US Health System Research Paper

The next most prominent form of health-care delivery consists of services provided by hospitals. With the exception of tax-supported government institutions, hospitals, like physicians, charge patients according to a fee-forservice system. Nonprofit hospitals charge patients for hospital services using the standard of recovering the full cost of services provided and meeting the hospital’s general expenses. Profit-making or proprietary hospitals not only calculate the cost of services rendered but also operate to realize a profit from those services. Nonprofit and profit-making hospitals rely heavily on third-party sources, either private health insurance or government agencies, to pay most or all of a patient’s bill.

Besides office-based medical practices and hospitals, the other types of organizations involved in the delivery of health care to the American public are official agencies, voluntary agencies, health maintenance organizations, preferred provider organizations, allied health enterprises in the business community, and traditional healing services.

Official agencies are public organizations supported by tax funds, such as the U.S. Department of Health and Human Services, the Centers for Disease Control and Prevention, the U.S. Public Health Service, and the Food and Drug Administration, which are intended to support and conduct research, develop educational materials, and provide services designed to minimize public health problems. Official agencies also have the responsibility for the direct medical care and health services required by special populations like reservation Indians, the military, veterans, the mentally ill, lepers, tuberculosis patients, alcoholics, and drug addicts.

Voluntary agencies are charitable organizations, such as the Multiple Sclerosis Society, the American Cancer Society, the American Heart Association, and the March of Dimes, who solicit funds from the general public and use them to support medical research and provide services for disease victims.

Health maintenance organizations (HMOs) are managed care prepaid group practices in which a person pays a monthly premium for comprehensive health-care services. HMOs are oriented toward preventive and ambulatory services intended to reduce rates of hospitalization. Under this arrangement, HMOs derive greater income from keeping their patients healthy and not having to pay for their hospital expenses than they would if large numbers of their subscribers were hospitalized. There is evidence that HMOs and other managed care organizations reduce hospital use and produce lower overall medical costs than the traditional open-market fee-for-service pattern (Wholey and Burns, 2000). Most of the savings are due to lower rates of hospitalization, but surgical rates and other fees may be lower for HMO populations. Physicians participating in HMOs may be paid according to a fee-for-service schedule, but many are paid a salary or on a capitation (set amount per patient) basis. Membership entitles patients to receive physicians’ services, hospitalization, laboratory tests, X-rays, and perhaps prescription drugs and other health needs at little or no additional cost.

There are some disadvantages to HMOs, namely, that patients (especially at night or on weekends) may be treated by whoever is on duty rather than their personal doctor, and a patient may need a referral from his or her primary care practitioner to consult a specialist. HMOs have attracted considerable attention because of their cost control potential and emphasis on preventive care. The number of HMOs and their enrollment have been rapidly increasing in the last few years. In 1970 there were 37 HMOs serving 3 million people; in 2003 there were 454 HMOs enrolling 71.8 million people. The peak year was 1999, when there were 651 HMOs with 81.3 million enrollees, or 31% of all Americans. The failure to meet expenses or make profits, along with patient dissatisfaction, has caused a decline in the number of both HMOs and patients, leaving HMOs with some 24.6% of the population as their clients. Included in this percentage are patients seen by individual practice associations (IPAs) which are solo practitioners or small groups of physicians who contract independently with HMOs to provide care to patients enrolled in their plans.

Preferred provider organizations (PPOs) are a form of managed care health organization in which employers who purchase group health insurance agree to send their employees to particular hospitals or doctors in return for discounts. PPOs have the advantage of being imposed on existing networks of hospitals and physicians without having to build clinics or convert doctors into employees. Doctors and hospitals associated with a PPO are expected to provide their usual services to PPO members, but lower charges are assessed against the members’ group health insurance. Thus, the health-care providers obtain more patients and in return charge less to the buyer of group insurance.

Allied health enterprises are the manufacturers of pharmaceuticals and medical supplies and equipment which play a major role in research, development, and distribution of medical goods.

