• Health Care is More Than Emergency Room Care

    This post is coauthored by Aaron Carroll and Austin Frakt.

    Earlier this week, Mississippi governor Haley Barbour asserted, “There’s nobody in Mississippi who does not have access to health care.” He is neither the first, nor likely the last, to suggest that access to emergency room care is equivalent to access to all necessary health care, that everyone gets what they need whether insured or not. This is an old argument meant to make people feel better about the status quo. To believe it is to believe that health reform is not necessary. But Gov. Barbour’s simple statement uses one truth to obscure many others.

    It is true that nobody can be denied emergency care, and perhaps that is the basis for Gov. Barbour’s claim.  The 1986 Emergency Medical Treatment and Active Labor Act, or EMTALA, requires any hospital accepting Medicaid or Medicare — meaning pretty much every hospital in the US — to screen for and treat emergent medical conditions.

    But here’s another truth: emergent care is not the same thing as necessary care. Not even close. An emergent condition is defined by the law to mean a woman in active labor, or a health problem that, if not treated immediately, would lead to death, serious harm to bodily organs, or serious impairment of bodily functions.

    So, yes, if you’re actively giving birth, you can expect to receive care at an emergency room regardless of ability to pay. If you’re actively having a heart attack, you can also get emergency room care. If you’ve been seriously harmed in a car accident, you can go to the emergency room.

    But access to an emergency room is not the same as access to health care in general. It only provides access to a very narrow piece of what most Americans consider health care.

    Over 25 million people in the United States have diabetes, requiring regular access to medication to stay alive. They can’t get insulin in an emergency room. They can’t get needed eye exams or kidney function tests in the emergency room. They can’t get a checkup in the emergency room. But once they go into hypoglycemic shock or once their feet become gangrenous, then they can get examined and treated. Does that sound like access to health care?

    About 20 million people in the United States have asthma. They can’t get their prescription refills in an emergency room. They can’t get the equipment then need, like nebulizers or inhalers or spacers in an emergency room. They also can’t get checkups in an emergency room. Once they have an attack so bad that they could die they can get examined and treated, but that’s not access to health care.

    Over 200,000 women were diagnosed with breast cancer in 2010. Not a single one of them could get a mammogram in an emergency room. Over 140,000 people were diagnosed with colorectal cancer in 2010. Not a single one of them could get a colonoscopy in the emergency room.

    Nearly one in 100 children have Autism, and not a single one of them can get any treatment at all in the emergency room. More than 5 million children have attention deficit hyperactivity disorder (ADHD), and not a single one of them can get any treatment at all in the emergency room. Around ten percent of all children may qualify for interventions for developmental delay, but few get them, and not a single one of them get them from an emergency department.

    Emergency care is important, but it’s not the same thing as health care. We know that people with depression require treatment, but in an emergency room we can’t do anything about it until they are ready to commit suicide. We may know that you would benefit from a hip replacement, but until it fractures, there’s not much that will be done in an emergency department. We may know you  have arthritis, or ulcerative colitis, or migraines, or lupus, or hypothyroidism, or any of a host of other disorders, but until they are life threatening – there’s not much we can do for you.

    The consequences of this attitude are real and significant.  First, the emergency room is still not free; the hospital will likely bill even those will few resources, potentially bankrupting them. The costs to the system are prohibitive, since often the end-stage emergencies of chronic disease are significantly more costly than proper management. But most importantly, the suffering this “system” adds to those who are ill is inhumane, unnecessary, and hard to accept in the richest country in the world.

    A health care system that guarantees equal access only to emergency care is self-defeating, like shooting yourself in the foot. Ironically, the law guarantees emergency treatment for that action; short of anything that serious – you’re on your own.

    • This is wishful thinking on the part of Barbour and his ilk. Rather than address the issues of the uninsured, simply claim that they can get treatment, for free. Rather than take the position that they do not want to pay for the care of others, the end result of their policies, they avoid that admission by pretending these people get care.


    • Both side forget this from time to time. Most healthcare is not emergency must be done now care. This observation cuts both ways.

    • Excellent post. Keep ’em coming.

      Seems like someone should request every seated (and wannabe) politician.to answer a short, but vetted survey that “tests” their knowledge on facts like this. They do this all the time when re-election rolls around. Results get published for all to see – voter awareness. And when (OK, I’ll be kind – if) politicians decline to respond to surveys (assuming they are well thought out surveys) that says something, too.

      Hint hint.

      Actually, every American adult probably needs to take the same “test.” Preferably before they turn on any of their many electronic “communication” devices.


    • I work as an ER physician, and there are MANY patients who come to the ER for a ‘med refill’, for insulin, asthma medication etc. I would agree this is not the best way for a system to provide this care, but there is no ER in the country that refuses to see these patients or prescribe their medications. Often these patient’s ER care involves blood tests that could be done by a primary care doctor…but if the patient does not have one, ER staff try to do what is necessary while being aware we cannot replace the role of a primary care physician.

    • ghufran,

      The authors of this blog apparently have not noticed(or intentionally ignored) the fact that much of the care that is provided in the ED is not emergency care. Imagine: They actually think that only emergencies are addressed in the ED!

    • “The authors of this blog apparently have not noticed(or intentionally ignored) the fact that much of the care that is provided in the ED is not emergency care.”

      Yes, we provide non-emergent care in ERs, but without much follow up, especially monitoring the effects of those drugs. Then you end up with a patient coming to the ER with that double digit INR.


    • So, what are you trying to advocate? Should other people’s health care be my responsibility? Should I be taxed so that other people can get health care? Should another burden be laid upon the working class of this country so that the freeloaders of this country can get free health care? I hope that is not what you are advocating. I hope that you are only trying to raise awareness of the tragic state of the health care system and appealing to the humanity in all of us and that we should care enough about our fellow humans that we would contribute to the well being of others, whether it is volunteering time to help or donating to a charitable organization.

