• Meme-busting: We have universal coverage because of emergency rooms

    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.

    • My son has special needs and when we moved 6 years ago, we couldn’t find any pediatrician or family doctor that would take the particular HMO he was enrolled in. It was secondary insurance but they still wanted no parts of him. We hadn’t changed anything when he got pink eye. My wife called lots of places and finally got an appointment with someone. When they got there, the receptionist said the woman that answered the phone made a mistake and they wouldn’t take the Medicaid insurance. They, the doctor’s office, told her she could take him to the emergency room. For pinkeye. They finally agreed to see him IF we canceled our Medicaid insurance for him. Thanks for the meme busting but I don’t have much hope for this one until the insurance system we have right now is fixed. I’m not holding my breath.

    • I don’t want to detract from what I think is the larger point of this post (EDs *shouldn’t* be what our nation counts as guaranteed access to care) but I think you might be confusing readers when you write that EDs can’t or don’t provide a much broader spectrum of services than what you’re describing here.
      Your post lists the EMTALA definition of emergency as though it were the upper limit of what EDs provide, rather than a floor defining the bare minimum of what they must do to avoid hefty fines. There are many, many patients with complaints that will never, ever reach the life-, limb- or organ- threatening stage, most of which could be managed equally well in other settings, who come to EDs for treatment every day and get it. Asthma is just one example and as an emergency physician who trained in a safety-net hospital I have written more prescriptions for pumps, nebs (and neb machines) and spacers than I can count for patients who come in with a very mild exacerbation and are out of their meds, or even patients who are just plain out of their meds and can’t be seen by their PCP for a few weeks. If you want more than my anecdotes, feel free to check out for some national (NHAMCS) numbers on the role EDs play in providing this type of care, particularly for the uninsured.
      Patients get this care in EDs in part because emergency providers are generally skittish about denying treatment to people who show up requesting it, potentially generating an EMTALA investigation and/or a malpractice claim if the patient turns out to be sicker than they looked, and in part because everyone recognizes that in many cases patients just don’t have timely, affordable alternatives so you might as well suck it up and write the scrip. And in part, it’s because if the patient is insured, the ED will generally get reimbursed for the visit regardless.
      What EDs don’t provide, in most cases, is preventative or screening care (although many do offer universal HIV screening). But in general the overlap between services provided in EDs and services provided elsewhere in the healthcare setting is actually a lot bigger than your description here implies.
      Your point about the significantly higher bills generated by an ED visit is well-taken, but it’s important to note that if you’re uninsured (or in some communities, underinsured) other, ‘less-expensive’ care settings won’t even let you in the door without cash up front, which effectively makes them just as unaffordable for many patients for whom a $20 fee and a $1000 fee are equally out of reach. Even low-cost CHCs are required to charge up-front fees for the care they provide, although I’ve heard some providers say that they don’t enforce the requirement rigorously. Universal coverage might solve this problem, depending on what reimbursement levels, post-reform access to CHCs and other low-cost providers, and deductibles/copays look like. Then again, it might not. The lessons of Medicaid are not particularly inspiring here.
      Again, I’m in no way trying to detract from what I understand to be your larger point, which is that constructing a healthcare system that relies on EDs as the universal safety-net is bad for patients, EDs and other providers alike. But I think you’re confusing a normative point about the way our system *ought to* work with a meme-busting point about the way it actually does. Your limited account of the range of care provided in EDs may end up weakening your argument, because it doesn’t fit in with either national data or many, many patients’ experiences.

    • Shrug. You don’t get universal coverage anywhere else, either. You can be denied all sorts of treatment by nationalized systems — especially diagnostics like those you mention above. And then there’s the long waits for specialists. Health care delayed is health care denied!

      Besides which, the ER is not the primary source of free health care for nonemergency problems. The country is littered with free clinics and charities and whatnot.

    • You did a classic strawman. Those of us who point out that the U.S. has “universal” care aren’t just talking about emergency rooms. We’re talking about free clinics, community clinics, non-profit research hospitals (e.g. St. Jude’s), charity programs, etc. We’re also talking about the fact that free healthcare is often available to people – who choose not to take it. (Heck, even people with great insurance often avoid going to the doctor.)

      Whitman-Walker, in Washington DC, is a good example of a large urban clinic that provides a wide variety of free care, most of which is preventative in nature. There are hundreds, perhaps thousands, of similar clinics across the country. Additionally, plenty of doctors and for-profit clinics provide free care in the communities to those in need.

      Moreover, we need to remember that many of the people who truly cannot afford insurance qualify for Medicaid. Many of them are too lazy or illiterate or afraid to fill out the paperwork for it. Many of these same people also suffer from ailments such as diabetes, and they could easily get free help from free clinics if they sought it.

      And just as TallDave pointed out, a government law that decrees “universal healthcare” doesn’t necessarily mean it will exist. One of the problems of the left is that they always assume that the goal of a policy will necessarily result from the policy. That’s seldom the case. More often than not, government policies do not achieve their stated goals, and they sometimes achieve the exact opposite of their goals. Just because the goal of “universal care” is providing universal care, doesn’t mean it will actually happen. A socialized system will find some other means of limiting consumption – typically some form of death panels.

    • Alan O wrote: “More often than not, government policies do not achieve their stated goals…”

      Hard, statistical proof of this big claim, please. Otherwise it sounds like just another teabag-windbag sounding off on AM radio. But you don’t have any backup, do you?

