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On the Uninsured Patient

Fifteen percent of Americans lack health insurance, says the U.S. Census Bureau. That’s nearly 46 million people, and many millions more have only intermittent coverage. Uninsured patients receive fewer preventive services and are more likely to delay needed medical care; see Allison Diamant et al, “Delays and Unmet Need for Health Care Among Adult Primary Care Patients in a Restructured Urban Public Health System,” American Journal of Public Health 2004; vol. 94, pgs. 783–89, and Joseph Sudano and David W. Baker, “Intermittent Lack of Health Insurance Coverage and Use of Preventive Services,” American Journal of Public Health 2003; vol. 93: pgs. 130–37.

We provide de facto universal health care through our emergency departments (EDs), thanks to the 1986 law known as the Emergency Medical Treatment and Labor Act (EMTALA), which was intended to protect access to emergency medical services regardless of a patient’s ability to pay.

Because of EMTALA, and because of the absence of any other mandate to provide health care to all, EDs have become the first point of contact in the health care system for many of the uninsured. Many EDs are now overloaded with uninsured patients. Needless to say, the ED is an expensive and inefficient setting to treat the tens of millions of people who lack access to routine medical care; decision-making in the ED generally focuses on the patient’s most immediate problems. See Jonathan Glauser’s “Rationing and the Role of the Emergency Department as Society’s Safety Net,” Academic Emergency Medicine 2001, vol. 8, pgs. 1101–6.

The cost of caring for the uninsured is picked up by everyone else. Based on data compiled from several government databases, including the U.S. Census, health services researcher Kenneth E. Thorpe of Emory University and the advocacy organization Families USA estimate that $922 of the typical family health insurance premium in 2005 went to cover the cost of the uninsured (the average family paid $226 per month for health insurance that year). This cost is expected to rise to $1,502 per family by 2010. One-twelfth of health insurance fees paid by employers goes to fund care for the uninsured.

An intriguing argument about health inequality comes from Stephen Bezruchka, an emergency physician and epidemiologist at the University of Washington, who argues that inadequate nutrition, medical care, education, etc. do not fully account for health inequities, and that poverty itself can cause illness. See “The Status Syndrome: How Social Standing Affects Our Health and Longevity” in the New England Journal of Medicine 2005, vol. 352, pgs. 1159–60.

On Doctors and Health Reform

The role that physician professional organizations have played in shaping America’s health care system is documented in Paul Starr’s outstanding book, Social Transformation of American Medicine (Basic Books, 1982).

On Uncontrolled Growth in Health Care Costs

Richard A. Deyo and Donald L. Patrick write about our obsession with new technology and our rush to adopt these products without real proof of their efficacy in Hope or Hype: the Obsession with Medical Advances and the High Cost of False Promises, (AMACOM/American Management Association, 2005). Many health policy experts believe that this focus on medical technology and specialization has raised the cost of health care dramatically, and this has paradoxically worsened health outcomes.

In “Medical Care—Is More Always Better?” from the New England Journal of Medicine 2003, vol. 349, pgs. 1665–67, Elliot Fisher argues that more is not necessarily better, and in the U.S. more care often means worse health outcomes. He and his colleagues at Dartmouth, including John Wennberg, have shown convincingly that medical practices are influenced by regional factors as much as anything else. Their body of work is known as the Darthmouth Atlas of Health Care.

Health services researcher Kenneth E. Thorpe has found that nearly two-thirds of the rise in health care spending is caused by increased disease prevalence (meaning we spend money on potentially preventable conditions like diabetes, obesity, and heart disease), new technologies, and new patterns in diagnosis and treatment (we now prescribe medication for asymptomatic diseases). Health promotion may save money, he writes, but little research has been done on specific interventions. See “The Rise in Health Care Spending and What to Do About It.” Health Affairs 2005; vol. 24, pgs. 1436–45.

On the Business of Health Care

Joel Weissman’s “The Trouble with Uncompensated Hospital Care,” in the New England Journal of Medicine 2005; vol. 352: pgs. 1171–73, describes the tension between a hospital’s mission of charitable action and survival in a competitive marketplace.

R. Edward Freeman has advocated for what he calls “Stakeholder Theory,” under which corporations address the needs of all stakeholders, not just financial shareholders; see “Business Ethics and Health Care: A Stakeholder Perspective,” Health Care Management Review 2002; vol. 27: 52–65; Mattia J. Gilmartin is the lead author on this paper.

Two interesting scholarly works on the business of health care are Michael E. Porter and Elizabeth Olmsted Teisberg’s Redefining Health Care: Creating Value-Based Competition on Results (Harvard Business School Publishing, 2006) and Clayton Christensen’s Innovator’s Prescription: A Disruptive Solution for Health Care (McGraw-Hill, 2008). Christensen has written extensively about disruptive innovations, which are new services and products aimed at previously unrecognized markets. When disruptive innovations are adopted widely, as with Southwest Airlines’ low-cost airplane tickets, they can change not only who the customers are but how customers spend money. In Innovator’s Prescription Christensen turns this analysis on the health care industry.