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Where's the big healthcare emergency? In the ER

The deteriorating condition of the system and its patients cries out for reform.

August 22, 2009|Brian Johnston | Brian Johnston is the chief of emergency services at White Memorial Medical and Center.

The paramedics bring in a 47-year-old laborer, a father of four, with untreated high blood pressure, dying of a cerebral hemorrhage. A woman in her 40s enters the ER complaining of feeling "lousy," unaware that her blood pressure is extremely high and that her kidneys are destroyed. She goes on dialysis and disability. An elderly widow is brought in severely dehydrated and comatose, with a blood sugar level over 800. Medi-Cal had switched her to a "share of cost" program, which forced her to choose between paying her rent or taking her medicine. She'd chosen to pay the rent.

These are all patients I have seen in my ER in recent weeks. I have practiced emergency medicine in Los Angeles for 36 years and have witnessed a steady decline in system capacity as hospitals, county clinics and ERs have closed, even as our population has grown. People needing treatment arrive in far worse condition than before. Larger numbers of uninsured people and those whose managed-care facilities limit their access now come to the ER, which is the only option left to them. We see people suffering from preventable complications of treatable diseases. ERs are so crowded that patients aren't seen as quickly as they should be, and some even leave before they're seen by a physician.

In June, the L.A. County Department of Public Health published its biannual report analyzing healthcare in the county. The report shows that people have become poorer, with the percentage of households with children and living below the federal poverty level rising from 28.5% in 1997 to 36.8% in 2007. In L.A. County as a whole, 22% of people 18 to 64 years old had no health insurance. But in two poorer parts of the county, that percentage rose to 31.4% and 32.9%, and 13.7% and 18.7% of adults, respectively, could not afford to fill their prescriptions.

Poverty and lack of access to care affect the outcome of disease. The diabetes death rate per 100,000 people is 24.6 nationally, but 43.5 in the Antelope Valley and 37.9 in South L.A. The coronary heart disease death rate per 100,000 is 153.9 nationally, but it's 205.2 in the Antelope Valley and 217.6 in South L.A. The combined percentage of adults who have either diabetes or hypertension or are obese rose from 35.8% in 1997 to 55.6% in 2007. Based on the last finding, we can expect strokes, heart attacks and kidney failure to place increasing strain on our healthcare system.

We have a system incapable of meeting our basic needs. It all comes together in the ERs, where the rich and poor, insured and uninsured meet and are treated based on need, not net worth, and where all must wait.

While folks in Washington are arguing about the cost of basic care, they ignore the cost of delay, and some lack the sense of urgency that a closer look at our system would provide.

The latest budget negotiations in Sacramento cut healthcare by more than $1 billion, making more than 400,000 low-income children ineligible for coverage. L.A. County government, which runs the hospitals and clinics, was cut a mere $5 million, according to the county Department of Health Services, but that comes on top of a $24-million cut last year and adds more stringent eligibility requirements.

We need healthcare reform, and we need it now. People in L.A. are at greater risk and need improved access to basic care sooner. We need definitive action in Washington, and we need Sacramento to restore its recent cuts and then increase funding for healthcare significantly. We have spent trillions of dollars on wars, on tax cuts and on bailouts. We should be willing to spend what's needed to make our own people healthy and productive.

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