About seven and a half years ago, in the middle of the great Blizzard of 2005, my daughter climbed on top of a coffee table and then fell off, splitting her forehead open on the tabletop's edge. As she stood crying, huge drops of blood rolled down her forehead, and my wife and I knew instantly that she needed stitches. Meanwhile, there was already several inches of snow on the ground outside our house, if not a foot, and more was piling up fast. We borrowed my father-in-law's 4WD and high-tailed it to Jersey Shore Medical Center in nearby Neptune, NJ, where a skeleton crew manned the hospital. The staff there was able to care for my daughter, and they could have fixed her up on the spot, but they strongly suggested that we get a pediatric plastic surgeon on the case, since the scarring would be a lot less noticeable if the stitching was handled by a specialist. We agreed, and even though it took the plastic surgeon three hours to dig out and get to the hospital, get to the hospital he did, and he did an expert job putting my little girl back together again. Today, you can't even see the scar.
My wife and I have always appreciated this visit to Jersey Shore, and were impressed with how well they could handle child patients. It turns out that had we gone to Monmouth Medical Center in equally close-by Long Branch, NJ, they too could have cared for my daughter. A big reason for this is because in 1992, the state mandated that all hospitals in the state had to have a state-certified Emergency Department Approved for Pediatrics, or EDAP. All states have their own criteria and certification processes for making sure that there is some kind of EDAP capabilities reasonably scattered across the state. Most states prefer to centralize their EDAP services. Some states prefer a more isolated approach, where individual hospitals may develop their own EDAP capabilities. But to date, New Jersey is the only state where the law demands that all hospitals be EDAP-ready.
Two common complaints against PPACA is that it constrains the free market with a bunch of socialistic rules and that it is does nothing to address the cost of health care itself. To be fair, I rarely hear both complains come from the same people at the same time. Those who find PPACA offensive on purely political grounds tend to point out the socialism aspects, especially the individual mandate. Those who find PPACA offensive to how the business of health care conducts itself tend to point out the cost aspects. (This second line of argument has always struck me as being a little specious, since it tends to come from the same folks who are deeply concerned that things like abolition of pre-existing conditions, medical loss ratios and health care exchanges will all make it impossible for them to turn a profit selling health insurance. That's a fair complaint. Why not go with that, then, instead of banging a drum nobody in the general public cares much about over lowering the cost of health care?)
In the case of pediatric emergency care in NJ, the state could have let hospitals determine for themselves which ones might profit by offering pediatric ED care - a free market solution, if you will - but it did not. In fact, it went so far as to say that if you want to do business in New Jersey, you have to be ready, willing and able to do it for kids also. Not exactly a free market approach, nor much of a surprising one, really, given New Jersey's reputation for having a heavy regulatory hand.
The proof, however, is in the pudding. The speed to treatment for child ED patients upon arrival at the hospital is 30% lower than in states where EDAP is more centralized. (This makes sense: in a state as densely populated as New Jersey - you're rarely more than a 30-minute drive from the nearest hospital.) But more importantly, according to 2008 data (the most recent available) from statehealthfacts.org, New Jersey is tied for having the 2nd lowest rate of child deaths (ages 1-14) per 100,000 children. It is tied with Connecticut, at 12. Only Massachusetts - with its socialized Romneycare - is lower, at 11. Obviously, you cannot credit the New Jersey model for EDAP for the state's low child death rate, but Robert Sweeney, DO, a physician at Jersey Shore Medical Center and an author of a paper on the new Jersey EDAP model told me, the mandated EDAP can't possibly hurt.
So what about cost, then? Surely making every hospital in the state pediatric ED-ready will drive up the cost of healthcare, right? Wrong. According to Sweeney, isolating EDAP rather than centralizing it actually drives costs down. There is little functional difference in the medical techniques used to treat pediatric emergency care and adult care, especially during triage. Pediatric EDs don't need a lot of extra specialized equipment, and regular ED techs can be skilled up to handle pediatric patients with relative ease. in contract, regionalized EDAP facilities that tend to keep a dedicated pediatrician on hand 24/7 can rack up an additional $1.2 to $1.3 million in costs each year, per center. That is not small money. Moreover, regionalizing pediatric care can decreae the quality of service. As Sweeney pointed out to me, regional EDAP hospitals are likely to be fairly busy already; making them the only place to bring your hurt or sick child is likely to overtax and already hectic facility. It just puts more noise into the system, Sweeney said.