Traditional healing services are healing options outside biomedicine that constitute forms of complementary and alternative medicine (CAM). CAM refers to the use of treatments that are not commonly utilized by the medical profession, such as visits to chiropractors, faith healers, folk healers, acupuncturists, homeopaths, naturopaths, and the use of dietary supplements to cure or prevent disease. CAM also includes Ayurveda, aromatherapy, shiatsu, crystal healing, biofeedback, and various other nonmedical techniques. The National Center for Complementary and Alternative Medicine was established by the U.S. Congress in 1992 to facilitate research, evaluate, and disseminate information on CAM techniques. The proportion of the population who use CAM is not known, although it is popular among some people (Baer, 2001). However, in relation to other health professionals, CAM practitioners occupy a marginal position in U.S. health-care delivery.

The majority of Americans have health insurance benefits provided through their place of employment and paid for by contributions from both the employee and employer. In 1984, some 96% of all insured workers were enrolled in traditional health plans that allowed them to choose their own doctors and have most of their costs for physician and hospital services covered in an unmanaged fee-for-service arrangement. However, this situation changed dramatically because of soaring costs of health care and limitations being placed on the insurance benefits provided. By 1998, only 15% of all insured workers had unmanaged fee-for-service health plans, while the remainder had managed fee-for-service plans in which utilization was monitored and prior approval for some benefits, like hospitalization, was required. The day in which doctors and their patients decided just between themselves what care was needed without considering cost appears over, as financial concerns are increasingly influencing how patients are cared for.

Some features of the health-care delivery system in the United States remain unchanged. The system is pluralist, that is, it has more than one major client. It serves a substantial private sector, the elderly and the poor with government-sponsored health insurance, and a large uninsured population. But there has also been widespread change. As employers, both government and private corporations are the major purchasers of health services and so dominate health policy. Managed care is now the primary form of medical practice. This development means that more people with private health insurance are limited in their use of health services to a particular managed care network, such as an HMO or PPO. Physician practice has shifted away from its historical roots in self-employment toward group and salaried arrangements that are better positioned to meet the current demands on providers stemming from both the change to managed care and the growth of medical technology (Gold, 1999). Physician incomes are increasing less rapidly than in the past, and professional autonomy is declining as well.

Given the magnitude of these changes – the reorganization of medical practice into managed care, along with constraints on income and autonomy – it is not surprising, as Gold (1999: 14) points out, that the satisfaction of physicians with their work situation has decreased. However, as Warren and her associates (1998: 364) explain,

Whereas physicians twenty years ago may have been horrified at the prospect of managed care, physicians now accept it as the rules of the game – at least in areas in which high percentages of patients belong to such plans – and recognize that the price of refusing to play by those rules is bankruptcy.

Thus, many physicians have had to make the adjustment to managed care, and the revenue, especially capitation fees, from this type of practice now constitutes a growing percentage of physician incomes.

Traditionally, doctors and hospitals have been paid on a fee-for-service basis. This method of payment is consistent with the principle of the open market, in which the consumers of health care, like the consumers of other products, are free to choose which health-care providers offer the best services at prices they can afford. High-quality services and affordable prices are supposed to result from competition among providers. Theoretically, physicians who are incompetent or who charge excessive fees and hospitals with lower-quality services would be driven out of the market by more competent, reasonably priced, and more effective physicians and better hospitals. To eliminate or reduce free choice would supposedly undermine the incentive of physicians and hospitals to satisfy patients.

The fee-for-service system is a highly attractive situation for doctors. It allows physicians to decide how much money they should charge for their services, how many patients they should have, how many hours they should work per week, what branch of medicine they should specialize in, and where they should practice medicine. The market, professional ethics, and sense of duty to their patients are supposed to block any desire to make as much money as possible.

Fee-for-service health-care delivery, however, is not a good example of a competitive marketplace. The fundamental law of the marketplace is supply and demand. When the supply of a product exceeds the demand for it, prices should drop. However, that law does not apply to medicine because physicians define what patients need and provide their services at prices they, their employers, or the federal government set. Therefore, doctors and hospitals create their own demand. Organized medicine has traditionally opposed changing the fee-for-service system because of the advantages it provides the profession. Yet fee-for-service discriminates against those people who are unable to pay the fees, making them dependent on welfare or charity. It also contributes to increased costs through high fees and the unnecessary duplication of technology and services by various providers and hospitals seeking to gain or maintain income.

