving more than 20 million poor and near-poor uncovered. 3o Furthermore, fiscal pressures in the 1980s led the federal government to limit Medicaid expenditures. Federal reductions in indigent health care began with the Tax Equity and Fiscal Responsibility Act of 1982. Since then, 26 states have increased Medicaid cost-sharing requirements. 31 Tightening of states' enrollment criteria between 1975 and 1983 reduced the proportion of low-income US citizens receiving Medicaid from 63% to 46%. 27,32 Another response of state and federal governments to the federal cutbacks has been to decrease physician reimbursement, either by failing to authorize rate increases to match inflation or, in some cases, by actually cutting fee schedules. The meager provider reimbursement under Medicaid has led most physicians to limit the number of Medicaid patients that they will see. 8 Robert Wood Johnson Foundation surveys showed improvements in access to health care between 1976 and 1982 that reversed in 1986. 26,27,33 The reduction of Medicaid eligibility in California in 1982 demonstrated that health status worsens for patients losing access to Medicaid. 34-36 Coinciding with the cutbacks, the decline in the infant mortality rate that began in the late 1960s has slowed since 1982. 37
ROLE OF T H E PRIVATE SECTOR I N T R E A T I N G THE MEDICALLY I N D I G E N T If the government is unable to provide adequate health care for the uninsured and underinsured, can the private sector be expected to bridge the gap? The private sector's reluctance or inability to provide care for the uninsured is reflected by the disparity between the a m o u n t of uncompensated care provided by private and public hospitals. In 1982, public ("county") hospitals in the 100 Annals of Emergency Medicine
largest US cities contained only 5% of US hospital beds, but they provided 26% of uncompensated care. In contrast, private ( " n o n p r o f i t " and "for-profit") hospitals in these cities contained 30% of US hospital beds but provided only 27% of uncompensated care. 3s Significant cost-shifting from private to p u b l i c h o s p i t a l s o c c u r s through various forms of "patient dumping," defined as "the denial of or limitation in the provision of services to a patient for economic reasons and the referral of that patient elsewhere. ''39 It is estimated that 250,000 patients a year in n e e d of emergency care are transferred for financial reasons, 39 and many of these p a t i e n t s are at increased risk of dying. 40-4z Although regulations and sanctions against financially motivated transfers of unstable patients enacted by the federal government 43 are necessary to protect these unstable patients, 44 regulations fail to remedy the underlying problem of indigent health care funding.
ROLE OF PUBLIC H E A L T H CARE FACILITIES US public hospitals can no longer provide adequate health care for all of the poor. As described above, public hospitals bear a disproportionate share of the burden for the health care of medically indigent persons who are ineligible for Medicaid. 3s Furthermore, increases in the number of uninsured persons have been accompanied by reductions in funding for public programs and facilities. Public hospitals are becoming too overloaded to provide adequate, let alone optimal, health care for the uninsured. Cook County Hospital reports a nine-month wait for clinic appointments. 45 Even public hospitals have begun to erect barriers to health care. 46 Clinics limit their volumes by requiring patients to be seen in the emergency department before they can be referred to a clinic. Some public h o s p i t a l s refuse to see " n o n emergent" patients w i t h o u t insurance, Medicaid, Medicare, or other public funding sources unless the patients provide cash payments in advance. 34 Public hospitals have even begun to divert ambulances to other facilities, a practice labeled "reverse dumping. ''46 One university hospital ED with a heavy indigent caseload 20:7 July 1991
INDIGENT HEALTH CARE Lowe et al
reported turning away 19% of ambulatory patients after a nurse made the determination that the problem was " n o n e m e r g e n t , " removing a vital safety net for the medically indigent. 47
EMERGENCY MEDICINE AND THE INDIGENT HEALTH CARE CRISIS
