No, You Do Not Have the Right to Free Emergency Care

Below, a guest post by Harold Pollack, who has recently joined The Century Foundation as an adjunct fellow focusing on issues of Economics and Inequaiity.  Pollack is the Helen Ross Professor at the School of Social Service Administration, and faculty chair of the Center for Health Administration Studies at the University of Chicago .–MM

During the health reform debate, many people asserted that the uninsured are, de facto, already covered because they can always get emergency care. Here, for example, was President George W. Bush in 2008: I mean, people have access to health care in America," he said. "After all, you just go to an emergency room."

Thursday, one of Ezra Klein's commenters says something similar, though from a different locale on the ideological spectrum:

If the Republican Party is serious about decreasing government control of health care, they should start by introducing a bill that would repeal the law signed by President Ronald Reagan that mandates free health care for all who seek it. That law, the Emergency Medical Treatment and Labor Act (EMTALA), was the largest expansion of government mandated health care since Medicare.

For obvious reasons, it would be terrible health policy to make emergency departments into our all-purpose free-care safety-net, even in a hypothetical universe where these facilities were actually capable of providing all the care that people need. But that's not what EMTALA actually does.

It's true that under EMTALA that emergency departments must assess and stabilize patients regardless of ability to pay. Hospitals can't provide a lower level of emergency care to patients they do not believe can pay. EMTALA provides other important protections to guard against "patient dumping," and the most heavy-handed hospital tactics. The law was a necessary Band-Aid to deter serious abuses. Unfortunately, it did not address the underlying supply and demand fundamentals that lead so many patients to seek emergency care, and so many hospitals to balk at providing it.

Moreover, the right to receive care is not the right to receive free care, as many Americans have learned to their sorrow. Under EMTALA, your hospital ER must assess you and stabilize your emergent condition. It may then discharge you or transfer you to the county hospital for further care. Two weeks later, that same ER is perfectly entitled to send you a $10,000 bill. Of course, many of these bills go unpaid. Often—but not always—hospitals write off this debt as unpayable.

And as these Jonathan Cohn stories underscore, hospitals can get pretty snippy trying to collect these debts. This happens all the time, sometimes with poignant or tragic results. Hospitals are within their rights to haul you into civil court if you do not pay. Even when patients are unlikely to pay, hospitals may still pursue things.

I can understand why individual hospitals feel driven to do this. They don't want to look like easy marks when their catchment area includes tens of thousands of uninsured or under-insured people. Many hospitals are closing their emergency departments or trying to constrain the financial bleed these facilities can cause. This is hardly surprising within a medical economy that includes 50 million people without health insurance coverage.

Some supporters of the Affordable Care Act claim that universal coverage will reduce emergency department use by providing access to more appropriate care. I'm skeptical. The new law will help to financially stabilize the emergency medical care system, so hospitals feel less of a need to build up their defenses when patients walk through that ER door. This is an essential step in creating an effective and humane emergency care system.

15 thoughts on “No, You Do Not Have the Right to Free Emergency Care

  1. Brad–
    Good to hear from you.
    I’m going to let Harold know about the comments section HeathBeat so that he can respond.
    In the meantime,I agree, it’s an excellent post.

  2. The sad fact is, though, many hospital admissions are “social” admissions intended to protect hospitals from liability.
    I see two sorts of things happen in ERs that must change.
    One is physicians who practice defensive medicine and insist on expensive diagnostic tests for complaints they have already diagnosed. The tests aren’t going to change the diagnosis. Just satisfy the patient that they didn’t waste their time coming to the ER (I’ve actually seen patients get indignant when told they have a simple head cold) or protect the physician from liability.
    The other is physicians whose first task is to check the face sheet. Got insurance? Red carpet treatment, whether you need it or not. No insurance, or Medicaid? Out the door.

  3. Panacea–
    I tend to agree. Though when I was talking to Harold P. about the amount of testing that goes on in ERs, he explained that in many cases, doctors put the patient through a battery of tests “because they know they may never see him again.”
    This is their one shot at diagnosing the 3 or 4 diseases that afflict many patients–espeically older patient or low-income patients.
    At the same time, I agree their are many patients with one clear complain– sprained an ankle, have a sore throat (is it strep) etc., and I suspect these are the patients who should be going to an “urgent visit” clinic witin an ER– not going through full triage.
    (Patients who knew they had one straightforward complaint could also get in and out much more quickly by using a urgent patient center set up within the ER).
    As for doctors who check your insurance before deciding how well to treat you . . .all I can say is that I don’t see why that information should be made available to the doctors (or nurses.)
    This is the kind of rationing of care by ability to pay that we are trying to eliminate.