      Meanwhile, what can one do about the (“Shrug”) Talldaves of the world? There’s a lot of health care denied for Americans who are denied health care, and that is millions and millions of people. It only begins with the “pre-existing conditions” racket that makes it impossible or prohibitively expensive for so many, many people–and more every year–to even buy health insurance from our wonderful insurance companies.

      Everybody likes to beat up on France, so I’ll leave their excellent experience out of this debate. But people in Germany, Sweden, Denmark, Finland, the Netherlands, Norway, Japan, and our Canadian neighbors–they are very far from stupid. Given the opportunity to switch to the U.S. system: they have not and they never will. The Conservative prime minister of the UK this spring had to expressly deny any intention of moving to a U.S.-type system of health care delivery, or he would have lost his parliamentary majority, maybe even his head. The wise Taiwanese studied the health care systems of the world within the last 5-10 years before deciding how to set up their own system of national health care–needless to say, the U.S. model was the first to be rejected. And whenever China figures it is finally wealthy enough as a nation to to do something about everyone’s health care, then it’s dollars to Ferraris that the one they will not even think about emulating is our accidentally-born and stupidly-upheld system, almost as inefficient as it is expensive.

      • KUDOS TO THE several patriots on here that dont support this Obamacare monstrosity….we just need market based care and not try to imitate France, Canada, etc….leave the system the way it is

        • Grow up. “Obamacare monstrosity”?? That is one of the dumbest statements I have ever, ever read. And Richie, can’t you READ?


          Just emergency care if you’re having a health crisis. NO chemo. NO insulin. NO medications. What is so hard to understand about that? Oh, I’ll bet I know. Your ears are plugged by Fox News.

    • Antosha: “Hard, statistical proof of this big claim, please. Otherwise it sounds like just another teabag-windbag sounding off on AM radio. But you don’t have any backup, do you?”

      The alleged goal of minimum wage laws is to help the poor. The reality is that minimum wage laws actually hurt the poor because they increase unemployment, esp. among young people from minority populations. Did you know that there was a time when black youth unemployment was lower than white youth unemploymernt? You want to guess which year that ended? 1938 – the year the federal minimum wage started. Almost all economists agree that minimum wage laws hurt the poor. It’s an example of a government policy that aims at helping the poor but in reality hurts the poor. Yet the left continues in its ignorance to believe that just because their precious minimum wage law aims at helping the poor that it actually will – and that anyone who is against their policy must also be against helping the poor.

      Another hard example? Rent control. Rent control has as its goal helping poor people find housing. Yet the practical reality (and this has been proven over and over again in countless markets on various continents) is that rent control actually reduces the amount of affordable housing, which increases poverty and increases homelessness.

      Another example? Tax rates. A couple years back the state of Maryland thought it could raise revenues by increasing taxes on millionaires. Simple enouigh goal, right? Raising taxes = more revenue. But in reality when they raised the tax rates, many of the state’s millionaires suddenly dissapeared. They either left the state or moved their money around. Maryland’s revenue actually went down. The goal of the policy was to raise revenue; the reality of the policy was to decrease revenue.

      Another example? “Cash for clunkers” was supposed to help the environment – the practical reality is that it consumes far more energy to produce a whole new car than to fill an older one with slightly more gasoline. Cash for clunkers actually hurt the environment. It also hurt millions of low income Americans by taking hundreds of thousands of cheap, working used cars off the roads.

      Unemployment insurance gives people an incentive to stay in parts of the country where there are no jobs (usually blue states) – which increases the unemployment rate. It’s long been shown that welfare actually increases poverty, and the welfare reforms of the 1990’s decreased poverty. The examples could go on and on.

      Most government policies either don’t achieve the original stated goals, or they achieve the exact opposite of the stated goal. But leftists consistently believe that a policy will always achieve the stated goal of that policy – and from this they conclude that any of us who are against the policy must also be against the goal. If we’re against minimum wage law, they think we must therefore hate poor people. If we’re against rent controls, we must be against affordable housing for the homeless. If we’re against a law that decrees “universal healthcare” we must be against people having healthcare. But the reality is that access to a waiting list is not access to healthcare. In countries with socialized medicine, they control consumption by putting people on waiting lists. Universal care might be the goal, but it’s not the actual result.

    • Alan O. writes “Those of us who point out that the U.S. has “universal” care aren’t just talking about emergency rooms. We’re talking about free clinics, community clinics, non-profit research hospitals (e.g. St. Jude’s), charity programs, etc. We’re also talking about the fact that free healthcare is often available to people – who choose not to take it.”

      Ah, the classic reverse strawman. “There were plenty of lifeboats on the Titanic. Some of them even had empty seats when rescue vessels reached them. Why hold the shipping line responsible if some passengers who refused to use them drowned?”

    • What nonsense..nobody gets denied by the hospital..thats the law! Stop the liberal propeganda

    • Oh, I can read just fine. And yes, Obamacare must be replaced. You can get cared for at the ER, but beyond that I don’t want to pay for your way, and you don’t need to pay for me..I can pay my own way. If you want something, buy it on the free market. Don’t like what the insurance companies offer? Pay your doctor Cash. I’m not responsible for your health, and you’re not, for mine. I think you CAN’T READ! Yes, Obamacare must be repealled. The ind. mandate will be strick down by the supreme court. The majority of the country is against this bill. And fox? Theyre no. 1 in the ratings for a reason, . They beat CNN, MSNBC, HLN combined! Recently O’Reilly beat Braian Williams mon NBC (cable never beats broadcast)…look it up, liberal…..