E m e r g e n c y m e d i c i n e carries a greater burden than most specialties w i t h r e g a r d to i n d i g e n t h e a l t h care. 2-4 Emergency physicians have become the physicians of last resort for the uninsured. Our sense of responsibility as physicians, reinforced by state and federal laws and by medicolegal standards of practice, requires that medically indigent patients presenting to the ED be evaluated. However, the ED is not the optimal source of primary care for patients with chronic illnesses, who would benefit from a continuing relationship with a single health care provider. Furthermore, when a medically indigent patient requires admission or referral for specialty care, the e m e r g e n c y p h y s i c i a n m u s t often spend an extensive period of time locating a physician willing to provide subsequent care. These administrative activities detract from the delivery of e m e r g e n c y care to o t h e r patients. ED problems created by the indigent health care crisis affect the insured as well as the uninsured. Hospitals have come under increased financial pressure to avoid caring for p e r s o n s w h o c a n n o t pay. W h e n trauma center designation leads to financial losses, hospitals withdraw from regional trauma systems. Such withdrawals have jeopardized the trauma systems in Chicago and Los Angeles, decreasing the level of trauma care for all residents in those cities. Uninsured patients, unable to obtain care elsewhere, are drawn to EDs for m i n o r problems, creating overcrowding and prolonged waiting times for all users of the ED. If entire public hospitals fold, uninsured or u n d e r i n s u r e d p a t i e n t s w o u l d be forced to seek care in private physicians' offices and community hospitals, thereby taxing their resources. All of these factors create problems extending beyond the boundaries of individual EDs or public hospital systems. 20:7: July 1991
IMPACT ON ACADEMIC EMERGENCY MEDICINE
This situation affects academic emergency physicians in particular because inadequate funding for indigent health care has a disproportionate impact on emergency medicine training programs in both public and private hospitals. As discussed below, the indigent health care crisis undermines emergency medicine training programs by 1) taxing them financially; 2) burdening emergency medicine residents with custodial, social, and nursing tasks that do not contribute to their education; 3) diverting faculty from teaching and other academic pursuits; 4) exposing physicians-in-training to a suboptimal standard of practice; and 5) shifting excellent teaching cases away from private hospitals' teaching programs. The results threaten the fin a n c i a l v i a b i l i t y of t r a i n i n g programs, skew training venues and resident experience, and undermine the public health orientation of the specialty. Teaching hospitals provide a disproportionate a m o u n t of indigent care. Although the members of the Council on Teaching Hospitals of the Association of A m e r i c a n Medical Colleges operate fewer than 20% of the nation's hospital beds, these hospitals account for almost half of all US hospitals' revenue losses for charity care. 48 This burden of care - reimbursed by neither the patient, private health insurance, nor government agencies - drains the resources of educational programs. 49-54 Residency and faculty positions may be cut or program accreditation may be threatened by lack of financial assets needed to provide proper schedules, appropriate attending coverage, and supportive training environments. When hospitals lack funds for ancillary staff, residents inevitably perform tasks that do not contribute to their education. 49-54 Furthermore, many public hospitals shift the patient care burden from overloaded clinics into their EDs. This practice overloads the ED with subacute and chronic illnesses and disturbs the desired patient mix for a good teaching environment. Also, when a patient presents to the ED with complex psychosocial and medical problems (eg, an uninsured demented patient with inadequate social support to ensure that he will return for an outpaAnnals of Emergency Medicine
tient evaluation), consultants are often reluctant to admit the patient. This situation represents a drain on the e m e r g e n c y p h y s i c i a n ' s t i m e without educational benefit to the resident. To maintain competitive faculty incomes, many teaching hospitals are i n s t i t u t i n g faculty practice plans. Under favorable conditions, such plans can increase efficiency and provide an incentive for high-quality medical care. However, in financially stressed facilities, such plans may act as incentives for faculty to preferentially care for the "paying patients" - decreasing time for teaching and other academic pursuits and presenting an explicit model to housestaff of a two-tiered health care system. A more subtle problem is the false impression that physicians-in-training receive of the standard of care for many patient problems. In an overburdened health care system, many illnesses are inevitably treated suboptimally. Residents may come to believe that only a life- or limbthreatening illness justifies hospital admission, that follow-up in several months