Lindsey Woodworth of the National Interest recently noted that the wait times in emergency rooms are so out of control that researchers recently tested whether aromatherapy would make waiting in the ER more tolerable.

It didn’t.

Over a decade ago, the Institute of Medicine offered an ominous warning: “Underneath the surface, a national crisis in emergency care has been brewing and is now beginning to come into full view.”

Now the view is quite clear. ERs are packed and wait times are growing longer each year. In fact, even if you’re having a heart attack, you may have to wait to get to the doctor.

The problem is, patients get sicker the longer they wait.

Oh, by the way, sicker patients cost more to care for.

I am an economist at the University of South Carolina. In a new study, I analyzed how ER wait times affect health care costs. I found that a 10-minute increase in ER wait time among the most critical patients will increase the hospital’s cost to care for the patient by an average of 6%. Some critical patients are currently waiting close to an hour, according to my study.

Costs grow a little more slowly among patients who begin their wait in a better condition.

An intriguing relationship

Health care costs are an issue of national concern. Presidential candidates have focused on health care reform as a major issue in the 2020 presidential election.

One complication in lowering health care costs, however, is that reductions in health care spending could compromise patient outcomes – spend less on health care, and you might very well jeopardize health.

Yet, this is exactly what makes the finding that ER wait times exacerbate costs so intriguing. It suggests that targeting ER wait times could both improve patient outcomes and lower the cost of care. A double win like this hardly ever occurs in health care.

Longer wait = higher costs

One major challenge in measuring the effect of ER wait times on costs is that ERs prioritize sicker patients. This means that relatively healthy patients have longer waits. The sickest patient in the ER will always get treated first. A lot of resources will probably get poured into this patient, making his costs quite high. On the other hand, a patient who arrives at the ER with a splinter will wait in the ER for hours. Treating this patient will be super cheap.

This creates a persistent correlation between long waits and low costs. On the surface, this correlation can deceptively send the signal that longer ER wait times reduce health care costs.

To uncover the real effect of ER wait times on costs, I needed to use a “trick” in my research to untangle the mess. The “trick” I used was to leverage something in the ER that slightly bumps patients’ wait times but has nothing to do with their health at their time of arrival. Triage nurses provided the answer.

These nurses are the people who determine the order in which patients are seen. Yet, because triage nurses are not robots, they sometimes differ in terms of their judgments. This means that some triage nurses are “tougher” than others – at least “tougher” in the sense that they’ll look at a problem and not see it as quite so urgent. This causes their patients to have longer wait times, on average.

It is effectively a coin toss whether a patient will get a tough triage nurse, so the patients who get a tough triage nurse look remarkably similar to the patients who do not, in terms of their health at arrival. Yet, the patients who get a tough triage nurse have to wait in the ER longer.

The study revealed that the patients who had longer wait times only because they coincidentally got a tough triage nurse had higher health care costs by the end of their visits. In other words, longer ER wait times cause health care costs to go up.

Why? It seems that patients’ health deteriorates the longer they wait. Therefore, by the time they get to the doctor, it takes more resources to get their health up to speed.

What’s the treatment?

How might ER wait times be reduced and costs lowered?

Fixing ER wait times will require taking a step out of the emergency room and looking at the whole health care system.

Drs. Arthur L. Kellermann and Ricardo Martinez recently wrote in The New England Journal of Medicine: “The quickest way to assess the strength of a community’s public health, primary care, and hospital systems is to spend a few hours in the emergency department.”

ER overcrowding often occurs when people are blocked from care elsewhere. For instance, when people with Medicaid are unable to find primary care physicians who accept their insurance, they often resort to ERs instead.

Another contributor to ER overcrowding is a recent shift in how patients are admitted to hospitals. It used to be that primary care physicians directly admitted their sick patients to the hospital if inpatient care was required. Now, many first recommend that their patients go first to the emergency room.

Inpatient wards inside hospitals can also contribute to ER overcrowding. Often inpatient wards get filled with high-paying, elective-case patients. These patients take up valuable bed space, leaving little room for ER patients who need to be hospitalized. As a result, the ER patients who have already been seen by the ER doctor end up staying in the ER waiting for an inpatient bed to become available. This practice of “ER boarding” generates a log jam inside the emergency room. Patient volumes balloon and the overcrowding prolongs all patients’ waits.

Growth in ER wait times shows no sign of slowing. Therefore, policymakers should consider system-level changes that would take the pressure off of ERs. It is time to turn the tide on ER wait times given their impact on both patient outcomes and the overall cost of care.

