Will the ER doors close to the poor?

An emergency room nurse describes the problems at safety-net public hospitals in major cities–and the bigger crisis looming on the horizon as cutbacks continue.


Paramedics bring a patient to an Alameda County emergency room

WHAT DO you do when someone right in front of you is slowly being murdered for the sake of profit?

Part of his heart was dying, and the man fought back tears of frustration as the doctor told him he needed another surgery. The first heart attack had happened last winter. He had insurance through his job, and after a tube was placed to open the blocked vessel, he started taking half a dozen medications to maintain his health.

In his early 60s, he lived a healthy lifestyle, eating right and exercising, but he had no choice when it came to his family’s history of heart disease. He maintained his habit of biking daily, and it was during his rides that he noticed the pain in his chest that brought him back into the hospital.

He also had no choice about being laid off over the summer or about losing his insurance, and then running out of his medications.

As we quickly worked to prepare him for the immediate surgery, I thought of the countless times I’ve heard patients in the emergency room tell similar stories:

— “I have diabetes, and after my divorce, I lost the insurance I had through my husband, and now I can’t afford the medication.”

— “I fell off a ladder at work, went to the closest hospital, but they sent me here because they wanted $300 just to talk to a surgeon to fix my broken wrist, and my boss is refusing to pay because I’m supposedly an independent contractor.”

— “I have depression, my medicine was stolen from the shelter I stay at, and I’m thinking about stepping in front of a train.”

– – – – – – – – – – – – – – – –

THE MISSION of the hospital I work at is to “provide quality health care, regardless of [the patients’] ability to pay.” As a safety-net hospital, it serves people who literally have nowhere else to turn. In these economically hard times, with no clear end in sight, the funding of the few such institutions that do still exist in major metropolitan areas is even more critical.

In this light, the proposal to cut back on the government’s Medicare and Medicaid health care programs–likely to emerge from Barack Obama’s National Commission on Fiscal Responsibility and Reform, co-chaired by Erskine Bowles and Alan Simpson–would be disastrous.

At the hospital that I work at, of the over 771,000 outpatient visits in 2008, 29 percent of patients had either Medicare or Medicaid and 67 percent had no insurance, according to a report by the National Association of Public Hospitals and Health Systems (NAPHHS). Forty-six percent of the revenue came from Medicare and Medicaid reimbursements, and 53 percent came from state and local revenues.

As an August 2010 policy brief by the NAPHHS put it:

Since the beginning of the recession, public hospital systems that care for a disproportionate share of low-income patients have provided 17 percent more uncompensated care. These health systems have also treated 11 and 15 percent more uninsured and Medicaid patients, respectively. At a time when states are facing large budget shortfalls, continued federal assistance is critical.

The Center on Budget and Policy Priorities (CBPP) recently released its assessment of the outline for the deficit reduction commission produced by its co-chairs. On the Medicaid and Medicare spending cuts, Bowles and Simpson are proposing to increase the amounts that individuals who use these programs pay out of pocket. As if the people who need Medicare and Medicaid aren’t already being squeezed enough!

According to the CBPP, the cuts suggested by Bowles and Simpson “would mean that as the share of the population that is elderly increases, cuts of increasing severity likely would have to be made in Medicaid and Medicare to fit total federal health-care expenditures within an entirely unrealistic constraint. Over time, the effects on vulnerable Americans could be grim.”

Meanwhile, a study conducted by the Commonwealth Fund found that one in three Americans say that they have done without medical care or skipped filling a prescription because the cost to them was too high. This is in a country that spends far more than any other on health care per capita–and it’s before any proposed cuts to an already broken system.

During his time at the G20 summit in South Korea, Barack Obama responded to grumblings about the proposed cuts by insisting that “we’re going to have to make some tough choices.” From the man who chose to bail out Wall Street casino gamblers over people being evicted from their homes, these are empty words.

Far too many people are now making “some tough choices” between paying rent and paying for medication, between buying a bus card and buying food. We can’t let the political leaders of either party dictate what our choices are–because we don’t have to live this way.



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