Rising costs and lack of universal access to quality care finally forced changes, beginning with Medicare and Medicaid in the 1960s, and continuing today with the dominance of managed care systems charging a set capitation fee to patients each month. However, as noted, managed care constraints have eroded, leading to higher contributions for health insurance benefits on the part of both employers and employees, as well as higher costs for the care itself. Not surprising, the number of people without health insurance continues to increase. Light (2004) depicts the American health-care delivery system as the most costly, inefficient, wasteful, and inequitable system of health care in the industrialized world, while Mechanic (2004) describes it as disorganized and irrational. ‘In the final analysis,’ states Mechanic (2004: 83), ‘fault is in the failure of the United States to introduce a rational system of universal health care.’

Rising Costs

Any discussion of the organization of health-care delivery services in the United States would be incomplete without considering the problem of rising costs. Besides cost, the central issues in the public debate about health-care delivery in the United States include problems of equity and the distribution of services. However, no other single issue in medicine has attracted more public attention in recent years than the increasing cost of health care and the diminished ability of certain segments of American society to obtain health services adequate for their needs. Despite living in a wealthy country, a substantial portion of the American population does without even minimally adequate health care. The Americans most affected by the sharply escalating costs of medical services include not only the poor but also the near-poor who are unable to contend with rising health-care expenses. Furthermore, the proportion of the population without health insurance has increased. About 13.9% of the population under the age of 65 did not have health insurance in 1990; this figure stood at 16.6% in 2002.

In 1980, an average of $1063 per person was spent on health care in the United States; by 2003 this figure had risen to $5670 – up by $353 from 2002 and still the highest in the world by far. For comparative purposes, Switzerland (based upon 2001 figures) spent $3322 per person on health, which was the second highest figure in the world that year, whereas Mexico spent $536 and Poland $629 per capita. United States’ figures for 2001 were $5021 per person. Not only is health spending in the United States the highest in the world, but the jump to $5670 per capita for 2003 is the highest yet recorded.

Also in 1980, Americans spent a total of $247.3 billion on health needs, as compared with expenditures of $1.7 trillion in 2003. Spending on hospital care was $412.1 billion in 2000, $451.2 billion in 2001, and $486.5 billion in 2002. However, hospital costs alone in 2003 were $515.9 billion – $268.1 billion more than all health expenditures in 1980. Between 2000 and 2003, annual hospital costs had risen over $1 billion in the United States. Drug spending has soared as well from $121.8 billion in 2000 to $140.6 billion in 2001, $162.4 billion in 2002, and $179.2 billion in 2003. Total national spending on prescription drugs doubled between 1995 and 2000, tripled between 1990 and 2000, and continues to rise.

The rapid increase in drug expenditures has been due not only to the aging of the population but also to the effects of prescription drug advertising, the wider availability of insurance to cover drug costs, an increase in the number of prescriptions written by doctors, and a shift toward greater use of new, high-priced drugs. The use of certain drugs can reduce health spending by lowering the need for hospital care, but that is not the case for all drugs. Whereas spending on drugs has shown a significant rise in recent years, the greatest increases overall since 1960 are for hospital care and doctors, dentists, and other professional services.

An illustration of the increase and magnitude of the cost of health care in American society can be found in an examination of the U.S. consumer price index. As in most other nations of the world, the cost of goods and services has been steadily rising. Between 1982 through 1984 and 2003, the cost of medical care increased more (297.1%) than any other major category of personal expense.

Within the general category of medical care, the largest single increase since 1982–1984 has been in the cost of hospital and related services (394.8%). This category is followed by increases in prescription drugs (326.3%) and physician services (267.7%).

The greatest innovation in the delivery of health services during the 1980s and 1990s was in the area of cost containment, and little was accomplished with respect to problems of equity and distribution of services. In the public sector, the federal government instituted cost controls for services to Medicare patients by establishing set fees for diagnostic related groups (DRGs). As Ruggie (1992) points out, the use of DRGs demonstrated the government’s increasing role in controlling costs. The federal government is no longer inclined to accept charges set by health-care providers, but has instead taken the lead on establishing the pattern of funding. In the private sector, business corporations have increasingly turned to lower-cost HMOs and PPOs to provide health care to their employees. Some corporations have required second opinions from other doctors before surgery could be scheduled, and some have required data from insurance carriers to enable them to evaluate the performance of doctors and hospitals serving their employees. Many firms have also increased the amount their employees had to pay out of their own pockets for health care.

