Best care everywhere: here's an idea: a civilian VA for the uninsured, and maybe the rest of us.

• Author: Longman, Phillip
• Position: SPECIAL HEALTH CARE ISSUE - Vista Health Care Network

Back in July, while trying to justify his opposition to expanding government health care cover age for children, President Bush made a telling comment. The uninsured, he said, "have access to health care in America. After all, you just go to an emergency room."

That remark stuck many as blithe and callous, and in many ways it was. The uninsured don't receive in ERs anything like the full array of health care they need. Indeed, one of the abiding arguments for universal health care is that patients often wind up in the emergency room with acute illnesses that could have been treated earlier, and more cheaply, had they been able to afford regular doctor's visits.

Still, there was a kernel of truth to Bush's comment--one that we ought to take as a jumping-off point for rethinking how best to provide health insurance for all. The fact is, as a nation we already have an extensive, if ad hoc, system for providing health care to the uninsured. A fair amount of money flows through that system. And the quality of care it provides is far better than you might think.

According to the Kaiser Commission on Medicaid and the Uninsured, Americans who lacked health insurance in 2004 received an average of $1,629 per person in medical services. That's only about 55 percent of what fully insured Americans consumed that year, but it's still more than the total average per capita health care expenditure in Europe.

Some of that medical care is delivered at the suburban hospitals and doctor's offices where those of us with health insurance generally get treated. But the lion's share of health care for the uninsured is provided by assorted "St. Elsewhere" institutions: typically big, old, nonprofit community or teaching hospitals in poorer neighborhoods, with additional help from smaller public clinics.

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This Spartan, patchwork system is in financial trouble, due largely to the cost of the uncompensated treatment that St. Elsewheres provide. But it nonetheless continues to offer surprisingly good care. A recent RAND study found that uninsured patients receive only 53.7 percent of the care experts believe they should get. Not so hot, right? But according to the same study, patients with private, fee-for-service insurance are even less likely to receive appropriate, evidence-based treatment. Indeed, among Americans receiving acute care, those who lack insurance stand a slightly better chance of receiving proper treatment than patients covered by Medicaid, Medicare, or any form of private insurance.

Counterintuitive as this may seem, in health care less is often more. The uninsured are virtually immune from receiving unnecessary surgery or other forms of overtreatment that the system constantly encourages. Once uninsured patients are through the door, they cost the hospital money until its doctors make them well enough to leave. There is no incentive to give them treatments they don't need. Since about 20 percent to 30 percent of all health care spending in the United States goes for overtreatment--much of it dangerous--this is no small advantage.

It's also true that the nation's public hospitals, while they may have a Dickensian atmosphere and lack the very latest imaging machines, tend to deliver higher-quality health care than their more prestigious counterparts. For example, Dartmouth researchers John E. Wennberg and Elliot S. Fisher have found that among Medicare patients who are not terminally ill, and who share the same age, socioeconomic, and health status, the chance of dying in the next five years is greater if they go to a high-spending hospital than to a low-spending hospital. Whether suffering from heart attacks, colon cancer, or hip fractures, patients live longer if they stay away from "elite" hospitals, with their overabundance of specialists, and choose a lower-cost St. Elsewhere. Given this unexpected reality, it is perhaps not surprising that patient satisfaction also declines as a hospital's spending per patient rises. It's not fun to be overtreated, even if you get valet parking and the finest in pudding.

None of this is to minimize the plight of the uninsured, who die at higher rates than the rest of us in large part because they don't have access to affordable primary care. But the fact that uninsured patients receive higher-quality acute care than do those with insurance ought to make us think twice about all the plans being put forth by presidential candidates to expand health insurance.

Virtually every one of those plans, Democratic and Republican alike, rests on the assumption that the uninsured should be brought into the health care system the rest of us use. But what if something like the opposite is true? What if the best way to help the uninsured is to make the health care delivery system they already use--the St. Elsewhere model--better and more affordable? What if that path to 100 percent coverage turns out to be not just better for the health of the uninsured, but cheaper for taxpayers than any other universal health care plan out there, and politically more viable...