Reports conclude: ED safety net is in danger

The ED functions as a health care safety net, but that role is in danger, warns Steven J. Davidson, MD, MBA, chair of the department of emergency medicine at Maimonides Medical Center in Brooklyn, NY.

"Through EMTALA [the Emergency Medical Treatment and Active Labor Act], ED care is an entitlement available to the entire U.S. population and all U.S. visitors," says Davidson. "For those without insurance or other means of obtaining care, they’re assured of at least a screening exam and stabilizing care. But the safety net is fraying."

According to a new report from the Washington, DC-based Institute of Medicine (IOM), America’s Health Care Safety Net: Intact but Endangered, rising numbers of uninsured patients, changes in Medicaid policies, and cutbacks in government subsidies are putting unprecedented pressure on EDs.1 (For details on how to order the report, see box, p. 104.)

A similar report issued by the Dallas-based American College for Emergency Physicians (ACEP) last year, Defending America’s Safety Net, echoes those concerns.2 (See box, p. 104.)

ED staff soon may be unable to care for the growing numbers of uninsured, says ACEP president Michael Rapp, MD, FACEP, an ED physician at Arlington (VA) Hospital. "This is especially true for the nation’s EDs, which are the most vital components of the nation’s safety net. The ED is the portal of entry for as many as three out of four uninsured patients admitted to U.S. hospitals."

The IOM report says the growth of Medicaid managed care, elimination of subsidies that help defray the costs uncompensated care, and a growing demand for charity care make it increasingly difficult for EDs to survive. Roughly one in five Americans is uninsured. Between 1988 and 1998, the number of uninsured increased by almost 20%, Rapp notes.

The IOM report recommends the creation of a new government body to monitor and assess the condition of safety net providers and to review the impact of federal and state policies on the system, he says.

A national prudent layperson standard for emergency medical services is needed, Rapp adds. ACEP will host a national conference this month to address the issue of the uninsured, he reports. (See "ACEP conference: Preserving the safety net," p. 103.) Rapp recommends a series of incremental reforms that don’t undermine employer-sponsored programs.

The ability to meet the needs of indigent patients is a cornerstone of emergency medicine, emphasizes Davidson. "Compassionate care of people regardless of their means is a personal, professional, and ethical credo for all I know and esteem who work in the ED."

A recent study showed that despite current econom-ic prosperity, poverty and hunger are commonplace among ED patients at the University of Minnesota in Minneapolis.3 "We found that our patients are often forced to make choices between buying food and buying prescription medications," says Margaret Kersey, MD, principal investigator. "Often, this directly leads to potentially preventable ED visits and hospital admissions." The study showed that lack of access to a reliable food source can have a direct and indirect impact on patient health, says Kersey. "Hunger and food insecurity should be routinely addressed as health care issues, particularly in the urban ED setting where they are likely to be very common."

Several studies have found that the populations most likely to use the ED for their primary care are often disenfranchised and need social services in other aspects of their lives, says Kersey.4-5 "Therefore, in some ways the ED is actually an ideal place for intervention," she says.

Although ED medical staff don’t have time or resources needed to evaluate the social service needs of every patient thoroughly, there are simple steps EDs can take, says Kersey. For example, screen patients about access to medical care, food, and safe shelter, she recommends. "This practice would catch many people who would otherwise fall through the cracks."

Although the short-term cost of increasing social services in the ED might seem high, the potential benefits could be substantial, she says. "There are both financial benefits and improvements to patient quality of life."


• Steven J. Davidson, MD, MBA, Department of Emergency Medicine, Maimonides Medical Center, 4802 10th Ave., Brooklyn, NY 11219. Phone: (718) 283-6030. Fax: (718) 283-6042. E-mail: davidson@

• Margaret Kersey, MD, University of Minnesota, Department of Pediatrics, MMC 391, 420 Delaware St. S.E., Minneapolis, MN 55455. Phone: (612) 624-4477. Fax: (612) 626-7042. E-mail:

• Michael Rapp, MD, FACEP, Arlington Hospital, 1701 N. George Mason Drive, Arlington, VA 22205-3698. Phone: (703) 558-6169. Fax: (703) 780-3129. E-mail:


1. American College of Emergency Physicians. Defending America’s Safety Net. Dallas; 1999.

2. Institute of Medicine Committee on the Changing Market, Managed Care, and the Future Viability of Safety Net Providers. America’s Safety Net: Intact but Endangered. Washington, DC: National Academy Press; 2000.

3. Kersey MA, Beran MS, McGovern PG, et al. The prevalence and effects of hunger in an emergency department patient population. Acad Emerg Med 1999; 6:1,109-1,114.

4. Baker DW, Stevens CD, Brook RH. Regular source of ambulatory care and medical care utilization by patients presenting to a public hospital emergency department. JAMA 1994: 271:1,909-1,912.

5. Pane GA, Farner MC, Salness KA. Health care access problems of medically indigent emergency department walk-in patients. Ann Emerg Med 1991; 20:730-738.