is appropriate for diabetics, and that the evaluation of chest pain patients concludes "when the cardiac enzymes come back." Although it is facile to condemn these practices as sloppy, they actually represent the crude attempts of health care providers to ration limited resources. When all of the cardiac care unit beds are full and the ward resident has admitted 15 patients, is it essential to obtain an exercise tolerance test before discharging a chest pain patient? When all patients have to wait a month to get a clinic appointment, is it fair to make them wait longer so that diabetic patients can be seen more often? Residents may learn inadequate standards' of care in the overworked indigent health care setting and bring those standards with them into community hospital practice. A related problem faces the academic emergency physician who is based in a private hospital and is asked to transfer indigent patients out of the facility. Indigent patients often have more advanced medical illnesses and sustain more than their share of penetrating trauma, so residents trained exclusively in community hospitals are deprived of valuable learning opportunities. In the 792/131
INDIGENT HEALTH CARE Lowe et al
100 largest US cities, private teaching hospitals provide 32% of medical care, but only 21% of uncompensated care. 4s Residents in private hospital training programs are inadequately exposed to illnesses and injuries common among the indigent. These problems are not merely hypothetical projections. When directors of emergency medicine residencies were surveyed about the impact of various socioeconomic factors on their training programs, 22 of 34 respondents (65%) reported overloaded clinics spilling over into EDs, 56% reported financial problems causing inadequate staffing, 53% reported financially motivated patient dumping, 35% reported financial problems resulting in critical care bed closures, and 29% reported financial problems resulting in residents being forced to perform menial tasks. 5s
PROPOSED SOLUTIONS Several legislative proposals have addressed parts of the problem created by inadequate access to health care by the uninsured. The Comprehensive Omnibus Budget Reconciliation Act (COBRA) of 1986 and the Omnibus Budget Reconciliation Act (OBRA) of 1989 p r o h i b i t p a t i e n t dumping, although some state statutes require hospitals with EDs to maintain lists of on-call consultants who will see and admit patients regardless of ability to pay. These regulations may be necessary in the short term, but they tend to pit emergency physicians against consultants and private hospital physicians against public hospital p h y s i c i a n s r a t h e r than encouraging them to work together to solve the larger problem. Some medical societies have developed proposals to reimburse physicians for treating uninsured patients, t h r o u g h expanding eligibility for Medicaid or other funding pools. Unless these proposals contain cost-containment measures, however, they are unlikely to succeed politically. More comprehensive solutions must be explored.3°,s6, 57 A n u m b e r of plans have been proposed, S,ss-64 as has an excellent framework for evaluating the merits of different proposals. 65 C O N C L U S I O N A N D CALL
FOR ACTION We have discussed five components of the crisis in access to health 132/793
care: 1) while the U n i t e d States spends more of its gross national p r o d u c t on h e a l t h care t h a n any other nation, the federal and state governments are reducing their support of health care for the poor; 2) the private medical c o m m u n i t y is not prepared to compensate for these cutbacks; 3) public hospitals are overwhelmed, with some closing and the remainder unable to provide adequate health care for the poor; 4) poor people in the United States are experiencing serious, preventable morbidity and mortality because of lack of adequate medical care; and 5) the medical and economic environments created by these inequities endanger education and research in emergency medicine. SAEM believes that inadequate access to medical care jeopardizes the health and survival of the insured as well as of the uninsured. The unique vulnerability of EDs (especially academic EDs) to the health care crisis endangers the future of emergency medicine. A long-term solution to the crisis is essential. The solution will require funding from government and employers, provisions for cost containment, and compromises between diverse political constituencies. Whatever compromises are accepted, it appears inescapable that the solution must provide some form of universal access to comprehensive health care. SAEM and other physician groups must work actively toward this goal. Members can promote awareness of the