Why Most Americans Can’t Afford to Get Sick

Simon F. Haeder reviewed the financial costs of health care finding that Americans are being bankrupted by the costs of providing health care. Medical bankruptcy has been a talking point for many Democratic candidates as they make their individual cases for health care reform. This begs a few questions about how widespread these bankruptcies are and what causes them.

1. How big a problem is medical bankruptcy?

Medical bankruptcy, which refers to situations where individuals were forced into bankruptcy because of medical bills, loss of income due to sickness or accident, or both, is widespread in the U.S.

While the exact contribution of medical bills to the number of bankruptcies is difficult to determine, one important study prior to the Affordable Care Act found that medical debt was the single biggest contributor to bankruptcies for well over 60% of Americans. Even today, while the overall number of bankruptcies has been cut in half over the last decade to roughly 750,000 in 2018, a recent study indicated that two-thirds of bankruptcies are connected to medical bills.

It is interesting to note that the concept of medical bankruptcy is entirely alien to Europeans.

2. How did the Affordable Care Act help?

Individuals have gained coverage via the Medicaid expansion, their parents’ insurance or the insurance marketplaces. Moreover, other ACA insurance regulations have added protections for all Americans with insurance.

3. Who’s still vulnerable?

Close to 30 million Americans remain uninsured. While a significant number are eligible for varying degrees of public support, the refusal by many states to expand their Medicaid programs creates challenges. It is important to note that while the ACA expanded coverage to millions, it did little to reign in the biggest contributor to medical bankruptcy: high medical costs.

Even Americans with insurance are not immune to the specter of medical bills. While the ACA limited deductibles and out-of-pocket payments, many insurance plans still require consumers to pay tens of thousands of dollars annually.

Similarly, many Americans may incur bills ranging in the hundreds of thousands of dollars from so-called surprise bills. Inaccurate provider directories can compound these problems, misleading patients to believe they seek care from a provider in their network.

Finally, evidence from ACA and commercial plans, as well as Medicare Advantage, has highlighted problems with regard to “artificial local provider deserts,” situations in which providers are located in the area but excluded from the network. These situations might force patients into seeking costly out-of-network carefully aware of the potential financial consequences.

4. How do concerns about medical costs affect Americans beyond medical bankruptcy?

Half of Americans have less than US$1,000 in savings. This lack of financial security has implications for how Americans access medical care. A study found that costs have kept 64% of Americans from seeking medical care. Millions of Americans are skipping their medications for the same reason. Avoiding needed medical care often has implications for people’s health and well-being. Of course, it may also ultimately force them to seek care in more expensive settings, like emergency departments or at advanced stages of the disease.

New medical bankruptcy study: Two-thirds of filers cite illness and medical bills as contributors to financial ruin

Physicians for a National Health Program looked at the contributors to financial ruin and found that medical problems contributed to 66.5% of all bankruptcies, a figure that is virtually unchanged since before the passage of the Affordable Care Act (ACA), according to a study published yesterday as an editorial in the American Journal of Public Health. The findings indicate that 530,000 families suffer bankruptcies each year that are linked to illness or medical bills.

The study carried out by a team of two doctors, two lawyers, and a sociologist from the Consumer Bankruptcy Project (CBP), surveyed a random sample of 910 Americans who filed for personal bankruptcy between 2013 and 2016, and abstracted the court records of their bankruptcy filings. The study, which is one component of the CBP’s ongoing bankruptcy research, provides the only national data on medical contributors to bankruptcy since the 2010 passage of the ACA. Bankruptcy debtors reported that medical bills contributed to 58.5% of bankruptcies, while illness-related income loss contributed to 44.3%; many debtors cited both of these medical issues.

These figures are similar to findings from the CBP’s medical bankruptcy surveys in 2001 and 2007, which were authored by three researchers in the current study (Himmelstein, Thorne, and Woolhandler), and then-Harvard law professor Elizabeth Warren. As in those earlier studies, many debtors cited multiple contributors to their financial woes.

The current study found no evidence that the ACA reduced the proportion of bankruptcies driven by medical problems: 65.5% of debtors cited a medical contributor to their bankruptcy in the period prior to the ACA’s implementation as compared to 67.5% in the three years after the law came into effect. The responses also did not differ depending on whether the respondent resided in a state that had accepted ACA’s Medicaid expansion. The researchers noted that bankruptcy is most common among middle-class Americans, who have faced increasing copayments and deductibles in recent years despite the ACA. The poor, who were most helped by the ACA, less frequently seek formal bankruptcy relief because they have few assets (such as a home) to protect and face particular difficulty in securing the legal help needed to navigate formal bankruptcy proceedings.

