Everyone should know by now that over 47 million Americans were uninsured in 2012. As a medical student, I knew that this well-known statistic contributes to healthcare costs, but my experiences during residency has opened my eyes to exactly how.
First off, insurance companies generally work with hospital systems and standalone practices (which are becoming less common over time), to predetermine rates for the provision of medical care. For being included in a insurance company's list of "in-network" providers, these hospitals provide discounted rates for a given healthcare commodity. This benefits both parties, as hospitals get preferred access to the patients on the insurer's books, while insurer's pay discounted rates for their customers' care. Patients would also obviously benefit from lower costs, as this may mean lower deductibles and copays.
Therefore, when an uninsured individuals goes to an Emergency Room and gets admitted to the hospital, they receive bills that are significantly higher than they would if they had been insured. This is especially more difficult at the lower end of the socioeconomic spectrum: about 38% of the uninsured include people under the Federal poverty line. The average cost of a hospitalization in 2010 was almost $10,000. The average night spent in the hospital in the United States is over $1,500, but this number varies widely from state to state and in different types of hospitals. Imagine the impact of such a bill for a family making less than $23,050 who do not have health insurance! This highlights the potential cost-saving benefits to individuals and the system as a whole of expanding coverage, whether it is with an individual mandate or not.
Working in the ER early in my first year of residency revealed some of the implications of the Emergency Medical Treatment & Labor Act (EMTALA). EMTALA was passed in 1986 by Congress with good intentions: any person that requires emergency medical treatment can receive it at any ER without any questions asked about their ability to pay for care. First of all, physicians should ideally never consider a patient's socioeconomic status and ability to pay for care. However, from a cost perspective, the impact of this law has been atrocious - millions of people who do not have insurance have utilized the ER for all of their healthcare needs. The practice of defensive medicine in the ER alone has served to amplify the effects of millions of people using the ER as their primary care physician for even trivial chief complaints and medical conditions (more on this later). Hospitals often have to front these costs; about 55% of the costs of caring for the uninsured are not reimbursed.
How can we overcome this challenge? First of all, more people need to be covered with some type of insurance plan. This is the goal of the individual mandate that has caused so much political controversy. However, from a cost modeling standpoint, if more healthy, young, otherwise uninsured individuals join the market, it should spread the risks undertaken by insurance companies now obligated to cover people with pre-existing illnesses. Unfortunately, at this point in time, enrollment of these healthy individuals is far below what is needed to make this feasible. It is believed that the penalty of failure to enroll is too low to incentivize enough individuals to sign up.
Certain populations, especially those in less wealthy parts of the country and in big cities, will still have plenty of uninsured patients even after broader implementation of the individual mandate. Therefore, whenever an uninsured patient has an interaction with the healthcare system, whether it be in the ER, the clinic, or the inpatient setting, every effort should be made to encourage and assist patients in seeking out an insurance plans; this is where case managers can potentially make a huge impact. Hospitals benefit from this too - the reimbursement for a future hospitalization for a patient at high-risk for readmission (such as one with CHF or COPD, for example) will be higher if that patient presents with insurance.
There have been been instances during my training where I have seen patients have longer hospital stays because they have no health insurance. For example, if a patient presents with something as life threatening as a blood clot in the lung, known as a pulmonary embolism, and this patient cannot afford an outpatient anticoagulation regimen that could hasten discharge (bridging with Lovenox), then as physicians, we are obligated to keep the patient in the hospital to bridge with heparin. Situations like this still happen frequently, but I hope the incidence drops over the next few years.
The ACA applies to US citizens as well as naturalized citizens, but does not apply to undocumented immigrants. Almost 20% of the 47 million uninsured are undocumented. This is a travesty, as many of these patients also utilize the ER, and are essentially left out of the healthcare overhaul. Furthermore, these individuals often suffer from the same chronic illnesses (heart disease, diabetes, obesity) that cost our healthcare system billions of dollars. When they present to the emergency room for care, it is often because of the catastrophic consequences of these illnesses (myocardial infarctions, strokes, etc.) that add significantly to cost and negatively affect the balance sheets of hospitals. I have taken care of plenty of such patients. Ideally, we should allow undocumented immigrants to purchase health insurance from exchanges - but that would be politically tricky, as people against immigration reform would consider this legitimization of what they consider their "illegal" status. I hope that the immigration reforms currently being consider in Congress considers the provision of health care to undocumented immigrants, since addressing this issue is something both sides of the aisle can agree on - cutting the cost of healthcare overall.
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