Academic emergency medicine : official journal of the Society for Academic Emergency Medicine
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The American health care safety net is threatened due to inadequate funding in the face of increasing demand for services by virtually every segment of our society. The safety net is vital to public safety because it is the sole provider for first-line emergency care, as well as for routine health care of last resort, through hospital emergency departments (ED), emergency medical services providers (EMS), and public/free clinics. Despite the perceived complexity, the causes and solutions for the current crisis reside in simple economics. During the last two decades health care funding has radically changed, yet the fundamental infrastructure of the safety net has change little. In 1986, the Emergency Medical Treatment and Active Labor Act established federally mandated safety net care that inadvertently encouraged reliance on hospital EDs as the principal safety net resource. At the same time, decreasing health care funding from both private and public sources resulted in declining availability of services necessary to support this shift in demand, including hospital inpatient beds, EDs, EMS providers, on-call specialists, hospital-based nurses, and public hospitals/clinics. The result has been ED/hospital crowding and resource shortages that at times limit the ability to provide even true emergency care and threaten the ability of the traditional safety net to protect public health and safety. This paper explores the composition of the American health care safety net, the root causes for its disintegration, and offers short- and long-term solutions. The solutions discussed include restructuring of disproportionate share funding; presumed (deemed) eligibility for Medicaid eligibility; restructuring of funding for emergency care; health care for foreign nationals; the nursing shortage; utilization of a "health care resources commission"; "episodic (periodic)" health care coverage; best practices and health care services coordination; and government and hospital providers' roles. ⋯ There is a base amount of funding that must be available to the American health care safety net to maintain its infrastructure and provide appropriate growth, research, development, and expansion of services. Fall below this level and the infrastructure will eventually crumble. America must patch the safety net with short-term funding and repair it with long-term health care policy and environmental changes.
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In virtually every community in this nation, the emergency department (ED) is an integral part of the health care safety net, often serving as the only available point of access to the health care system for many vulnerable and disenfranchised individuals. The authors present a brief overview of the March 2000 report released by the Institute of Medicine that described and assessed the current status of the nation's health care safety net. The authors discuss the role of the ED as a safety net provider and as a window onto the status of the rest of the health care system. The authors describe the Andersen behavioral model of health services use and suggest it as a useful theoretical framework for emergency medicine researchers who are interested in studying these issues.
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In 1997 the U.S. government funded the Children's Health Insurance Program (CHIP), but the 48 billion dollars initiative has had limited success in finding and enrolling uninsured children. While such children are more likely to receive care in emergency departments (EDs), no national initiative has targeted EDs for child health insurance outreach. ⋯ The ED may be an important outreach site for child health insurance programs. National efforts to address the lack of insurance among children should include partnerships with the ED.
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The authors review the evolution of the emergency medicine literature regarding emergency department (ED) use and access to care over the past 20 years. They discuss the impact of cost containment and the emergence of managed care on prevailing views of ED utilization. ⋯ By the late 1990s, demonstration of the risks of denying emergency care and more sophisticated analyses of actual costs led to reconsideration of initiatives to limit access to ED care and renewed focus on the critical role of the ED as a safety net provider. In recent years, "de facto" denials of emergency care due to long ED waiting times and other adverse consequences of ED crowding have begun to dominate the emergency medicine health services literature.
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The U. S. health care system continues to rely on a diverse and poorly organized health care safety net to provide care for its uninsured and underinsured residents. ⋯ This paper reviews the findings of the IOM report, highlighting the key issues for emergency medicine. In response to the IOM's challenges, emergency departments should be used more effectively to monitor local safety net viability and to enhance the integration of community health care safety net delivery systems.