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

October 11, 1987|Brian D. Johnston | Brian D. Johnston is an emergency physician in Los Angeles.

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.

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