An Elephant—But Not Just in the Emergency Room

An article ¹ elsewhere in this issue of Population Health Management addresses the topic of disparities in access to medical services by looking at the use of emergency departments (EDs) for initial cancer diagnosis by economically-disadvantaged people. The authors use claims data from a safety net hospital to document the extent to which the ED is used for initial diagnosis of cancer. Initial cancer diagnoses were relatively high for safety net hospital patients and disproportionately higher for African Americans, leading the authors to conclude that there are “profound disparities in cancer care and outcomes.”

There are policy implications of the authors' findings: “insurance type had a significant impact on the proportion of ED-related cancer diagnosis versus non-ED sources. Those with no insurance were 267% as likely to have initial diagnosis associated with ED use as those with private insurance.” The implication of the findings is that the identified disparities should be addressed by an expansion of health insurance (the data analyzed represent a time period prior to the Affordable Care Act), something that is controversial in Florida where the governor has opposed Medicaid expansion.

There is, however, an alternative interpretation of the authors' data, with policy conclusions that are not as clear. The insurance status of the safety net patients with cancer diagnoses, and the source of the initial diagnosis, is shown in Table 1.

The insurance disparity argument would lead us to expect a higher percentage of uninsured patients among those in the safety net hospital patient population, which is indeed true. However, patients with insurance of some kind represent nearly two thirds of the population (63%). Of significance is that half of the patient population (494) have some form of government-provided insurance.

The insurance disparity argument would suggest that the uninsured patients would have a higher proportion of initial diagnoses through the ED. Although those with private insurance have a much lower proportion of ED initial diagnoses, the uninsured also have a lower percentage of initial diagnoses than the average, while 40% (196) of patients with government-provided insurance receive their initial diagnoses through the ED.

The argument for reducing disparities by expanding health insurance is a powerful one; however, these data show that this is by no means the whole story. When almost 50% of a population with comprehensive coverage (Medicare) are diagnosed with cancer through the ED, there are more factors at work in the population that we should investigate before concluding that insurance expansion is the solution.