The difficult realities of healthcare in our country.

EMILY FRIEDMAN AND Deborah Chollet raise important issues about the future of health insurance, the uninsured, and the underinsured; Friedman also focuses on possible consequences to our nation's hospitals. These two authors reflect my own view that the healthcare system in the United States is broken and that structural reforms are long overdue. The ultimate solution-universal healthcare coverage-is not currently a popular political choice. Even with bipartisan support, universal coverage would take time, intense effort, and unprecedented cooperation to accomplish. Still, it is the one solution that would ensure care for all, in the most appropriate settings, particularly for the most vulnerable among us. For now, however, we must deal with the difficult realities of healthcare in our country. I agree with many of the points that Friedman and Chollet make and would like to expand on some of them. HOSPITALS ARE THE SAFETY NET Friedman discusses a number of factors that contribute to continuing growth in uninsured and underinsured populations. She states that "although it is not universally accepted, there is a widespread (and, in my opinion, correct) belief that hospitals serve as the safety net for the uninsured." Those of us who work in not-for-profit and faith-based hospitals can attest to the absolute correctness of this belief. Every day, Catholic Health Initiatives' emergency departments serve as a safety net for people who have no insurance, no primary care, and no knowledge of any other way to access the healthcare system. Sometimes, ours is the only emergency department in a community and, therefore, the only refuge for someone who needs care. Sometimes, we are one of several providers but our emergency department is still the provider of choice because our mission and faith-based tradition dictate that we help all of those in need, regardless of their ability to pay. As the uninsured population grows, our country continues to see significant and systematic constraints on public program funding. For many hospitals, this situation has precipitated a financial crisis that not only severely constrains their ability to provide care to the uninsured but also threatens their continued viability-the impending disaster to which Friedman refers. However, many individuals, including influential policy-makers, do not acknowledge this crisis. They know that more than 45 million uninsured people live in the United States, but they argue that those people need not go without healthcare; all they have to do is walk into a hospital emergency department. Policymakers must take this scenario to the next step: who will pay for the care? If there is little or no insurance or if federal or state health funding is lacking, the hospital must pay for the care. And with millions of uninsured people in communities throughout our country, that is too great a burden for hospitals to bear. In addition, not-for-profit hospitals in a community do not always share that burden equally. In some markets, I see a reduction in the quantity of care that city-, county-, and state-run facilities are providing to the poor. Faced with the same financial hardships as other not-for-profit providers, they are devising ways to reduce the number of uninsured and underinsured people they treat, thereby limiting their exposure in ways that would have been unthinkable just a few years ago. HIGH-COST EMERGENCY CARE Another essential issue that many policy-makers fail to recognize is that emergency care is a far more costly safety net than primary care. Regular primary care can identify and resolve health problems before they become serious and much more expensive to treat. I started my career in healthcare as an emergency department administrator, working at one of the busiest emergency departments in the country during the late 19703. The department had 130,000 patient visits per year, or roughly more than 350 patients a day. …