This is an ongoing series on health care system “memes” that continue to permeate our debate, even when evidence shows them to be false. The introductory post contains links to all entries. This one is coauthored by Aaron Carroll and Austin Frakt.
Give it time. Someone is bound to say that no one is truly uninsured in the US, or there’s no problem with access, because they can always go to the emergency room. This is an old argument meant to make people feel better about the status quo, to believe it is to believe that health care reform is not necessary.
It is true that nobody can be denied emergency care, and perhaps that is the basis for this 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.
Granted, we’re sure you can find some anecdotal exceptions to this. Perhaps you personally know someone who has had meds refilled at the emergency room. Or, perhaps, you know someone who has gone to the emergency room for some primary care complaint. The important thing to remember that these are anecdotes, and the plural of anecdote is not data. Emergency rooms are not equipped to provide, nor are they delivering on a population level, anything more than emergency care.
The consequences of believing in this meme 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.