      • We try to illuminate, not advocate. However, sometimes information suggests something to some people, something else to others.

      • Can you seriously not realize that you are already currently being taxed for the more expensive emergency care of these same people? Is it possible you’re that in the dark?

        ****You’re getting taxed for it either way****, would you rather pay for the cheap method of treatment or the expensive one?

        The only alternative is to tell emergency rooms not to treat if people can’t pay, and throw them out on the sidewalk to die. How about that? Think that’s an option we should be putting on the table?

      • Kyle, you are too generous. People who volunteer their time to not for profit organizations are wonderful people. At free clinics those people are Dr. and nurses. If you are not one of them; then you cannot really help, but thanks for donating to your local free clinic.
        The Health Care Industry(Doctors, Nurses, Hospitals, and drug manufactures) is designed to make money. Free Clinics do not have the expensive equipment to diagnose more serious medical problems; therefore, people have to go to the ER. If everyone in your community donated 0.5% of their income to these Free Clinics, then everyone in your community would have access to the expensive equipment. Hospitals are for surgery and monitored care. The ER really does not need to be part of this for profit industry.

    • ” Should I be taxed so that other people can get health care? ”

      That should be part of the debate. What people who think like you suggest should realize is that this will result in preventable deaths and more chronically disabled people. What I object to, and what Aaron and Austin appear to be pointing out, is that you cannot claim that we will not tax ourselves to care for others, but they will somehow still be ok.


    • The idea that providing people with health insurance will somehow reduce costs is a fallacy. One patient being treated in the ER for diabetes is cheaper than paying for dialysis for one patient: however, there are probably at least one thousand patients who get neither ER care or other care who do not get renal failure (or some other complication). ‘giving’ these people ‘free’ health insurance will increase overall costs: the cost of medications, referrals to specialists etc for the many will greatly outweigh the reduction in cost from fewer complications.
      I am in favor of health care reform on moral and efficiency grounds, but let’s not fool ourselves that we’ll be saving money unless we make other changes to control cost. One method is rationing (like on England where I used to practice), the other is to give patients more control. My preference would be health savings accounts and high deductible plans, with prepayment to the hsa by the government for low income people so they have control over the money instead of the insurance company or government, and they benefit if they use resources wisely.

    • “So, what are you trying to advocate? Should other people’s health care be my responsibility? Should I be taxed so that other people can get health care? Should another burden be laid upon the working class…”

      Everything in life is connected. You own a business? The person without health insurance who suddenly has to go to the emergency room and spend $1000 could’ve been saving up to spend $500 in your used-car lot. Or $400 in your flat-screen TV store. Congratulations. You just lost a customer. I’d rather pay $10 more in taxes so these people can get health insurance and have a doctor’s visit than $100 more in taxes to finance the overcrowded, overburdened emergency rooms.

    • Thanks Doc. Excellent post, keep informing everyone.

    • I’m an ER doc, and while I agree with the overall tone of the article the RNs who wrote in were right: we give out a lot of refill prescriptions in the ER, as well as doses of medication that really aren’t life-and-death issues.

      The sad truth is that tons of people who come to the ER for non-emergency treatment already have doctors. They just can’t get an appointment. Listen to any MDs voicemail, or call and try to get an early appointment, and I’ll bet you good money they’ll tell you to go to the ER. So we get tons of people with yeast infections, sore throats, seasonal allergies, and athlete’s foot heading on in and dragging the system down, when all of these people have access to primary care already. Part of the reason they are sent to the ER rather than given advice over the phone is because of that threat of a lawsuit if something goes wrong (always a risk).

      The upshot? Having primary care does not always mean having ACCESS to that care. In the Burger King Drive-Through mentality of the USA, people want to be fixed immediately with minimal risk. Not necessarily a bad goal, but not a very manageable one at times.

    • I practice in 3 different EDs. In one of them, we provide the required Medical Screening Exam (MSE), and if there is no emergency, the patient is “screened out”. In my setting, the patient is given the opportunity to make a down payment on their very expensive ER care ($180.00) and if they do so, we treat them. The other hospital across town does the MSE and if there is no emergency, you are discharged, period.

      The VAST majority of the patients I see and screen have Medicaid, but can’t be bothered to call and make an appointment for their FREE clinic care. Many others have private insurance, but don’t want to make their co-pay. (We ask for that co-pay and screen them out if they can’t pay it). The rest seem to be self pay (better known as never-pay).

      We don’t screen anyone under the age of 12, and I usually go ahead and treat any kid who is dependent on a poor parent to actually bother to make them an appointment, because they won’t.

      Most of these people don’t have jobs, and have the flexibility to go to the clinic. I don’t have that luxury. Most of these people absolutely could work, if they tried. But since other people pay into a system that supports them, they don’t have to work.

      People who can’t possibly afford to purchase a bottle of Tylenol never run out of money to purchase cigarettes.

      People with Medicaid are forever wanting a “refill” on their meds from me. They can get a free appointment to get their free medication.

      People who can’t seem to understand how to access their FREE healthcare, seem to have no problems operating their fancy complicated cell phones, laptops, video games and MP3 players that accompany them to the ED, which they can’t turn off, even while you’re are trying to examine them.

      Here’s how to add millions of dollars to the health care system – if you can’t pass a drug screen, you get your Medicaid taken away.

      I’m tired of working, paying taxes, and providing a living for drug addicts, drunks, and lazy people. I am happy to continue working and paying taxes to care for the truly needy.

    • Actually Haley is right..they can’t refuse anyone at the hospital