October 2004
Reporter
State of Emergency
What happens when 130,000 kids lose their taxpayer- funded health insurance? To find out, visit the ER at Children's Medical Center Dallas, where the waiting room is always full and chances are you're footing the bill.
THERE'S A THEORY MAKING THE ROUNDS in the emergency department at Children's Medical Center Dallas: "I'm not sure why it is," Dr. Thomas Abramo told me one morning last April as he headed toward one of the ER's cramped treatment rooms, "but it just seems like the cutest kids with the nicest parents always turn out to be the sickest."
Inside, Valeria Galarza, a seven-year-old girl with cinnamon-colored skin and giant eyes lay quietly on a gurney. Abramo gently probed her abdomen, while her father, Luis, described how she'd been complaining of pain in that region for a few months. They hadn't sought help, he explained, because the family had no health insurance, but the pain had become more acute the night before. Abramo nodded, then asked Valeria if she'd been coughing a lot, and she shook her head. "I was thinking it might be pneumonia with referred pain to the lower abdomen," he said, turning to the resident taking care of Valeria. "But we need blood tests to see what else it could be. It could be worse than that."
Abramo left the examining room and headed out to an L-shaped counter that is the hub of this sprawling trauma center just northwest of downtown Dallas. The six corridors that extend out from the hub were filled with doctors and nurses striding briskly to and from the ER's eighteen treatment rooms, their blue surgical togs color-coordinated with the unit's walls. Abramo, 48, has helped run this department since it opened, back in 1991, watching it go through multiple expansions and become one of the busiest and most respected pediatric emergency facilities in the country. But while there is never a shortage of patients at Children's (the waiting room was full that morning), Abramo and his staff see more upset tummies and runny noses these days than true emergencies. The Children's Medical Center emergency room has always been the hospital of last resort for the indigent and uninsured in North Texas. But since last year's cutbacks in the Children's Health Insurance Program (CHIP), the federal- and state-funded health-care program for families of the working poor, nonemergency traffic has only increased, and Abramo and his ER colleagues have occasionally found themselves overwhelmed.
After checking in with a few residents at the hub, Abramo headed for the "wheezer room," a long, drab rectangular space where children with breathing problems are treated. That morning a dozen or so kids who'd suffered asthma attacks sat with their mothers and fathers, sucking on nebulizers to open their inflamed bronchial tubes. Two of them belonged to Sonia Yguerabide, an attractive and talkative young mother. As Yguerabide described her children's symptoms, Abramo used his stethoscope to listen to them breathe. "She has asthma," he said, addressing Yguerabide's seven-year-old daughter first. "Has she been taking medication?" Her mother told him that it had run out; when she lost her job, she'd been dropped from CHIP. Then Abramo turned to her son, a frail four-year-old who had a deep, braying cough. "He may or may not have asthma," said Abramo. "But he definitely has croup." While he wrote a prescription, Abramo explained to Yguerabide that in the future, her children would be better off with regular doctor's visits than trips to the ER. She said she understood, but with no insurance to cover those visits, it was hard to imagine that her children wouldn't one day be treated again by the emergency pediatricians at Children's.
Abramo made his way through the rest of the patients in the wheezer room and was walking down another corridor when his cell phone rang. It was the hematology department with word on the blood tests for Valeria. "It looks like she has leukemia," Abramo told me as he hung up. The hospital would try to qualify the Galarzas for public assistance, he explained, but if that failed, Children's would wind up eating the cost of her treatment. Fighting the disease could take months to years and tens—maybe hundreds—of thousands of dollars. "What did I tell you about the cutest kids?" he said.
IF YOU WANTED TO WITNESS firsthand how the rising number of Texas's uninsured families has affected the health-care industry on the ground, you couldn't find a better place to start than Children's Medical Center. The story, of course, has been all over the state's newspapers: Last year, faced with a projected $10 billion shortfall in the state budget, the Legislature ordered cuts in social services to make up the difference. One of the hardest-hit programs was CHIP. By instituting more-restrictive eligibility requirements and raising premiums, the Legislature forced nearly 130,000 kids—25 percent of CHIP's enrollment—out of the program. A year later, one in five Texas children—more than in any state in the country—are uninsured.
What you may not know is where those kids are going. Increasingly, their parents have turned to emergency facilities like the one at Children's instead of doctors' offices. For every vehicle-wreck victim or leukemia patient Abramo and his staff see, there are at least three minor wheezers or kids with a winter flu bug. Their parents bring them here because they know that the law mandates that the ER, as an emergency facility with federal funding, treat them. As such, the patient load at the Children's ER has increased by 17 percent since 2000, from about 90,000 patients a year to 105,000. "There are times when we're overwhelmed," nurse Richard Escobedo, a ten-year veteran of the Children's ER, told me during one visit. "We've had to go on a minor divert status, where we get patients sent elsewhere." Bobbie Minns, another veteran nurse, agreed. "I've seen the waits in winter go as long as twelve hours," she said. "I come in for my shift and see this family in the waiting room, and they're still there when I leave."
Meanwhile, the amount that the hospital spends out of its own pocket on patients who have no insurance has more than doubled over the past decade. And it's not just the administrators at Children's who are feeling those costs. The shift from preventative care to emergency care is driving up the cost of health-care premiums statewide. A visit to the emergency room, after all, where a patient's life is always assumed to be at risk, demands a much more expensive treatment protocol than a trip to the neighborhood clinic. Take, for example, the treatment of asthma attacks, one of the emergencies Children's has found itself increasingly inundated with. The ailment could be brought under control for a few hundred dollars a month by a private physician. But if a child is not insured and not getting regular treatment, his asthma is more likely to flare up, and the cost of an ER visit and resultant hospitalization might be as much as $7,000. Meanwhile, minor asthma attacks are just one of many such nonemergencies being treated in the Children's ER. On one visit, I found Abramo treating a young boy with an infection on his scalp. "He has a fungus," Abramo patiently told the child's mother. "Use Selsun Blue if you can."
Cases like these have created a sort of negative feedback loop: More and more uninsured children show up at the ER with minor problems, which drives up the cost of everybody else's health care, which drives more children out of the health-care system. "We're just headed in this direction where a smaller and smaller group of people is paying for the health care of more and more," said Abramo.
The shift is beginning to affect the hospital's bottom line. Though Children's operated in the black for the first half of 2004, there were danger signs lurking on the books: Income from operations was down 28 percent from the first half of 2003. The hospital's provision for "doubtful accounts"—money it is owed but will probably not be able to collect from patients who did not qualify for charity care—had jumped 21 percent over the same six months in 2003. Administrators haven't been shy about identifying the cause. "In the 2003 Texas legislative session, significant changes were made to the CHIP and Medicaid eligibility criteria," the hospital's management wrote in its six-month audit this past July. "The impact of these changes was seen in the quarter and in the six months ended June 30, 2004, as the volume of CHIP admissions declined 27 percent. . . compared to comparable periods in 2003."