problem. Many people still think that Medicaid provides coverage to all of the poor (or at least to the "deserving poor"). Few see the catastrophic impact as clearly as emergency physicians. We are in a unique position to educate our communities about the seriousness of the problem, including its potential i m p a c t on middle-class, insured patients who may be hurt by the impact of the "uninsured crisis" on trauma centers, other specialty centers, and medical education. The media may help disseminate information about patients who have suffered from lack of access to care. Because an individual physician's statements can be distorted by legislators or the media (intentionally or not), we must train a multitude of speakers to deal effectively with this challenge in every community. Annals of Emergency Medicine
We must use our strengths as researchers and educators to document the health impact of the access problem. Academic emergency physicians should study the frequency of medical complications resulting from delays in care when patients cannot be seen by clinics or community physicians. We can perform cost analyses of Medicaid patients seeking care in EDs for minor problems after they have been refused care in less expensive settings, addressing the question of w h e t h e r better access to care might actually save money. We can look at the impact of cutbacks in indigent health care funding on the quality of emergency medicine residency training and research, and we can educate the insured middle class regarding how deterioration in today's research and education will affect the emergency medical care that they receive in the future. We can track the impact of the indigent health care crisis on patient care, education, research, and financial stability at our own institutions and use the resources of SAEM to establish a data base with which to analyze i n f o r m a t i o n from m u l t i p l e EDs. SAEM will encourage the study of indigent emergency care and promote solutions; resolution of these problems is essential to the health of our training programs and the specialty. Finally, in our clinical practices, emergency physicians must continue to act in the patient's interest. If we s u c c u m b to e c o n o m i c pressure to compromise patient care based on ability to pay, we will lose our credibility as patient advocates and our distinctiveness as a specialty. The authors gratefully acknowledge the assistance of the Board of Directors of SAEM. They especially appreciate the helpful comments and encouragement of Arthur Sanders, MD, FACEP; Jerris Hedges, MD, MS, FACEP; and Edward Bemstein, MD, FACEP; and the superb administrative support of Mary Ann Schropp and Eric Gupton.
REFERENCES 1. American College of Emergency Physicians: Access to emergency medical care: Emergency physicimls and u n c o m p e n s a t e d care. Ann Emerg Med i 9 8 7 ; 1 6 : 1302-1304. 2.' Koska MT: Indigent care and overcrowding threaten e m e r g e n c y d e p a r t m e n t s . Hospitals January 20, 1989;63:66-70. 3. Melniek GA, Mann J, Golan I: Uncompensated emergency care in hospital markets in Los Angeles
20:7 July 1991
INDIGENT HEALTH CARE Lowe et al
county. A m J Public Health 1989;79:514-516. 4. L0we RA: Academic emergency medicine: Impact of government indigent health care policies. STEMLetter 1988;9:4-8. 5. Enthoven A, Kronick R: A consumer-choice health plan for the 1990s: Universal health insurance in a system designed to promote quality and economy. N Engi J Med 1989;320:29-37,94d01. 6. Himmelstein DU, Woolhandler S: Pitfalls of private medicine: Healthcare in the USA. Lancet 1984;2: 391-394. 7. Rogers DE, Blendon RJ, Moloney TW: Who needs Medicaid? N Engl J Med 1982;307:13-18. 8. Ginzberg E: Medical care for the poor: No magic bullets. JAMA 1988;259:3309-3311. 9. Nutter DO: Medical indigency and the public health care crisis: The need for a definitive solution. N ~ng] J Med 1987;316:1156q158. 10. Wilensky G, Berk ML: DataWatch: Health care, the poor, and the role of Medicaid. Health Affairs 1982; 1:93-100. 11. Sullivan LW: Shattuck lecture - The health care priorities of the Bush administration. N Engi J Med 1989;32h 125-128. 12. Iglehart JK: Medical care of the poor - A growing problem. N EngI J Med 1985;313:59-63. 13. Reagan MD: Health care rationing: What does it mean? N Engi J Med 1988;319:1149-1151. 14. Centers for Disease Control: Mortality in developed countries. M M W R 1990;39:205-209. 15. Braveman P, Oliva G, Miller MG, et ah Adverse outcomes in lack of health insurance among newborns in an eight-county area of California, 1982-1986. N EngI [ Med 1989~321:508-513. 16. Sachs BP, Brown DAJ, Driscoll SG, et ah Maternal mortality of Massachusetts: Trends and prevention. N Engf J Med 1987;316:667-672.
