The Decline of Emergency Care

The news isn't any better for emergency departments. In a 2011 paper in Journal of the American Medical Association, Hsia, Shen, and Arthur Kellerman discussed factors behind emergency department closure nationally. Again, they found a higher risk of closure for departments that serve communities of uninsured patients, patients in poverty, and minorities. When Hsia and colleagues studied this association on the regional level in California, they reproduced the results.

What they found is disturbing. For every increase of 0.1 in the proportion of African Americans treated, the risk of emergency department closure went up 41 percent. Published in the Annals of Emergency Medicine, this result and others confirm what they've found before. When hospitals admitted more Medi-Cal patients (the California Medicaid program), or were for-profit, their emergency departments were also more likely to close.

The populations associated with greater closure are the populations that need these services the most. Medicaid patients are more likely to use the emergency department than privately insured patients. But, contrary to conventional wisdom, these visits aren't routine. A Center for Studying Health System Change research brief shows that Medicaid patients are three times more likely than privately insured patients to visit for complex or disabling needs. Sometimes there's no other choice. In a study of physicians who accepted new patients in 2011, 31 percent were unwilling to accept new Medicaid patients.

We also know that African Americans tend to use emergency departments at twice the rate of whites and Hispanics. This difference is the product of other racial disparities in health care, especially insurance coverage. In 2010, 21 percent of African Americans relied on Medicaid programs. Nearly a quarter did not have employer-sponsored health insurance. And nearly one in five African Americans under the age of 65 are without insurance entirely. This is also the product of income disparities. By 2010, African Americans lived below the poverty level at nearly three times the rate of whites. These factors together help explain why African Americans are more likely to lack access to primary care specialists -- and why they tend to rely on emergency departments.

This is why emergency departments are sometimes called the "safety net" of the health care system. What happens when the safety net moves farther and farther away from the people it's supposed to catch?

When resources and the people who need them are located in two separate places, sociologists call this a "spatial mismatch." Here's one example: In his 1987 book, The Truly Disadvantaged: The Inner City, the Underclass, and Public Policy, sociologist William Julius Wilson argues that spatial mismatch helps explain the concentration of urban black poverty, especially in the 1970s. Here's the idea: When manufacturing in cities declined, jobs moved to the suburbs. When they moved to the suburbs, they separated urban black residents from the labor force and networks. Spatial mismatch helps explain the rise of joblessness and how social isolation damages people's chances of a good life.

Closing trauma centers and emergency departments that serve vulnerable populations will create a spatial mismatch in health care. This will not introduce disparities into our health care system -- it will widen the ones already there.

Presented by

Jason Silverstein is a Ph.D. student in anthropology at Harvard, where he also works with the W.E.B. Du Bois Institute for African and African American Research.

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