Would the "American Girl Doll Hospital" accept Medicare and Medicaid patients? This question was posited by a viral tweet
a few weeks ago. My answer? Not if doll hospitals operate anything like American urgent care centers.
Data from CDC released in late December showed that U.S. life expectancy had dropped to its lowest in 2 decades. With an average of 96 excess deaths per 100,000 people, the U.S. leads all developed nations in deaths that can be prevented by timely intervention, compared to just 83 in the U.K. and 65 in France. COVID-19 deaths certainly contributed to this decrease, but this is not the full picture. While the entire globe felt COVID-19's burden, some experts suggest the precipitous drop in the U.S. is more so led by our health system's inability to provide universal health coverage, ensure equitable access, and address administrative inefficiencies. These factors make it harder to mitigate not only COVID-19 deaths, but also other preventable deaths from accidental injuries, drug overdoses, and chronic conditions, such as heart disease.
These shortcomings in coverage, access, and efficiency are exacerbated, at least in part, by a convoluted two-tiered system to address medical emergencies. While "emergency room (ER)" and "urgent care center (UCC)" may sound like semantic preference, in reality, the name has profound implications for our patients' bodies and wallets.
Urgent Care Centers Versus Emergency Rooms
At a surface level, ERs vary by state, but must meet rigorous national-level emergency treatment guidelines set by HHS; they are typically open 24/7, always staffed with physicians, and equipped to handle a wide range of injuries. However, these supposed distinctions often blend with the characteristics of UCCs. Unlike ERs, UCC have no formal guidelines nationally, and states allow operation through an individual physician's emergency medicine license, a parent hospital's license, or even as a professional LLC if the owners are physicians. Even without similar certifications, UCCs in some cases still market themselves as open 24/7, having on-call physicians, and possessing state-of-the-art technology.
The real differences between the two types of facilities? It comes down to admissions and billing. Unlike ERs, which admit all patients under the Emergency Medical Treatment and Labor Act, UCCs can decline to see patients based on insurance status, ability to pay, or religious beliefs.
What does this mean for our patients? It means when they walk into a UCC, regardless of their dire state, staff can refuse to admit them arbitrarily. If they have Medicare or Medicaid, they can be rejected. If their insurance is out-of-network, they may be unknowingly burdened with a massive ambulance bill for transfer to an ER. They may be refused critical reproductive health services based on the religious affiliation of the center. Furthermore, staff can decide whether they want to treat the patient's injury by deeming it too severe or too minor. Not to mention, the patient probably won't even have a UCC if they live in a poor neighborhood or rural area. The U.S. is the only developed nation with this type of urgent care system.
Urgent Care Centers Fill Holes in a Broken System
Ultimately, UCCs are for-profit entities -- and business is booming. With lower operating costs than hospitals, UCCs are attractive investment vehicles and prime for private equity consolidation. Some companies are going on shopping sprees; for example, HCA Healthcare purchased 24 UCCs in 2019 alone. Profits are high in part because UCCs now fill the gap left by primary care shortages. UCC utilization is skyrocketing, increasing by more than 1,700% over the previous decade, as other healthcare safety nets are chipped away. Many policymakers on both sides of the aisle are giving up on meaningful healthcare reform, and primary care usage has been on the decline. This trend worsened during COVID-19, prompting the American Academy of Family Physicians to issue a letter to HHS warning of, "rapid collapse of the community-based primary care system in many parts of the country." As a result, UCCs must step in as a catch-all; but the fail-safe itself is failing to care for us.
I've seen this firsthand. This summer, my mom was refused care for a non-emergency panic attack at a UCC in my old neighborhood of Capitol Hill in Washington, DC. During the crisis, my Google search for an "emergency room near me" returned both a nearby UCC and an ER a bit further away. Both are 24/7 medical centers, and the UCC's website provided zero details to distinguish it from the ER. On arrival, the UCC refused to see us due to out-of-network insurance. Pleading to be let in, I offered to pay out-of-pocket, but the facility was unrelenting. The insurance company went as far as to demand my mom get on the phone to purchase a new plan, even though she was unfit to speak. Eventually, instead of letting us through the doors, the UCC called an ambulance to transport my mom from the lobby to the ER across town, saddling us with an additional ambulance bill. How can such an occurrence transpire regularly in the capital of the wealthiest nation on Earth? In my opinion, nowhere are our health system's shortcomings more glaring than at UCCs.
Potential Policy Solutions
What can be done to provide better urgent care? Creating an ER system based on the model in some European countries where you can walk into any emergency or urgent facility without worry of being turned away would solve many problems. For example, accident and emergency centers and urgent treatment centers in the U.K. are similar to American ERs and UCCs, respectively. However, the National Health Service (NHS) requires both centers to see all patients who walk through the door, even non-British citizens and tourists. The NHS sets strict guidelines to ensure urgent treatment centers across the country operate at a similar level of quality. Furthermore, patients can dial 111 and speak with an operator who will direct them toward accident and emergency centers or urgent treatment, so the patient doesn't have to scour Google themselves. We have much to learn about UCC efficiencies from nations across the pond.
Since our U.S. political parties love patchwork solutions, reform will likely start incrementally at the state level. Health policy experts recommend
states adopt stricter licensing and accreditation requirements to standardize care across UCCs. Following Vermont's lead, states should take steps to prevent UCCs from turning away Medicaid and uninsured patients. Lastly, UCCs must do a better job of coordinating care with local hospitals and community health systems. With these initial steps, the U.S. may have a shot at starting to reverse its horrific drop in life expectancy.
Khaqan Ahmad is a first-year medical student at Dartmouth Geisel School of Medicine in Hanover, New Hampshire. He previously worked as a health policy consultant in Washington, D.C.
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