Distribution of Infant Mortality and Low Birthweight in the United States, 1978-82. Washington, DC, Food Research and Action Center, 1984.
46. Friedman A: Problems plaguing public hospitals: Uninsured patient transfers, tight funds, mismanagement, and mispemeption. JAMA 1987;257:1850-i857.
25. Mundinger MO: Health service funding cuts and the declining health of the poor. N Engl [ Med 1985; 313:44-47.
47. Derlet RW, Nishio DA: Refusing care to patients who present to an emergency department. Ann Emerg Med 1990;19:262-267.
26. Aday LA, Anderson RM: The national profile of access to medical care: Where do we stand? A m J Public Health 1984;74:1131-1139.
48. Vanselow NA: Academic health centers: Can they survive? Issues 8ci Tech 1986;summer:55-64.
27. Special Report 2. Princeton, New Jersey, The Robert Wood Iohnson Foundation, 1987, p 3-11. 28. Woolhandler S, H i m m e l s t e i n DU: A national health program: Northern light at the end of the tunnel. lAMA 1989;262:2136-2137. 29. Mnnoz E: Care for the Hispanic poor: A growing s e g m e n t of the A m e r i c a n society, l A M A 1988~ 260:2711-2712. 30. American College of Physicians: Access to health care. Ann Intern Med 1990~112:641-660. 31. "Seniors' health tab up a third." Fresno Bee April 14, 1987, p A6. 32. Blendon RJ: Health policy choices for the 1990s. Issues Sci Tech 1986:summer; 65-73. 33. Freedman HE, Blendon RJ, Aiken LH, et ah Ameri ~ cans report on their access to health care. Health Affairs 1987;6:5-18. 34. Lurie N, Ward NB, Shapiro MF, et al: Termination from Medi-Cah Does it'affect health? N Engi J M e d 1984;311:480-484. 35. Lurie N, Ward NB, Shapiro MF, et al: Termination from Medi-Cal benefits: A follow-up study one year later. N Engl ] Med 1986;314:1266-1268.
49. Cameron JM: The indirect cost of graduate medical education. N EngI J Med 1985;312:1233-1238. 50. Gerbert B, Showstack JA, Chapman SA, et ah The changing dynamics of graduate medical education: Implications for decision-making. West f Med 1987; 146:368-373. 51. Iglehart JK: Federal support of graduate medical education. N Engl J Med 1985;312:1000-1004. 52. Iglehart JK: Difficult times ahead for graduate medical education. N Engl J Med 1985;312:1400-1404. 53. Iglehart JK: Federal support of health manpower ed ucation. N E~gl f Med 1986;314:324-328. 54. Rieselbach RE, Jackson TC: In support of a linkage between the funding of graduate medical education and care of the indigent. N Engi J Med 1986;314:32-35. 55. Bernstein E, Lowe RA: A survey of public health and health policy issues addressed in emergency medicine t r a i n i n g programs: 1988. A c a d Emerg M e d 1990;2:7,10. 56. Greenberger NJ, Davies NE, Maynard EP, et ah Universal access to health care in America: A moral and medical imperative. Ann Intern Med 1990;112:637-639. 57. Auerbach PS: Toward a national health care policy in the United States. South Med ] 1989;82:1389-1396.
