As More Poor Get Less Medical Aid, Health Care Takes a Turn for the Worst

Los Angeles is quietly, thoughtlessly drifting toward a crisis in emergency medical services and health care in general. The principal reason is a simple failure to recognize and address the inescapable need to care for the medically indigent--a group that contains the homeless, illegal immigrants and the unemployed, and more recently many of the working poor, formerly insured workers who have surrendered health-care coverage.

Without fanfare, the numbers of medically indigent patients have increased significantly, while the resources available to take care of them have diminished. The result has been to shift a disproportionate burden on the most conscientious physicians and hospitals in the community. To an unreasonable and increasing degree they are being asked to donate their services, and the crisis is emerging as more and more of them finally conclude they can no longer afford to care for these admittedly deserving patients. Hospitals and doctors will take actions to limit their exposure to emergency patients of all types, thus relieving themselves of the risk and burden of caring for the unfunded. These decisions, in aggregate, will weaken and perhaps destroy our emergency medical system.

For many years, emergency services have depended to a significant degree on care provided by private doctors and hospitals. They have cared for rich and poor alike, admitting to their care those patients too critically ill or injured to be safely transferred, providing an excellent level of care regardless of the patient’s ability to pay. The system has worked reasonably well because the number of indigents in critical condition has been relatively small, the hospitals and doctors have made enough money on their paying patients to sustain the losses incurred caring for the poor and because they honored the principle that society and medicine had an ethical obligation to treat the poor.

What then has happened to bring the future functioning of this system into question?

-- The number of medically indigent has increased significantly. An estimated 37 million Americans have no health insurance, and an additional 15 million have grossly inadequate coverage. A recent study by the School of Public Health at UCLA estimates that 20% of the population of California and 26% of the population of Los Angeles are uninsured.

-- Hospitals are under serious financial pressures. Private insurance, state and federal programs have worked effectively to reduce hospital utilization--and to reduce payment to the hospitals for services rendered. Private insurers and the government now negotiate fixed rates per day or per diagnosis with the hospitals. The negotiated rates allow little of the excess that in the past was available to subsidize the care of the poor.

Since 1983, 15 hospitals in the Los Angeles area, principally in the poorer parts of town, have closed. The remaining hospitals in those areas are under significant economic pressure. Several Los Angeles hospitals recently made news by dropping out of the trauma system for economic reasons. Unnoticed, several other similarly located hospitals dropped their applications to serve as trauma centers, fearing they would sustain catastrophic losses caring for the uninsured and untransferable.

-- Physicians caring for indigents feel the cost personally and directly. Those donating services still have the same overhead expense and malpractice risk, with no offsetting income. Obviously, time spent caring for the needy comes at the expense of caring for paying patients. For a practicing physician, one critically injured indigent patient can absorb a significant fraction of available practice hours.

-- Government, at all levels, is refusing to fund care for the needy and those on entitlement programs. The Reagan Administration, unwilling to raise taxes, is threatened by huge budget deficits that even the Gramm-Rudman-Hollings deficit-reduction legislation is unable to erase. State government is limited by the Gann amendment. Gov. George Deukmejian, judging from his recent decisions on Medi-Cal, seems to be philosophically opposed to providing adequate health care for the poor. California currently funds the Medi-Cal program at a level lower than 46 of the 50 states, even though California has a larger tax base, is more affluent and has a higher cost of living than other states funding corresponding programs.

The end result is that county government receives increasing numbers of medically indigent--people who, by law, must be cared for--with inadequate and diminishing resources. To date, local, state and federal governments have not responded to this problem, except to make transfer of patients from private hospitals increasingly difficult.

Government, without explicitly stating its case or consulting with constituents, has altered a long-standing public policy of caring for the poor. It has declared large numbers of the poor (illegal aliens fall into this category) ineligible for care. It has imposed arbitrary and nonsensical rules that result in retroactive denial of payment for services already provided by doctors and hospitals. It has transferred patients from Medi-Cal and Medicare to prepaid plans that profit by restricting services. These actions have increased the amount of uncompensated care.

In March and April of this year, a joint study by the Hospital Council of Southern California and the Los Angeles County Medical Assn. documented $5.4 million in uncompensated care costs in Los Angeles County provided by private hospitals and $1.4 million provided by emergency physicians in one month’s time--apart from the cost of uncompensated care provided to inpatients by internists, family practitioners, obstetricians, surgeons and surgical specialists. Most of the loss is borne by a few hospitals surrounding urban poverty zones.

In this situation, the logical solution from the hospital administrator’s point of view is very simple: Close the emergency department. Close the one door through which the uninsured enter. Granted, there may be a public outcry, but if the survival of the hospital is truly threatened by enforced care of medical indigents, the hospital administrator would be delinquent not to consider closing his emergency department. Furthermore, the hospital may be able to recapture the insured emergency patients by replacing its emergency room with an urgent-care center or ambulatory center not required to see the poor.

Physicians also have the option of dropping out of the system; they will exercise that option more frequently when called on more often to take medical and legal responsibility for critically ill and injured patients whom they cannot transfer, even when stable. In the joint hospital council-medical association study, more than 67% of the responding emergency departments reported increasing difficulty maintaining a panel of physicians on call. As they come to realize that the increased demand represents a decision by society and government not to meet an obligation to the indigent, physicians feel abused; they are shifting practices to hospitals without emergency rooms or relying on non-hospital-based outpatient practice. From the perspective of the emergency medical system, they are simply disappearing.

If these doctors cease to be counted and hospitals in poor areas close their emergency rooms, what happens to patients? Where will the ill, the injured, the dying or the merely frightened go? They will go to the remaining open hospitals.

Based upon current experience, there will be large “holes” in the paramedic system centered around the poorer parts of town. Local trauma-center closures have followed this pattern and it is logical to expect emergency-department closures resulting from the same forces to do likewise. There will be prolonged ambulance transport times and delays in hospital care as paramedics bypass closed emergency rooms to get to areas that still have open departments. They will carry the medically indigent from the poorer parts of the city, threatening to destabilize hospitals and emergency departments currently not overburdened by non-paying patients. Paramedic service in more affluent areas will be adversely affected as paramedic units move to cover underserved areas.

What can be done to prevent this from happening? The answer, in simplest terms, lies in providing health-care dollars for those currently not covered. There are many forms that support can take:

--Keep our current system, but fund it adequately.

--Increase the capacity of our public hospitals, or close them entirely and use a system like the one well-received in Orange County, where there is no county hospital--physicians and hospitals caring for indigent patients are reimbursed by the county.

--Make health insurance a mandatory benefit of employment.

--Socialize medicine, as England has done, and make all hospitals public and all doctors government employees.

--Adopt Canada’s system, where hospital costs are tax-funded.

We can, in fact, devise any number of solutions depending upon our society’s values and resources, but we must recognize that the decision is both political and ethical and that no system will work unless it is adequately funded to meet the standard of care that Americans, as a society, demand.