Opinion: One ER doc’s take on what’s driving healthcare costs inexorably higher


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I received an e-mail this morning from Dr. Robert W. Robertson Jr., former director of emergency services at Western Baptist Hospital in Paducah, Ky., who now practices preventative medicine in that community. He was responding to one of my previous healthcare posts, and he gives the clearest explanation I’ve heard yet about why people with health insurance have a financial interest in extending coverage to the uninsured. He doesn’t get into the issue of illegal immigrants, so I’ll take that up in a later post. Besides, everyone else here is writing about Joe Wilson, so I’m feeling some pressure to do my part.

Dr. Robertson’s piece follows below.


-- Jon Healey

With the healthcare debate becoming more unruly and with people who are earnestly trying to address the situation being shouted down without having a chance to speak, I’d like to have those who are acting in such a strident manner make an effort to understand the reason that health care expenditures are on an unrelenting, accelerating, upward spiral, and why changes must be implemented.

It is a simple fact that it is the uninsured who are driving up the cost of healthcare for everyone.

Here are the facts.

In 2005, there were 44.8 million who had no medical insurance. In 2006, that number had grown to 47 million. Presently, it is estimated that there are 50 million who have no coverage, and that number will rise to over 52 million at the end of 2010.

As a former director of a hospital emergency department seeing over 50,000 patients annually, I am very aware of how the medical system works.

Anytime an uninsured person enters a hospital emergency department and registers in, the minute they cross the threshold, the hospital is mandated to (1) evaluate, and (2) make a disposition of the individual.


That disposition may be to: (1) reassure that no treatment is required; (2) provide appropriate treatment; (3) admit to the facility; or (4) make a referral.

If the hospital is unwilling to evaluate and make a disposition, it will lose reimbursement from Medicare and Medicaid programs, which is tantamount to financial suicide.

No matter what the ultimate disposition, the hospital incurs costs that are not reimbursed.

Hospitals have huge fixed costs which must be covered in order to operate the facility. Also, hospitals must have available resources to constantly be able to invest in new technologies in order to best provide service for those seeking care.

Thus is set in motion the unrelenting, upward spiral of ever-increasing medical costs.

  1. The uninsured numbers are constantly increasing.
  2. The unreimbursed expenses incurred by hospitals in treating those ever-increasing numbers of the uninsured are constantly increasing.
  3. Hospitals must increase their charges in order to cover the ever-increasing costs of treating the uninsured.
  4. Medical insurance companies must increase the premiums of those they insure in order to pay for the increased hospital charges when their insureds seek treatment.
  5. Each time insurance premiums increase, another portion of the population opts out of carrying insurance. Individuals or companies reach a point, finally, when they can no longer afford insurance, and individual policyholders or employees of companies which drop their benefits enter into the pool of the uninsured.
  6. More uninsured people = increased, unreimbursed hospital costs = increased hospital charges = increased insurance premiums = more uninsured people.... The upward spiral is incessant.

The pressure created by the ever-increasing number of the uninsured is the driving force behind the ever-increasing cost of medical care in the United States. That force is unrelenting. It can only accelerate. It has created a system which is unsustainable.

Other than refusing to offer treatment to those who are uninsured, there is no mathematical model which can be proposed that can slow or halt the inevitable, continuing rise in healthcare costs without removing the uninsured from the equation and including them in the system.


If we fail to address the underlying reason for the situation we find ourselves in, the ever-increasing numbers of the uninsured, the medical care delivery system, severely strained at present, will eventually break.

No rational person on either side of the aisle could want that to happen.

I would encourage people to enter into a civilized debate about healthcare in our country, all the while reminding them that each citizen has a responsibility to consider the consequences if we don’t take action before any action we may take is too little, and too late.

We simply must consider and include all of the uninsured into whatever plan is ultimately adopted. There is no other option available.

Those who simply shout down our elected officials who are attempting to rationally address our healthcare delivery crisis offer no solutions. Their actions are a disservice to each of us.

-- Robert W. Robertson Jr., M.D.