Emergency departments can't keep up with influx of uninsured
Emergency departments can't keep up with influx of uninsured
The future of those who may lose public health care is cloudy at best, according to a 2006 Kaiser Commission on Medicaid and the Uninsured study by Urban Institute researchers.
"It remains an open question as to how many will obtain private coverage and how many will become uninsured when public coverage is no longer an option," said researchers Sharon Long and John Graves. "We find that very few of the low-income working age adults who are currently covered by public programs would have any insurance options in the absence of public coverage. Only 8% would have the possibility of obtaining employer-sponsored insurance coverage, and less than 1% would likely find nongroup premiums that cost less than 5% of their family's income."
Ms. Long and Mr. Graves said that only when income is above 150% of the federal poverty level do other coverage options become available for more than a handful of adults who currently have public coverage. Even then, only 25% of the parents and fewer than 40% of childless adults would have an alternate insurance option.
"This research suggests that the vast majority of current enrollees affected by cutbacks in eligibility for public programs, particularly those with the lowest incomes, are likely to be left uninsured," they wrote.
Lower rates
The survey found that employer-sponsored insurance rates are low for most low-income adults enrolled in public health coverage programs and the rates have been falling over time, particularly among small firms, which are more likely to employ low-income workers. Also, as employer coverage premiums have increased, that option has become less affordable for low-income workers. The average annual employee contribution in 2005 was $2,713 for family coverage, the report said. With average family income for low-income families with public coverage projected to be below $12,000 in 2005, that employer coverage premium would account for nearly 25% of the family's income. The other potential coverage option — nongroup insurance — also is unlikely to be affordable to most low-income adults as premiums tend to be quite high relative to family income, with many facing premiums in excess of 25% of their income.
Premium assistance, tax credits of limited help
"While premium assistance programs or tax credits could help make the nongroup coverage option more affordable," Ms. Long and Mr. Graves said, "the premium subsidies would have to be substantial to bring the cost down to levels that are likely to generate much enrollment. And those premium subsidies and tax credits would address only one of the costs of nongroup coverage. Unlike Medicaid, which has no deductibles and minimal copay requirements, nongroup coverage often requires both high deductibles and high copayments when using care, making such coverage even less affordable for low-income families."
Given the obstacles to picking up some other type of coverage, Ms. Long and Mr. Graves said it is likely that most of affected current public coverage enrollees will become uninsured, with all the associated negative consequences such as higher rates of morbidity and mortality, inability to obtain screening and prevention services, and delays in seeking care when sick. There also are significant economic impacts on their communities. As the share of the community that is uninsured and, thus, in poorer health increases, businesses face higher absenteeism and lost productivity, and there are increased demands on the local health care system to meet the needs of those who lack insurance.
A study published in the January/February 2006 issue of Health Affairs found that decreases in Medicaid and SCHIP enrollment lead to an increase in emergency department visits by the uninsured, but little change in overall ED volume. The results also suggested that efforts that reduce Medicaid and SCHIP eligibility and enrollment will achieve cost savings for those programs largely by reducing access and shifting costs away from them to the health care safety net and providers who meet the needs of the uninsured.
Center for Studying Health System Change (CHSC) senior health researcher Peter Cunningham said there is concern among state and local officials that Bush administration efforts to make fundamental changes to Medicaid will shift the cost of caring for low-income people onto state and local governments and providers in the form of uncompensated care, with a particular problem for hospital EDs, many of which are already overcrowded.
"Because the uninsured are already more dependent on EDs for their care compared with their insured peers, Medicaid cuts that raise the number of uninsured people could result in a surge of uncompensated care by EDs," Mr. Cunningham said. "The effects would be particularly high on public hospitals and other safety net hospitals that provide a disproportionately large amount of care to uninsured and low-income people."
He reported there are other cost-containment efforts that also could inadvertently increase ED use. Many physicians already are reluctant to accept Medicaid patients because of low reimbursement, and further cuts could reduce the number of physicians who care for Medicaid patients, resulting in increased use of EDs. Although community health centers and other free clinics could pick up some of those unable to gain access to office-based physicians, reductions in Medicaid revenue, from which community health centers derive more than one-third of their total revenue, could reduce center capacity in a given area and increase use of the ED.
Compared with privately insured and uninsured people, notes Mr. Cunningham, Medicaid/SCHIP enrollees are much younger, poorer, more likely to be in single parent families, and more likely to have health problems. Differences in health status for adults are especially notable, he said. About 40% of adults with Medicaid/SCHIP describe their health as fair or poor, compared with 25% for uninsured and 13% for privately insured people. Also, more than 25% of adult Medicaid/SCHIP enrollees report multiple chronic conditions, compared with 5.9% for uninsured and 9.5% for privately insured adults.