Managed Care

Thus, in the early to mid-1990s, private health care in the United States experienced a dramatic reorganization into managed care plans. Changing from a largely office-based, fee-for-service system to an increasingly group or organization-based managed care system, American medical practice took on a dramatically different new structure (Pescosolido and Boyer, 2005). Some of this restructuring was in response to the anticipated health reforms of the Clinton administration, and some was due to a ‘buyer’s revolt’ by business corporations and insurance companies seeking to control health-care costs by controlling medical work (Budrys, 2003; Stevens, 2005). In 2003, about 62% of all Americans (some 177.8 million people) with health insurance were enrolled in managed care programs; in 1988, only some 29% of the insured were members of such plans. Managed care refers to health organizations, like HMOs and PPOs, that ‘manage’ or control the cost of health care by monitoring the work of doctors and hospitals, limiting visits to specialists within a particular managed care network and to all physicians outside it, and requiring prior authorization for hospitalization.

Managed care alters the patient–physician relationship by introducing a third party – the case manager – to the decision-making process. The case manager represents the bill payer, usually an insurance company, who certifies that the care to be rendered is both effective and the least costly alternative. The case manager also authorizes hospitalization. Another feature of managed care is its reliance upon capitation financing. Capitation (per capita) financing is a fixed monthly sum paid by the subscriber and his or her employer that guarantees care to that person and the person’s immediate family with little or no additional cost. Health-care providers, in turn, must provide necessary care and are not paid for any additional services. This measure is designed to discourage inefficient and unnecessary treatment.

In addition, patients are allowed to see a specialist only after being screened by the primary care physician who routinely cares for them. Since specialist care is usually more costly, the primary care physician serves as a gatekeeper to the use of specialists and is usually rewarded by keeping referrals to a minimum. Finally, patients are required to use the physicians within the managed care network – unless the subscriber or a family member has a medical emergency outside the plan’s geographic area.

The current cost containment effort in U.S. health care had its origins in the federal government’s effort to control payments to providers of Medicare services by the introduction of DRGs. Hospitals, in turn, sought to shift some of their costs from government payers to private payers, primarily health insurance companies. The insurance companies responded by playing a more substantial role in the organization and management of the use of services through managed care programs. Managed care organizations emerged because corporate and government purchasers of health care faced a crisis of excess spending by the physician-dominated system and a new concept was needed to control costs (Light, 2004). These purchasers became stakeholders in the nation’s system of health-care delivery. And, as stakeholders, observes Light (2004:19),

they sought to rein in the excesses, replace professional autonomy with accountable performance measures, and reorganize the center of health care from hospital-based acute intervention to community-based prevention and primary care.

Light finds that a large, new secondary industry arose in support of managed care organizations. These new businesses designed benefits, selected providers, managed services, defined outcomes, and established systems measuring quality and performance. The control of managed care was stripped away from physicians as the managed care model became a product of big business (Mechanic, 2004). The attraction for business corporations was to keep costs down through greater efficiency that would nonetheless provide a pipeline into the huge profit potential in the health-care market. No longer is managed care the alternative health-care delivery model that it once was; rather, it has become the dominant model.

Some medical sociologists now point out that the first ‘social contract’ between professional medicine and American society for health care featuring fee-for-service reimbursement, physician dominance, and limited government intervention has been replaced by a second one (Hafferty and Light, 1995; Light, 2004; Pescosolido and Boyer, 2005). The second social contract involves third-party reimbursements, greater use of nonphysician providers, and direct government involvement in financing and regulation. As Pescosolido and Boyer (2005:186) point out:

The nature of the second social contract has significantly altered the powerful position of physicians, making them more subject to limitations set by those who fund their services and the demands of those employers who purchase managed care plans.

This situation has led to a dramatic decline in the influence of physicians in the private medical market in the United States (Light, 2004).

Has managed care controlled costs? The answer appears to be that the system initially kept rising costs in check. Between 1993 and 1997, health care’s portion of the GDP fluctuated around 13.5%. In 1995, the U.S. Department of Commerce estimated that national health expenditures would exceed 15% of the GDP; however, only 13.4% of the GDP was spent on health that year – the smallest increase in several years. And by 1997, the percentage of the GDP had fallen to 13.1. But by 2003, the percentage of the GDP spent on health care had risen to 15.3 and the total amount of spending had soared to $1.7 trillion. If health spending continues to increase, then the percentage of the GDP spent on health care is certain to rise if expenditures in other economic sectors stabilize or decrease. Moreover, pressure from patients, physicians, and employers to give patients more choice in obtaining services has ended the requirement to obtain approval from a primary care physician before seeing a specialist in some managed care programs. And rising costs within managed care plans have resulted in higher insurance premiums and co-payments.

