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Monday, December 7, 2009

missing the safety net

What if you graduated from high school, left home, got a job delivering pizza, and were critically injured in a motor vehicle accident?

What if you had a part time job at a big company, a house, a family and got cancer?

What if you lost your job and your 8 year old daughter got appendicitis?

In the United States there are systems that act as safety nets for situations such as these, but they are not self sufficient and are severely strained in their ability to provide services with the progressive loss in adequate insurance coverage, the floundering economy and the increasingly outrageous costs of various forms of medical care.

If you were the first guy, ejected from your Geo Metro when you were t-boned at an intersection by a drunk driver, you would be taken to an emergency room at any hospital, transported to a trauma center if necessary, and treated until you were on the mend by that hospital. If you were eligible for medicaid or medicare due to the severity of your disability the hospital would eventually be reimbursed for the cost of your care (at least partly), and if you were not eligible, the hospital would attempt to bill you and when you were unable to pay, would eat the cost, part of which would be tax deductible.

If you were the second guy, the doctors who treated you would do so with little hope of being paid, might bill you, and would eventually eat the costs. You might be able to apply for a county emergency payment program to pay for things like surgery and CT scans, but you would eventually be expected to repay these costs. You would apply for public assistance based on disability, but the process of being approved for it would be slow. Your savings would inevitably be used up. You might lose your house.

In the case of the child, we have guaranteed medical insurance available for children through the government, but you do need to apply for it. The child with appendicitis might die or have some other bad outcome due to delay in treatment from lack of insurance. In a perceived emergency, though, treatment through the local emergency room would be assured.

Much of the problem with American health care stems from the escalating costs associated with it. Yet many of these costs, especially those associated with procedures and tests, go to hospitals who are the basis of our safety nets. In cutting costs, it is going to be vital that we pay attention to making sure that hospitals stay solvent. Providing adequate universal insurance will be a project that takes time, probably years. It is this insurance that can support hospitals and allow them to continue to support the communities in which they operate.

An article in the New England Journal of Medicine (http://content.nejm.org/cgi/content/full/361/23/2201) addressed our safety net system, and just how fragile it is. Because some hospitals are located in areas of particularly acute economic and social disaster, they are simultaneously vitally important to a safety net and totally inadequately reimbursed. Allowing hospitals like that to go under threatens the whole fabric of the larger medical system.

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