Relative to other bankruptcy filers, people who identified a medical contributor were in worse health and were two to three times more likely to skip needed medical care and medications.

Dr. David Himmelstein, the lead author of the study, a Distinguished Professor at the City University of New York’s (CUNY) Hunter College and Lecturer at Harvard Medical School commented: “Unless you’re Bill Gates, you’re just one serious illness away from bankruptcy. For middle-class Americans, health insurance offers little protection. Most of us have policies with so many loopholes, co-payments, and deductibles that illness can put you in the poorhouse. And even the best job-based health insurance often vanishes when prolonged illness causes job loss—just when families need it most. Private health insurance is a defective product, akin to an umbrella that melts in the rain.”

In the article, the authors note that “medical bills frequently cause financial hardship, and the U.S. Consumer Financial Protection Bureau reported that they were by far the most common cause of unpaid bills sent to collection agencies in 2014, accounting for more than half of all such debts.”

The study’s senior author Dr. Steffie Woolhandler, an internist in the South Bronx, Distinguished Professor at CUNY/Hunter College and Lecturer in Medicine at Harvard commented: “The ACA was a step forward, but 29 million remain uncovered, and the epidemic of under-insurance is out of control. We need to move ahead from the ACA to a single-payer, Medicare for All system that assures first-dollar coverage for everyone. But the Trump administration and Republicans in several states are taking us in reverse: cutting Medicaid, threatening to gut protections for the more than 61 million Americans with pre-existing conditions, and allowing insurers to peddle stripped-down policies that offer no real protection.”

Study co-author Robert M. Lawless, the Max L. Rowe Professor of Law at the University of Illinois College of Law noted: “In the Supreme Court’s words, bankruptcy is a fresh start for the ‘honest but unfortunate debtor.’ Our study shows that for many bankruptcy debtors, the misfortune continues to come from the way we pay for health care. Bankruptcy may provide a fresh start, but it comes at a high financial and emotional cost for those who file. Filing for bankruptcy can stop the financial bleeding that the health care system imposes, but curing that system’s ills is the only lasting solution.”

Health insurance is becoming more unaffordable for Americans

Megan Henny of FOX Business pointed out that Americans who receive health insurance through their employers are finding it increasingly unaffordable, as out-of-pocket costs continue to outpace wage growth, according to a new study.

Over the past decade, the combined cost of premiums and deductibles grew quicker than the median income in every single state, according to a study released Thursday by the Commonwealth Fund, a New York-based nonprofit that advocates for expanded health insurance coverage.

Last year, on average, middle-income workers spent 6.8 percent of their income on employer premium contributions, or fixed costs they pay every month. Deductibles, which you pay before your health insurance kicks in, accounted for 4.7 percent of median income on average.

That number is even higher in some states, however. In nine states — Arkansas, Florida, Georgia, Louisiana, Mississippi, Nevada, New Mexico, North Carolina, and Texas — premium contributions accounted for 8 percent or more of median income, reaching a high of 10 percent in Louisiana.

In Louisiana, on average, employees pay more than $5,000 in premiums. The state’s median household income is $46,145.

Workers in the majority of states put between 6 to 8 percent of median household income toward premiums, although in thirteen states — Alaska, Washington, Utah, Colorado, North Dakota, Iowa, Wisconsin, Michigan, Indiana, Maryland, Massachusetts, and New Hampshire — workers paid as little as 4.1 percent.

Worse for workers is that despite the high premiums, they’re still “potentially exposed to high out-of-pocket costs because of large deductibles,” the study said.

Last year, the average deductible for single-person coverage plans was $1,846, with average deductibles ranging from $1,308 in Washington, D.C., to $2,447 in Maine. Across the country, average deductibles compared to median income were more than 5 percent in 18 states, but ranged as high as 6.7 percent in Mississippi.

In 2018, the combined cost of premiums and deductibles exceeded 10 percent of median income in 42 states, compared to seven states in 2008. That means people could spend more than 16 percent of their incomes on premiums and deductibles in Mississippi, which has the second-lowest median income in the U.S., compared to an average cost burden of 8.4 percent in Massachusetts, which has a median income among the nation’s highest.

“Higher costs for insurance and health care have consequences,” the study said. “People with low and moderate incomes may decide to go without insurance if it competes with other critical living expenses like housing and food.”

So, in the midst of all this discussion of Medicare for All and modifications of the Affordable Care Act/ Obamacare the question is, is a single-payer health care system the answer and how is it created, managed and financed?