36. Brook RH, Ware JE, Rogers WH, et ah Does free care improve adults' health? Results from a randomized controlled trial. N EngI J Med 1983;309:1426-1434.
58. Himmelstein DU, Woolhandler S: A national health program for the United States: A physicians' proposal. N Engl J Med 1989;320:102-108.
37. Korenbrot CC: Risk reduction in pregnancies of low-income women. Mobius 1984;1:35--43.
59. National Leadership Commission on Health Care IUS): For the Health of a N~tion: A Shared Responsibility. Ann Arbor, Michigan, Health Administration Press, 1989.
17. Fisher ES, LoGerfo JP, Daling JR: Prenatal care and outcomes during the recession: The Washington State experience. A m J Public Health 1985)75:866-869.
38. Demkovich LE: Hospitals that provide for the poor are reeling from uncompensated costs. Nat J 1984~16: 2245-2249.
18. Gould JB, Davey B, Stafford RS: Socioeconomic differences in rates of cesarean section. N Engi J Med 1989;321:233-239;
39. Ansell DA, Schiff RL: Patient dumping: Status, imp l i c a t i o n s , and policy r e c o m m e n d a t i o n s . JAMA 1987;257:1500-1502.
60. Freedman SA, Klepper BR, Kuncan RP, et ah Coverage of the uninsured and underinsured: A proposal for school enrollment-based family health insurance. N EngI J Med 1988;318:843-847.
19. Hubbell FA, Waitzkin H, Rucker L, et ah Financial barriers to medical care: A prospective study in a university-affiliated c o m m u n i t y clinic. A m J M e d Sci 1989;297:158-162.
40. Schiff RL, Ansell DA, Schlosser JE, et ah Transfers to a public hospital: A prospective study of 467 patients. N Engl f Med 1986;314:552-557.
61. Butler SM: Assuring affordable health care for all Americans. The Heritage Lectures. Washington, DC, Heritage Foundation, 1989,218.
4t. Himmelstein DU, Woolhandler S, Harnly M, et al: Patient transfers: Medical practice as social triage. A m J Public Health 1984;74:494-497.
62. American Medical Association: The American Health Care System: Its Strengths, Its Weaknesses, and a Plan by Physicians to Improve It. Chicago, AMA, 1989.
20. Hubbell FA, Waitzkin H, Mishra SI, et ah Evaluating the health-care needs of the poor: A communityoriented approach. A m J Med 1989;87:127q31. 21. Woolhandler S, Himmelstein DU, Silber R, et ah Medical care and mortality: Racial differences in preventable deaths. Int J Health Serv 1985;15:1-22. 22. Berwick DM, Hiatt HH: Who pays? N Engl f Med 1989;21:841-542. 23. Wise PH, Eisenberg L: What do regional variations in the rates of hospitalization of children really mean? N EngI J Med 1989;320:1209-1211. 24. Sanders A: The Widening Gap: The Incidence and
20:7: July 1991
42. Kerr HD, Byrd JC: Community hospital transfers to a VA medical center. JAMA 1989;262:70-73. 43. New patient transfer laws take effect. ACEP News June i990;9: i, I4-i5,18.
63. American Medical Association: Health Access America: The A M A Proposal to Improve Access to Affordable, Quality Health Care. Chicago, AMA, 1990.
44. American College of Emergency Physicians: Principles of appropriate patient transfer. A n n Emerg Med 1990;19:337-338.
64. American Medical Association: Health Access America: Challenge for America: Background for the A M A Proposal to Improve Access to Affordable, Quality Health Care. Chicago, AMA, 1990.
45. Young Q: Physicians for Social Responsibility Panel Discussion: The Arms Race and the Health of Chicago, the Nation, and the World. Chicago, March 1987.
65. Brown ER: Principles for a national health program: A framework for analysis and development. Milbank Q 1988;66:573-617.
Annals of Emergency Medicine
794/133
