Not that we didn't basically already know this . . .

but it's not official till it's published in a peer reviewed journal.

Robert Hurley, Hoangmai Pham, and Gary Claxton, in Health Affairs (and this one is free to all, no subscription required), report on new information from the Community Tracking Study, which is a largely qualitative ongoing study of health care markets in metropolitan areas selected to be representative of the U.S.

There is too much detail here to really do justice to it in a summary, but the main idea is that there has been a strong trend toward growing inequality in access to high quality health care. Investments continue to be made in new facilities which are not only state-of-the-art, and have the latest and greatest equipment, but also offer lavish amenities to consumers. There has been growth in the development of free standing specialty care centers, where highly paid medical specialists can ply their trades without the burdens of working in a general hospital where they have to do things like cover the emergency department and take care of people without the best insurance. Meanwhile, primary care providers continue to lose ground in compensation. People with private, employer-provided insurance, and Medicare beneficiaries, have access to this high quality, high priced care, and they continue to benefit from the latest in medical technology.

At the same time, states have cut back severely on Medicaid benefits, both reducing payment to providers and eliminating coverage for some services. As a result, specialists don't want to take care of Medicaid patients. They are consigned to community health centers and other providers, which don't have the amenities, or the great equipment, and are overburdened. Medicaid beneficiaries often have difficulty getting specialty care at all. And then, of course, there is the sharp rise in the number of adults with no health care insurance at all, who get only urgent care when they are seriously sick or injured.

The disparities in access to high quality care are exacerbated by the tendency for investment to flow to affluent areas. Hospitals serving poorer communities can't raise the capital to upgrade their facilities and equipment, so poor people are harmed by geographic disparities as well as the kind of insurance they have.

Because emergency departments are required by law to take all comers, they are a potential portal to care for people without insurance, or to higher quality or specialty care for Medicaid beneficiaries. Consequently, other providers try to dump patients on emergency departments. However, the EDs are having increasing difficulty in finding specialists who will be on call for them, and follow-up care for people who come in through EDs is even harder to find.

The people who fare the worst, as our readers know well, are the chronically mentally ill.

In my view, we are moving beyond a class structure in the United States to a caste system, in which the boundaries between social strata are almost impossible to cross. Once you lose insurance, and become sick (in whichever order), you will never be able to recover, because you will not get health care or rehabilitative services, therefore you will not be able to work, and you will never again have insurance, unless you are lucky enough to make it to age 65. That's what the culture of life will do for you.