November 27, 2011
November 27, 2011 The Waitlist
A few weeks ago I was having breakfast with one of the senior physicians of the Cook County Health and Hospital System in Chicago. We were sitting in the wood-walled dining room of Rush University Medical Center the academic medical center where I work as Chief Medical Officer. As we breakfasted at the white linen clothed table, he spoke to me of the problems facing Chicago’s storied County public hospital and health system just down the street from where we sat. The chronic underfunding of this system and public health and safety net health systems around the country have led to wait lists for crucial clinical services. At any given time at the Chicago County Hospital there are four thousand people on the wait-list for diagnostic colonoscopies. These are patients with potential cancers or other serious conditions. The wait list for a prostate biopsy for a patient with suspected prostate cancer- one year. “The wait list for the eye-clinic is so long,” the physician said as he sipped his tea, “that you could go blind on the wait list!” The wait list for specialty care is emerging as one of the major problems in US health care. It contributes to premature morbidity and mortality and is likely to get worse with health reform. It’s a form of rationing that will not be fixed with the Affordable Care Act.
Wait lists for specialists are not just a Chicago phenomenon. Waitlists for crucial medical services have been reported across the United States. And this not just a problem for the 50 million uninsured individuals in the US, though they are the most affected by this. For patients on Medicaid and increasingly for patients on Medicare wait lists for critical services have become the norm. A recent study from the June 16, 2011 New England Journal of Medicine is one of the first to describe the extent of the problem. A researcher posing as a “secret shopper” called the offices of specialists in Chicago describing an imaginary child with an acute medical problem. The call to the orthopedic office for the child with a broken arm was emblematic of the problem facing those with the wrong insurance card. If the orthopedic office was told that the child had private insurance then over 90 percent received an appointment. But when the office was told the child had Medicaid, only 20 percent were offered an appointment and these appointments were delayed compared to those with private insurance. The rest were told to “go to County Hospital” where the wait list for critical orthopedic services exceeds that for the eye clinic. The reasons for this are straightforward. The orthopedic physicians get paid better from private insurers so they fill their slots with these patients.
In the 1980’s my colleagues and I described the phenomenon of “patient dumping.” Patients in need of emergency care who showed up in a private hospital’s ER were transferred to public hospitals because they had no insurance. A significant number of patients we studied were critically ill or died from their medical conditions. Our work led Congress to pass the Emergency Medical Treatment and Labor Act in 1986 and patient dumping of emergency patients was ended. But dumping never really ended. Hospitals and doctors offices closed in many impoverished neighborhoods leaving few options. As patients present in increasing numbers to emergency rooms for their routine care, emergency medicine doctors have few options when the patient needs follow-up clinical care. In cities like Chicago, NY, Atlanta and LA these patients are sent to join wait lists at the public hospitals. And the situation will likely get worse with the Affordable Care Act.
The Institute of Medicine recently released a frame work for defining “Essential Health Benefits” under the Affordable Care Act. But what good are essential benefits if the physicians who provide the care are unavailable. Health reform will test access to specialty care in the US. Health reform promises two major changes: the expansion of Medicaid and the new health exchanges. Both of these reforms will exacerbate the waitlist problem even while covering more people. Because most specialists in the US do not take Medicaid, Medicaid expansion will give people cards with limited access. The health exchanges will offer little relief as well. The health exchanges have four tiers, platinum, gold, silver and bronze. The bronze and silver options on the health exchanges will likely be lower paying managed care plans which will cater to lower income Americans. Since not all specialists are enrolled in all plans, this will likely limit specialty access of patients holding these bronze and silver policies as well.
Waitlists like the ones at the County Health and Hospital System in Chicago and elsewhere will be with us into the future without real health reform that aims at providing equality in care, not just expansion of insurance cards that cannot buy the care the cardholder needs. The only way to provide equal access to all is with a health care system that provides the same card to everybody. Only with a single payer system, Medicare for All that allows for equal access for all patients and equal pay for specialists, can we hope to end the wait lists for crucial services that the poor and underinsured face.