According to Mechanic (2004), some sources suggest that the managed care model is either ‘dead’ or transformed into ‘managed care lite’ as its controls on costs have weakened. Mechanic finds the central cause in managed care’s decline is the repudiation of its rationing services by the middle class. He points out that Americans are accustomed to having choice and autonomy in their utilization of health services and that the middle class in particular has reacted negatively to restrictions. Pressure on managed care plans by physicians, the media, and politicians responding to patients also helped dilute cost controls. Employers and health-care plans offering managed care health insurance retreated by allowing the relaxation of cost constraints. Managed care plans, in turn, adapted to the changing environment by devising new provisions and practice arrangements. As Mechanic (2004: 81) explains:

By the new century, health providers were increasingly successful at consolidating and strengthening their bargaining position as well, making it more difficult for health plans to demand low reimbursement rates.

The result was a return of upwardly spiraling costs for health care that are ultimately passed on to patients in the form of higher out-of-pocket costs and health insurance premiums. As for the managed care model, Mechanic forecasts that it will persevere by dispensing with gatekeepers and limited choices – instituting other ways of forcing patients to be more frugal in their choices – and reintroducing rationing.

Equity In Health Services

The problem of equity with respect to health services is and remains a serious problem in American society. In a free market system lacking national health insurance, those persons who are economically disadvantaged are also medically disadvantaged when it comes to obtaining quality services. The United States has a two-track system of health-care delivery divided into a private track and a public track. The public track is a system of welfare medicine supported by public health insurance, especially Medicaid (for the poor) but also Medicare (for the elderly).

Public health insurance has provided access to the American health-care delivery system for the poor, but the character of the services rendered – that of welfare medicine – has not changed dramatically. The urban poor have historically been dependent on public hospitals and clinics rather than private hospitals and practitioners for providing patient care. And that is still the case today for many of the poor and near-poor as physicians, pharmacists, and hospitals have joined banks, supermarkets, and department stores in migrating out of inner-city areas where the poor are concentrated. Vladeck (1983: 9) describes a pattern that has remained unchanged for years:

Apart from whatever esthetic differences such a pattern might imply, the fact remains that the poor – and to an even greater extent, the near-poor, who lack even the limited access to private physicians Medicaid provides – have no continuing relationship with individual physicians. This means that access to other services resides in the hands of bureaucratic strangers. The poor and nearpoor are more likely to be admitted to hospitals through emergency rooms than a scheduled admission, and more likely to be sicker when they are admitted. They are more likely to be treated by a foreign medical graduate, or a house staff physician still in training (or both) than a fully trained American graduate. Their drug prescriptions are written by physicians with less personal knowledge and understanding of the patients’ characteristics and problems, and they are likely to be seen on a follow-up visit by a physician other than the one who treated them originally.

The rural poor likewise have problems of access to health care as medical facilities and health practitioners may not be available locally. And the rural poor (as other people living in rural areas) also may be more likely to be treated by foreign medical school graduates. This situation is brought on by the doctor shortage in these areas caused by a reluctance of many American-trained physicians to work in small communities. Another segment of society particularly affected by problems of equity is the large number of Americans – over 16% of the population – who do not have health insurance. The largest proportion of persons (about 70%) without health insurance in 2003 were those whose family income was $50 000 or less. Most individuals and families without health insurance make too much money to qualify for Medicaid but still struggle financially. Many of them work for small businesses that cannot afford to offer health insurance to their employees. Not only does not having health insurance prevent or delay getting care for immediate health problems, but a lack of insurance over time has a strong negative cumulative effect on a person’s health (Quesnel-Valle´e, 2004). Without health insurance or available cash, people can be and are turned away from hospitals and sent elsewhere. Ultimately, they may be sent to ‘hospitals of last resort,’ which are generally public hospitals under the jurisdiction of city, county, or state governments. These hospitals are the ones that accept patients other hospitals refuse to treat because of an inability to pay for services.

