The Decline of Emergency Care

Last Monday, two bombs built to take lives exploded in a city that's built to save them. Five Boston hospitals are Level I trauma centers. Three specialize in pediatrics. Each one is ready to treat all aspects of injury. At all times, they have the full roster of emergency services available: the entire spectrum of surgical specialists; respiratory therapists; laboratory services; nurses; and radiologists. They can land helicopters. They can treat burns. And they're ready to support patients through rehabilitation. If you're severely hurt, this is where you want to be. The CDC has found that trauma centers reduce the risk of death by 25 percent.

As of now, every marathon bombing patient treated in a Boston hospital is expected to survive. This is to the credit of medical tent staff and first responders, volunteers with make-shift tourniquets, and physicians who ran the race, only to run back, jump barricades, and try to save lives. Because of their courage, and the communications systems between hospitals, mass casualties arrived at trauma centers within an hour of the blast. Some got there within twenty minutes. This is how an emergency system should work -- in response to a terror attack, or the more than 1,200 trauma cases that each center handles yearly.

But across the country, more and more trauma centers and emergency departments are closing. And they're closing in communities that need them the most.

It isn't that there are fewer emergencies. According to the American Hospital Association, from 1991 to 2010, emergency department visits soared from 88.5 million to 127.2 million. That's an increase of nearly 44 percent. But during this same period, emergency departments closed at a rate of almost 11 percent. We see something similar with trauma centers. Between 1990 and 2005, 339 trauma centers shut their doors. If we know these services work for terror attacks as well as ordinary traumas, such as car crashes, then why are they closing?

Over the past four years, Renee Hsia, an emergency medicine physician, and Yu-Chu Shen, an economist, have written about closing emergency rooms and trauma centers. They have been interested in two primary questions. First, they have tried to figure out what makes a trauma center more likely to close. It turns out a major reason isn't poor performance. It's cost. Trauma centers are expensive to run; they depend on public funding (such as Medicare reimbursements) and face financial pressures from HMOs to specialize in more profitable services.

Hsia and Shen have also asked how these closures impact vulnerable populations. Part of the reason that trauma centers are unprofitable is that they treat many uninsured, or self-pay, patients, and patients on Medicaid. According to the most recent National Trauma Data Bank report, 27 percent of trauma patients are self-pay or Medicaid patients. When trauma centers close, does it hurt these patients the most?

The answer is yes. To get there, Hsia and Shen studied how driving time to trauma centers changed over a six year period for 99 percent of the US population, or 283 million people. Here's how they did it. First, they pulled data on trauma centers from the American Hospital Association annual surveys between 2001 and 2007. Then, they linked this data with demographic data from the 2000 Census. To understand county-level insurance information, they drew from the federal government's 2005 Area Resource Files. Compared with travel times six years earlier, Hsia and Shen found that one out of every four people had to travel longer to get to a trauma center. And nearly 16 million had to travel at least thirty minutes more.

Here's where it gets worse. The more vulnerable the population, the farther they had to drive to a trauma center. This means communities with higher shares of African American residents, uninsured residents, and residents living under the federal poverty level. Rural communities, which we know suffer poor access to trauma centers, also experienced a significant increase in driving time. These are communities that, already, suffer from health care disparities.

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?

Recommended

God's Surgeons in Africa

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.