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Five reasons why ER’s don’t mean free healthcare for the uninsured

In an interview with 60 Minutes last week, Mitt Romney was asked if he thinks “the government has a responsibility to provide healthcare to the 50 million Americans who don’t have it today?” His response:

“Well, we do provide care for people who don’t have insurance … if someone has a heart attack, they don’t sit in their apartment and — and die. We pick them up in an ambulance, and take them to the hospital and give them care. And different states have different ways of providing for that care.”

In other words the uninsured can still get care through the emergency room. As a number of sites have pointed out, this is almost exactly the opposite of what he’s said in the past. To pick just one example, here he is two years ago on MSNBC (at one minute):

“It doesn’t make a lot of sense for us to have millions and millions of people who have no health insurance and yet who can go to the emergency room and get entirely free care for which they have no responsibility.”

But we’re less interested in Romney’s apparent flip flop, and more interested in the point he’s been consistent on. The idea that having access to the emergency room means access to free healthcare is one of the biggest myths about our healthcare system. Here are five reasons why it’s wrong.

1. Hospitals charge (a lot) for emergency care

The 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) requires any hospital that receives federal funding– and because of Medicare almost every hospital does–  to treat patients with life-threatening conditions or who are in active labor.

Hospitals have to provide this care regardless of whether or not the patient can afford to pay– but there’s nothing in the law stopping them from charging patients afterward. As University of Chicago health policy professor Harold Pollack told NPR:

“The emergency room is perfectly entitled to send you a whopping bill. And there are many people across America who are facing significant financial problems from serious bills that they’ve received for emergency care.”

Hospitals can be extremely aggressive in their efforts to get paid. The New York Times reported on one provider, Accretive Health, whose collection efforts started before patients were treated (possibly violating federal law):

In April, Lori Swanson, the Minnesota attorney general, disclosed hundreds of Accretive’s internal documents that outlined aggressive collection tactics, including embedding debt collectors in emergency rooms and pressuring patients to pay before receiving treatment.

Carol Wall, a 53-year-old Minnesota resident, said “a woman with a computer cart” told her she owed $300 as she was “vaginally hemorrhaging large amounts of blood” at an Accretive-affiliated emergency room in January, according to court records.

Another patient, Terry Mackel, 50, said he was asked to pay $363.55 at another Accretive-affiliated emergency room in Minnesota as he waited “alone, groggy and hooked up to an IV” waiting to see an emergency room doctor, according to court documents. Fearing that it was the only way to see a doctor, both patients paid.

2. Some for-profit hospitals ignore the law, “dumping” uninsured patients onto other hospitals

The Washington Post’s Sarah Kliff reports on a study by George Washington University’s Sara Rosenbaum, who looked at how well hospitals in Denver actually complied with the federal law to treat emergency patients without insurance:

Her results, published this year in Health Affairs, showed many instances where hospitals managed to dodge providing care for those without coverage. In one case, a doctor refused to see an uninsured patient; in others, ambulance drivers simply know which hospitals will be amenable to an uninsured patient. She writes about the case of one 39-year-old epileptic woman without insurance, who an ambulance picked up after repeated seizures.

“The ambulance drove [350 miles], past several for-profit hospitals much closer to her home, en route to Denver Health Medical Center,” Rosenbaum recounts. “The ambulance attendants reportedly explained to the patient’s husband that the facilities they were bypassing did not treat uninsured patients. The patient remained in Denver Health’s medical intensive care unit for nearly a week, incurring charges of $66,619.”

3. Emergency care is not the same thing as necessary care

The health policy professors at The Incidental Economist did a fantastic post making this point last year. Here’s a sample:

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.

[We highly recommend checking out their whole post here.]

4. The uninsured may have less access to the emergency room than other groups

Looking at data about emergency-room visits between 2000 and 2007, the Department of Health and Human Services found that the percentage of patients who left without seeing a doctor was over twice as high for those without insurance (3% versus just over 1%).

The study’s author offered Timothy Noah at Slate some possible explanations why the uninsured– who remember are least likely to receive care anywhere else— were more likely to leave the ER without seeing a doctor. None of them were good:

  1. The uninsured are more likely to live in poor neighborhoods where hospitals and ERs are understaffed and where everyone has to wait a long time.
  2. ERs may recognize the uninsured as money losers and make them wait longer.
  3. The uninsured may be more likely to go to [ERs] for routine care because private doctors will not see them for free. Because their care is not emergent, more urgent cases are seen before them.
  4. Patients with mental health and substance abuse disorders may be more likely to be uninsured. Such patients are also more likely to leave without being seen.

5. The uninsured may get worse care in the emergency room

The Washington Post’s Sarah Kliff (and if you haven’t already, you should really check out her entire article) points to a recent study in which a team of researchers at the Children’s Hospital in Boston found that uninsured kids were 22 percent less likely to receive tests, undergo procedures or receive prescription medication.

And remember we haven’t even talked about the costs. Emergency room care is ridiculously expensive, and when the uninsured can’t pay (or go bankrupt trying to pay) the costs are passed on to everyone else, in the form of higher premiums and government payments to hospitals. In other words, say the folks at Incidental Economist:

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.

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