Something else that Sweeney said that was eye-opening for me was that it wasn't until the 1970s and 1980s that we really had done any kind of scientific study of ED usage, and it wasn't until the 1980s and 1990s when we started doing the same for pediatric ED usage. Until then, our health care system was simply delivering results of questionable efficiency. When New Jersey set its EDAP standard, it did so with the understanding that when parents have a hurt or sick kid, they are going to take that kid to the nearest medical facility they trust for care. They cannot be expected to stop and weigh their options. That was certainly the case for me and my wife, and had New Jersey been running a regionalized EDAP standard rather than an isolated one, we could very well have taken our hurt shild to a place that really wasn't equipped to take care of her.
It took a forced government standard to deliver this capability. The free market had its chance here, and it failed to deliver. And while I am a big fan of the free market, I think we have to be honest with ourselves here: sometimes it just does not live up to its promise. And in the case of health care, it has not lived up to its promise for a very long time for a very large number of people, which is what really spurred the efforts to turn it all upside down. I don't know if PPACA will survive the SCOTUS vote (though if I had to bet, I'd say that it will), and I don't know if, in the long run, PPACA will really make our health care system any more efficient at delivering quality health care to as many people as possible. The intent is noble, the execution so far does not fill me with confidence. But to those who would write off PPACA as being capable of any success, I would just point out to the New Jersey EDAP situation. Sometimes, under the right circumstances, the government actually gets it right. The question with PPACA is, how right will the government get it?
I worked this up during an earlier draft of this blog, and now this section has nowhere to go, but I thought I'd throw it in for those who like to consider the purely political side of the health care debate. I was intrigued by claims that New Jersey is among the ten lowest child death rates in the country. What fared better, I wondered? Turns out that according to 2008 data from statehealthcarefacts.org, New Jersey is tied for second with Connecticut for lowest rate of child death rates (ages 1-14) per 100,000 residents. Only Massachusetts, with its Romneycare, did better. Have a look:
- Massachusetts (11)
- Connecticut/New Jersey (12)
- Rhode Island (13)
- Vermont/New Hampshire (14)
- California/Delaware/Virginia (15)
- Hawai'i/New York/North Dakota/Washington (16)
Conversely, here are the states that rank worst when it comes to child deaths:
- District of Columbia (45)
- Alaska/Wyoming (31)
- Louisiana (30)
- Mississippi/Oklahoma (30)
- Alabama (25)
- Montana/New Mexico/West Virginia (24)
- Indiana (23)
Looking at the handy interactive map on this, one thing immediately becomes clear to me: the more Blue the state, generally speaking, the lower the child death rate. The more Red the state, the higher the child death rate.
This a broad statement, to be sure. Among the low death-rate states, Virginia is a more Red than Blue state, and North Dakota is definitely a Red State. But when you see states like Massachusetts, New Jersey, New York and California, it's not a stretch to say that these are states with a greater willingness to impose government mandates on the business of health care are, if nothing else, enjoying some pretty good deliverables when it comes to caring for their children.
Likewise, when you look at states like Alaska, Alabama, West Virginia and Mississippi, these are swfully red states where you have an awful lot of anti-PPACA sentiment. And yet, the systems they have there, for whatever reason, don't seem to be passing muster when it comes to child deaths.
These are hardly perfect comparisons. They paint with very broad brushes. But still, there does appear to be at least a casual correlation to political spectrum and rate of child deaths. Is it enough for the guys over at Freakonomics to make a point of? Perhaps. Is the reality more complicated than what I'm pointing out? No doubt. It mght just be a factor of economy and urban blight - DC is a pretty Blue area, but as urban centers go, it's got significant problems. But whatever the reasons, it is very interesting, to say the least, even if it all reminds us of the saying popularized by Mark Twain: "There are three kinds of lies: lies, damned lies, and statistics."