Distribution Of Services

Besides problems with rising costs and equity, the American system of health-care delivery is not evenly distributed geographically, and primary care or family practitioners are underrepresented among physicians. A major factor in obtaining adequate medical care for some people is the numerical shortage of physicians serving patients in rural areas and urban slums. Physicians generally prefer to practice medicine in urbanized settings where they are close to cultural, educational, and recreational facilities. Another advantage of an urban practice is its proximity to extensive technological resources in the form of well-equipped hospitals, clinics, and laboratories staffed by well-trained personnel. Also important are the relationships with colleagues, which tend to enhance professional life, and these relationships are more readily available in urban areas where there are greater opportunities for professional recognition. And finally, it should be recognized that the more financially rewarding medical practices are those in large cities.

The maldistribution of physicians in the United States can be illustrated by comparing differences between predominantly urban and rural states. Differences within states are even larger. One out of every 20 counties in the United States does not have a single doctor, and more than half of all counties do not have a pediatrician. Even though small communities often advertise and try actively to recruit physicians, many doctors remain attracted to urban life.

The physician shortage is not limited to rural areas, however; it also extends into certain urban locales. Physicians in private practice are seldom found in neighborhoods characterized by large numbers of poor and nonwhite residents. Areas whose residents have relatively low levels of education and income tend to have proportionately fewer medical doctors in private practice. Consequently, shortages of physicians may exist in parts of New York City as well as in rural Alaska and Texas.

But there are a few signs that the distribution of physicians is beginning to improve. Part of this development is due to market conditions. Some areas have an oversupply of doctors, which encourages others to look elsewhere for establishing their practice. Also, rural areas with only one physician for every 3500 or more people and poverty areas with only one doctor per 3000 or more are eligible to apply for doctors under the National Health Service Corps (NHSC), a federally funded program designed to recruit and help organize the practices of health providers such as physicians, osteopaths, dentists, and physician assistants for isolated and low-income areas. Physicians who volunteer for NHSC service are paid financial incentives for joining, and medical students are given scholarships in return for participation in the program after graduation.

Another factor in the maldistribution of physicians is that of overspecialization, which has reduced the number of doctors engaged as general practitioners in primary care and family practice. The number of general and family practitioners declined substantially from 95 980 in 1949 to 60 049 in 1980; but, by 2003, there was an increase to 89 357.

A major reason for the trend in specialization has to do with the complexities of modern medicine. Kendall and Selvin (1957) noted years ago that as students progressed through medical school, more and more of them expressed a preference for specialized training. They found that the reason for the tendency to specialize was the students’ desire to restrict themselves to a particular area of knowledge with which they could be highly skillful, rather than trying to deal with what appears to be an insurmountable body of knowledge. In addition, a specialized and more manageable area of medicine may be less demanding of personal time, has more prestige, and provides a greater income. A particularly important factor for many younger doctors is having a controllable lifestyle and family time. This means more personal time away from the job and not having to deal with patients after their usual working hours. Consequently, medical specialties like dermatology, radiology, anesthesiology, and even emergency-room medicine became increasingly popular in the mid-2000s. For example, a dermatologist averaged $221 000 annually for 45 hours of work per week in 2005, while doctors in internal medicine and pediatrics earned about $135 000 a year for a 50-hour work week. In comparison, general surgeons made $238 000 a year for 60-hour weeks and orthopedists $323 000 for 58 hours a week.

There are more than 30 specialty boards affiliated with the AMA that certify physicians to practice in as many as 80 medical specialties, such as internal medicine, pediatrics, anesthesiology, family practice, obstetrics, gynecology, dermatology, psychiatry, general surgery, orthopedic surgery, urology, ophthalmology, and neurology. Although medical specialization has produced positive benefits by allowing physicians to concentrate their efforts on treating certain parts of the body, it has also produced negative side effects by making it more difficult to find a physician to take on continuing responsibility for the ‘whole’ patient.

The relatively low number and availability of primary care practitioners inhibits the access of patients to the health-care delivery system in the United States. Hospital emergency rooms thus become centers of primary care because of the lack of general practitioners, the reluctance of physicians to make house calls, and the unavailability of private physicians in the urban inner city. Also relevant is the fact that hospital emergency rooms are accessible, have a minimum of administrative barriers, and have the resources of an entire hospital behind them. Those who are most apt to use emergency rooms for primary care are the underprivileged, who have minimal social ties and no other regular source of medical care.

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