The Universal Coverage Quagmire

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A specialty divided on the fundamental issues of healthcare insurance reform can finally agree on one thing: The time for change is now.

For Pamela V. Cutler, MD, choosing a career in emergency medicine was a no-brainer. The 52-year-old says she was instantly drawn to the idea of treating all sick people, regardless of their ability to pay.  “Where else can you find that but in emergency medicine?” says Cutler, who works for the five-hospital Lovelace Health System in Albuquerque, NM. For years, however, Cutler’s egalitarian zeal has been tested by the growing crisis over the uninsured, a crisis that has rekindled a national debate over universal health.
The debate over universal health has been intricately tied to the larger question of health care reform. Whereas in the past discussions have ultimately fizzled, this time, according to a growing body of physicians, they may actually get somewhere.
“Do I think reform has a good chance? Yes, absolutely,” says Randy Pilgrim, MD, president and chief medical officer of The Schumacher Group, a 1500-member contract management firm in Lafayette, LA. “It’s just a question of what direction that reform will take.”
EM physicians, like the rest of society, appear divided over exactly how to reform the current unbalanced system of health care. Presently, the battle lines are drawn between advocates for a national government-sponsored, single-payer program, and those who embrace public-private subsidies to stimulate broader insurance coverage.
At least three of the presidential candidates currently seeking the Democratic nomination have pushed their own version of reform while a handful of large health care organizations, including the American Medical Association (AMA), have also weighed in on the question.
For EM, the issue cuts close to the bone. “The current system is crumbling. It’s unsustainable, which is the reason that real reform now has a chance,” says James C. Mitchiner, MD, MPH, an EP with St. Joseph Mercy Hospital in Ann Arbor, MI.
The uninsured, which account for 20 to 40 percent of EM patient visits, have been linked to a host of logistical and financial problems. Financially, losses stemming from treating patients without insurance are stunning. They account for a growing number of department closures and hospital downsizingsthat have eroded services in many communities and kept hospitals in red ink. Meanwhile, the uninsured have been indelibly linked to the pandemic of department overcrowding, long waits, higher acuity, and reduced outcomes, which in turn have aggravated the financial crisis.
“There’s an urgency this time to reforming the current system that hasn’t been seen since the dawn of Medicare,” says Mitchener. “What’s different is that it’s no longer just the elderly and poor.”
According to Mitchiner, 64 percent of the newly uninsured in 2006 came from households with family incomes greater than $75,000. “The concern now is that middle-income Americans are worried that their health insurance won’t be there for them.” Meanwhile, providers are deeply concerned over the gap being created as primary and specialty care practitioners leave the medical profession each year. “The amount of paperwork and hours spent on claims adjudication is partly at fault,” says Mitchiner. But the real villain is managed care.
Mitchiner, who advocates a single-payer system, says it’s the only answer that makes sense. Most physicians, however, disagree. They stop short of embracing a single-payer plan out of concern that a government-funded system will kill incentives, create inefficiencies, and stymie free-market growth.
In August, the 250,000-member AMA issued a policy proposal that called for tax incentives to help finance the purchase of health insurance coverage for working Americans. Under the plan, employees who purchase coverage would receive tax credits in the form of year-end refunds to help defray the cost of premiums. The plan, however, effectively omits certain groups such as the unemployed, and caps the credit at $4,000.
“That’s not universal health,” says Todd B. Taylor, MD, former president of the Arizona chapter of the American College of Emergency Physicians. Taylor stops short of advocating a single-payer program, but he condemns public-private incentives such as tax credits as doomed to failure.
The tax-approach “is not new and fundamentally flawed,” says Taylor. “What do you do with those who don’t qualify for Medicaid or pay taxes?”
Instead of a universal system of care, Taylor called for the industry to clean its own house and fix what’s wrong with the current system. “Define how you fund, regulate, and litigate health care, and eventually you will define health care itself,” he said.
EPs like Cutler and Mitchiner disagree. Economically, a single-payer plan is the only one that makes sense, Cutler said. “We provide so much care that’s never paid for. Under a single-payer system, everyone would get paid every time.”
The nation already has a single-payer health system, said Mitchiner, referring to the Medicare program. “It works well. It’s popular, and it pays its bills 92 percent of the time.”
Mitchiner dismissed criticisms of Medicare by pointing out that skeptics should weigh Medicare against the current system of private health insurance. “Yes, I think docs are a little disappointed [with Medicare]. But they have to put that into relative terms. How disappointed are they with Medicare versus the reimbursement policies of private-sector health plans?”
Cutler stated that in all likelihood, a higher percentage of EPs would favor a single-payer universal plan than any other medical specialty. EPs, she said, see the problems caused by the uninsured close-up each day.
The American College of Emergency Physicians has yet to survey its members on the question. A spokesperson said only that “Our doctors believe all patients should have health insurance. But as to how that is brought about, they do not put forth any theories or suggestions.”
In January, ACEP joined with nine other physician associations, including the AMA, on eleven principles for health care reform. The principles called for insurance coverage for all but did not state how to do that. It also called for the removal of financial barriers to care and stipulated among other things “shared access to and financing for appropriate services in “a shared public/private cooperative effort.” The principles stopped short of advocating for a single-payer universal plan.
In one respect, EMTALA has unintentionally aggravated the uninsured problem, according to some EPs. Requiring that EDs provide care to all comers has exacerbated an already financially stressed situation.
“They mandate those things [under EMTALA]but don’t fund them,” says John Braden, MD, an EP in Florida. “Unfortunately, the system has eroded to the point that now we’re getting desperate.” Braden believes the crisis has put the nation on a path toward looking for a fix, no matter what form the answers take.
Meanwhile, Pilgrim of The Schumacher Group called for caution. Physicians, he said, can’t make educated decisions about health reform without understanding all the facts. And all the facts, he said, aren’t in yet. What matters most is whether either kind of reform will truly help. “It’s difficult to comment on just one element of a proposal without seeing how all the elements will ultimately work together,” he said. “How will the system work with Medicare? With Medicaid? What about undocumented alien funding? Employer-based funding? How will they be affected by a universal plan?”
At the moment, supporters of reform can’t really answer these questions, and neither can physicians. However, everyone believes the moment is ripe for change.

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