Sunday, May 31, 2009

We CAN fix the ER closing problem

Lori Aratani's May 31 WaPo article District, Md. Hospitals Often Divert Ambulances points out one reason why District hospital ERs close:   "The reasons for the crowding often vary by hospital. Some, especially in the District, are overwhelmed by poor patients for whom the ER has become their family doctor's office."

Use of the emergency room may seen incongruous to the recently released data* that 96.5% of District's children were insured in 2007, higher than the national average of 90.9%.   ER use also seems inconsistent with data related to preventive health care visits (97.6% in the past year) and preventive dental care in the past year (81.7%).   The WaPo piece seems to make somewhat more sense considering that in 2007 less than half of young people, 49.7%, had a medical home compared with 57.5% nationally.   This, of course, in the context of the multi-million dollar investment in medical homes, an effort led by the DC Primary Care Association (DCPCA).

All of this data, even together, makes sense if you understand the history of SCHIP in the District.   Certainly, I'm no expert, but I was on the periphery of the SCHIP expansion in DC under the leadership of DC Action for Children with funding from the Robert Wood Johnson Foundation (RWJF).   The District's Income Maintenance Administration (IMA) in the Department of Human Services focused on getting young people and the adults in the household enrolled in DC Healthy Families, the city's SCHIP program.   Major policy and practice wins were achieved including a shortened application, intensive outreach to enroll and recertify, and customized engagement of "new" populations not usually considered when talking about public benefits.

One of the most vexing and challenging aspects of health care expansion and reform is behavior change.   This should come as no surprise if you have ever tried to change your behavior.   It should also come as no surprise given that a good proportion of adult Medicaid recipients are hourly workers or workers with inflexible work schedules.   What, in my view, we have to do now is to 1) prioritize behavior change and 2) address workforce challenges.

It is not too late to fix this problem.

*Child and Adolescent Health Measurement Initiative. 2007 National Survey of Children's Health, Data Resource Center for Child and Adolescent Health website. Retrieved [05/31/09] from

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