Sunday, July 1, 2012

Affordable Health Care

As an Emergency Physician, I am concerned about the effects of the Affordable Care Act (ACA) on Utah.  I agree that we need affordable health care available to all citizens.  We also need better access for patients.  However, a couple of observations: 

First, Utah currently has about 13% uninsured patients.  Most of these patients have no regular physician.  Currently, due to the EMTALA laws, any person seeking emergency medical care must be seen and treated in the ED at any time without regard to their ability to pay.  This effectively provides a safety net for them.   However, the safety net can entrap patients:  the care is episodic and the patient is often discharged without a primary care doctor relationship.  It is not ideal. Further, ED care is the most expensive outpatient treatment available.  Pres. Obama noted that each ED bill exceeds a thousand dollars or more.  This is NOT affordable or sustainable health care. However, thousands of uninsured Utah patients utilize EDs each month, because they have nowhere else to go. 

Next, under the SCOTUS ruling Utah will choose if we embrace expansion of Medicaid  eligibility.  According to the Dept of Health, the Utah Medicaid expansion under the ACA will provide health insurance to 100,000 or more currently uninsured Utah patients.  This will provide much needed insurance and it will cost millions of tax dollars.  Further, currently Utah is already underserved in Primary care and many specialties.  We do not have enough physicians for our existing patient population.  Adding thousands more to the Medicaid insured pool of patients will further crowd existing clinics and systems.  As a result, Medicaid patients who according to State Medicaid officials already over utilize EDs, will increasingly seek care in EDs due to limited Primary care access. 

The SCOTUS ruling will also affect those currently with private insurance.  The popular provisions such as additional coverage of patients to age 26, elimination of pre-existing conditions, and other modifications has and will raise insurance premiums.  Many patients will opt to use higher deductibles, health savings accounts and other methods to keep their costs down.  In order to save money, these patients may not visit their physicians as much, and get sicker and then, end up in the ED with even more serious conditions. 

From the emergency medicine view, implementation of this far-reaching law will be complex and challenging.  Here are some solutions I propose for increasing affordable and timely medical care: 

Restore the existing University of Utah Medical school class size to at least one hundred students a year.  Cutting class size was short sighted and this needs to be remedied this coming year. While a longer term solution, it will keep more talented Utah college students here and provide for physicians in the future. 

Increase Utah Medicaid community clinic staffing with more same date and weekend appointments.  This will provide lower cost, timelier access for patients and decrease ED over utilization by Medicaid and other patients. Primary care physicians would lead teams of mid level providers, nurse practitioners, etc. to expand affordable access while ensuring quality of care. 

Use coordinated care counseling in the EDs to educate patients on preventative medical care and appropriate utilization, communication and continuity of care with their primary care physicians. 

Encourage insurers and hospitals to establish lower cost urgent care hospital clinics as an alternative to full emergency care. 

Expand community clinics for substance abuse and psychiatric counseling and care.  Currently, thousands of such patients are treated in EDs, each year, due to lack of outpatient facilities. These clinics would be more effective, lower cost resource for and an alternative to the EDs.  Further, the jails and corrections facilities could also use such clinics and decrease the recidivism rates of their inmates.   

In summary, we are in a crisis regarding health care and reform.  The SCOTUS interpretation of the ACA is both a threat and an opportunity.  How we deal with this will make all the difference. 


  1. I agree with some of your solutions to the physician crisis not only in family care, but with the added mental health component that requires mental health issues be covered like other illnesses, we will also be short on mental health professions. But your party seems determined to repeal the Affordable Care Act and at first by your post it seemed that because so many people who before couldn't afford health insurance and will now be able to that they shouldn't therefore be given the opportunity for coverage because we just don't have enough doctors for everyone. I was pleasantly surprised to see your answer was to increase students in medical school while also increasing accessibility of family care that doesn't involve the Emergency Room. I guess I have to ask, as a doctor, do you believe the ideal way to provide care and reduce cost is single payer (ie., Medicare for all)? Do you believe that the ACA (in spite of it's flaws such as the giveaway to PHARMA and health insurance companies)is preferable to the even more unsustainable path we were on if we had continued to do nothing. Myself, I am grateful that I can keep my daughter on my insurance until she is 26, that I never have to worry about pre-existing conditions and that should god-forbid something terrible happen, I don't have to worry about a cap on my benefits. So do you agree with the national platform of your party that repealing the ACA should be the first thing they do if elected? Do you believe it's better to have all our citizenry covered to spread the cost/risk and to control costs? Do you believe that no one who can afford health insurance should get to free-load off everyone else who does pay for health insurance and let hospitals cost-shift to cover them?

    Because other than that I agree with the way you suggest addressing the need. Is having for-profit health care really the way to go? Health care isn't like shopping for a car where you can shop around, or just decide to not buy if you aren't happy with price or amenities? Not when a loved one needs quadruple bypass surgery or has cancer. You don't want to shop around for the best deal. And only the wealthy shouldn't get the best doctors.

    As a physician I'm sure you've seen a lot and had to deal with insurance companies far more than you ever wanted to. I doubt that is what sent you to med school in the first place.

  2. I agree with many of the provisions of the ACA incl having coverage for adults to age 26, eliminating the pre existing conditions, increasing the medical loss ratios of insurance companies, etc.

    As an ED doctor I treat almost 20 per cent uninsured patients who often have no other place to go. So, the hospital then cost shifts the expense of the no pay patients to those with insurance. We all then end up paying higher bills. This is wrong on many levels. It is non sustainable.

    I am concerned about costs however, to us as a community and a state. To embrace the ACA, it is a huge law and even its authors concede that they are uncertain about the full final costs and impacts on our current medical care. They admit that it is not perfect. Further, this may require a tax increase with all of its consequences. Are we ready for this, as it would probably draw us closer to a Canadian and European system.

    One of the reasons I am running as a physician is to bring a perspective to the Senate about how to solve this and other big problems there.

    I welcome further thoughtful dialogue. I admit I do not have every answer but I am willing to work hard on this.