  4. You hit on a good point with the urgent care, ER visit. One reason ER care is so expensive and they can charge so much boils down to this. Because they can. There is probably little difference other than the occassional missed diagnosis in the ultimate care of a sprained ankle seen in the ER and one seen in my office, X-rays, ice, NSAIDS. There is a difference in ease of access (walking in vs. calling for an appointment), but boy howdy is there a big difference in cost. Just because someone is seen on the 1st floor vs. the Third floor of a hospital doesn’t mean it should cost 3 times as much, if your lucky. And I’m the end of the line expert charging a fraction of the ER to boot.

  5. Jenga —
    Your observation about the high cost of ER care is true, but it is also true that ER’s are not profit centers for hospitals. In fact, as the article suggests, for most hospitals they are money losers.
    There are two reasons for this.
    The first and most obvious is that, as noted, ER’s cannot count on being paid for services all the time. In many cases, large fractions of ER patients do not pay for services. ER’s must work on a business model that factors this in, otherwise they would close — as many are deciding to do.
    Second, ER’s are not in any way like an orthopedist’s office. The orthopedist can count on the fact that patients are stable and reasonably healthy and he has no responsibility for the patient’s condition other than the broken ankle. The ER is staffed and equipped to deal with everything from major accidents to gunshot wounds to major infections to cardiac arrest to drug overdose to multi-system collapse due to complex underlying conditions. The ER is expected not only to be able to work up all these problems but be prepared to offer immediate treatment. The staff and equipment necessary for that mission are very costly whether they are being used or standing vacant, and that cost is built in to the ER’s business model.
    That is why ER’s are such poor places to manage more routine illnesses and why most ER doctors and administrators would dearly love to see those cases go elsewhere. And that is why in every country but our own there are models of care that avoid clogging ER’s with routine cases that consume space, equipment, and staff that would be more appropriately reserved for patients who really need them.
    In fact, keeping ER visits down is a major cost saving goal of any rationally designed system. Our system just does not happen to be rational.

  6. there’s a difference between denying people needed care because of their inability to pay and subsequently billing them for needed care.
    many people know they can take their acute problem to the local emergency room and get some help. unfortunately, few of them realize how negotiable the resulting bill is or how few people actually pay it in full. those few, who endeavor to pay the rack rate they are billed (which no one expects them to pay in full)are those who are really disadvantaged by today’s system

  7. Whether or not the current health bill will help, it’s obvious that it makes no financial sense not to find affordable health care options for those people who are likely to end up in an ER at some point in their lives. That’s pretty much a certainty, right?

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  9. Pat S. –
    I think ER’s are money losers for most hospitals, in large part, because of the way hospital accounting systems work. If an ER patient is sent down the hall for imaging, the radiology department captures the revenue for the test and not the ER. For many hospitals, 50% of their inpatient admissions come through the ER but it’s the various departments that provide the inpatient care that get credit for the revenue. Where would many of these hospitals be financially if they didn’t have an ER to help fill the inpatient beds?
    That all said, I think it makes a lot of sense to have an ER clinic in conjunction with the ER, either down the hall, on another floor or somewhere else close by so non-urgent patients can be sent there and treated at lower cost while the ER’s capacity to treat patients who need immediate attention can be maximized. If some of the clinic staff is not busy, they can even be called to help out in the ER if needed. As for treating large numbers of uninsured, I think that’s a more significant issue in cities and low income suburbs. There are many hospitals that provide comparatively little uncompensated care in the ER or elsewhere throughout the facility.

  10. Barry —
    I think that ER’s are often — not always — real money losers. This largely depends on what the population walking through the door is like in terms of insurance coverage, what that coverage is like, and what the underlying health status of patients is. If a large number of patients are either uninsured or insured only by Medicaid programs that pay a small fraction of charges, and if patients tend to have bad underlying health that has been neglected, they are real losers. If the patients are mostly well insured middle class people who get reasonably good health care in their regular lives, the ER can be profitable.
    For evidence I would point out that many hospitals are eager to get out of the ER business. If ER losses were merely accounting tricks and the ER contributed to profits, hospitals would certainly be unwilling to throw away that income. Hospital CEO’s and CFO’s are by no means naive about these issues.
    Hospitals that exist in markets where ER’s can be profitable are eager to compete with other hospitals for ER traffic. Hospitals in markets where ER’s are losers are eager to dump the ER.
    Nonetheless, ER’s are always more expensive, because of overhead issues I discussed earlier, than outpatient or clinic care, and any rational system would make getting patients to use those services in preference to the ER whenever possible a major goal. The best way, as other countries have shown uniformly, is to get the entire population plugged in to regular care outside the ER. Works well everywhere else, and would certainly work well here if we were willing to try.

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