"The high rate of health problems among adult Medicaid/SCHIP enrollees likely reflects the fact that many qualify for Medicaid through disability and Medically Needy programs, while most children qualify based on income eligibility," he said.
ED visits
Higher rates of health problems by Medicaid/SCHIP enrollees likely account for at least some of their higher levels of ED use compared with other low-income people. More than one-third of Medicaid/SCHIP adult enrollees had an ED visit in the previous year, compared with about 20% of both uninsured and privately insured adults. Overall, ED visits per adult Medicaid/SCHIP enrollee are 2½ to three times those of privately insured and uninsured adults.
Mr. Cunningham said the high use of EDs by Medicaid beneficiaries should be of concern to policy-makers, especially since about half of ED visits are for nonurgent medical problems. Redirecting much of this care into more appropriate settings would save program costs and could lead to improved access to and quality of care. Also, he said, reducing nonurgent ED use and making care delivery more efficient are much more likely than enrollment reductions to achieve cost savings without shifting the cost elsewhere.
Another reason for policy-makers to be concerned about the potential for increasing numbers of the uninsured turning to EDs is the low grade given the nation's emergency care system by the ACEP.
"Americans assume they will receive lifesaving emergency care when and where they need it, but increasingly this isn't the case," said ACEP president Frederick Blum. "Our report found the nation's support for emergency medical care is mediocre or worse. Most Americans would not accept mediocre treatment or mediocre medicines; they also should not accept mediocre support of an emergency medical system that they expect to be of the highest quality when their lives hang in the balance. In a nation that has prided itself on providing the highest-quality medical care in the world, anything less than an A is unacceptable."
No A's given
The American College of Emergency Physicians' overall grade of C- is the average of grades for all 50 states and the District of Columbia. No state received an A. California ranked first in the nation (see report card), followed by Massachusetts, Connecticut, and the District of Columbia, all earning the highest overall B grades. The report found that half the states were providing below-average support for their emergency medical systems, earning poor or near-failing grades. Arkansas, Idaho, and Utah had the weakest support, receiving the worst overall grade, a D.
The findings
Specific findings from the report card included:
• Access to emergency care. Seven states earned an A in this category — Connecticut, the District of Columbia, Maine, Massachusetts, Ohio, Pennsylvania, and Rhode Island — with no state receiving a failing grade. The category looked at availability of emergency care resources and certain kinds of state health spending, including public funding of health insurance, which makes more resources available to everyone. States receiving D's were Alabama, Arkansas, Arizona, Georgia, Idaho, Nevada, New Mexico, Texas, and Utah.
• Quality of care and patient safety. Eight states led the nation with A grades in this category — Connecticut, Delaware, District of Columbia, Georgia, Iowa, New Jersey, Pennsylvania, and West Virginia. Three states received failing F grades — Kansas, Nevada, and South Dakota — while 17 others received D's. The category looked at state support for training emergency physicians and EMS personnel as well as patient access to ambulances and 911 services.
• Public health and injury prevention. California, Maryland, Massachusetts, Michigan, and New York led the nation with A's in this category. But 41 states earned a C or lower in support for health and safety programs, with Montana and South Dakota receiving grades of F. The category focuses on lessening need for emergency care due to traumatic injury or preventable illnesses. It looks at indicators such as whether the state has seatbelt and helmet laws, domestic violence programs, as well as state immunization rates and the number of mothers receiving prenatal care.
• Medical liability environment. Four states earned an A in this category — California, Montana, Nevada, and Texas — but 12 states received failing grades for their medical liability environments — Arkansas, Connecticut, District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, Rhode Island, Tennessee, Vermont, Virginia, and Wyoming. Some 30 others had near-failing grades. The category assessed increases in state medical liability rates as well as reform initiatives.
ACEP officials said although the report card found a general correlation between state wealth and higher grades, it also found that some of the country's historically poorest states such as West Virginia and South Carolina earned better-than-average grades, demonstrating their commitment to high-quality emergency care. It also was found that states with lower population densities generally faced greater deficits in emergency care.
[Download the Kaiser report and other materials at www.kff.org/about/kcmu.cfm.
The authors can be reached through the Urban Institute at (202) 833-7200. Mr. Cunningham's study is available from Health Affairs at www.healthaffairs.org and he is available by e-mail at [email protected].
Materials on the ACEP report card are on-line at www.acep.org. Contact ACEP at (202) 728-0610.]
The future of those who may lose public health care is cloudy at best, according to a 2006 Kaiser Commission on Medicaid and the Uninsured study by Urban Institute researchers.Subscribe Now for Access
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