If you’ve had many conversations about healthcare reform, it is likely you’ve heard some variation on this theme:
“Hospitals have to provide care for people who show up. So everyone can get healthcare when they need it. So when people say that can’t get healthcare, that isn’t true.”
Is there any merit to that argument? Spoiler: NO. But if you want to hear more about where that idea comes from, take a listen.
[00:00:00] There’s been a lot of debate about health care lately.
[00:00:14] That may be the understatement of the year Amy.
[00:00:17] Well it’s been a heated, opinionated all out battle about how our health care system should work.
[00:00:23] Yes but that’s over, thankfully, for a bit. It seems the last vote in the Senate will give a reprieve.
[00:00:29] Yeah it is. But there was one point I heard made multiple times in conversations about health care law and it’s this: Hospitals are required to provide care for patients anyway. We already have universal coverage.
[00:00:42] Is that true?
[00:00:43] Yes and No. There is some truth to it but it’s not completely true. That’s what we’re going to talk about today.
[00:01:01] Hello and welcome to 2 Docs Talk, the podcast about how the science of medicine and everything.
[00:01:07] OK so imagine it’s back in 1985…
[00:01:10] Good year.
[00:01:10] …and you’ve started having shortness of breath and pain in your left shoulder. You show up at the E.R. in your town and they ask for your insurance card and you can’t produce it because you don’t have one. You are uninsured. In 1985 they were in their rights to say sorry if you can’t pay we can’t provide your medical care we’ll transfer you to the public hospital for charity care.
[00:01:31] OK so where I live the public hospital is very inconvenient. If I had to transfer from the closest hospital to me to the public hospital that serves my area it would take about 45 minutes by ambulance. I mean I’d have to go all the way down to Brack in central Austin.
[00:01:46] Yeah same for me. I’d have to go down to Parkland down in Dallas. And you know 45 minutes – that’s a long time, if you’re in labor or having a heart attack.
[00:01:54] That’s without traffic. Yeah. Yeah it could be a lifetime. Literally.
[00:01:59] Literally Yeah. So to be clear not all of these patients were transferred or turned away. In fact emergency room physicians provide the most charity care of any specialty E.R. docs aren’t generally built to turn their back on an emergency because of money.
[00:02:13] I think most people aren’t built that way.
[00:02:14] No I don’t think so.
[00:02:16] But as with any industry money rules and even the most charitable of ER docs may have had their hands tied by policy.
[00:02:23] So that led to EMTALA – the emergency medical treatment and Labor Act.
[00:02:27] Yes this law was passed in 1986. It addressed the issue of people showing up in the hospital in the middle of a heart attack or in labor and being transferred because they lacked insurance or some other way of paying for their medical care.
[00:02:40] Now EMTALA requires that hospitals with an emergency department that participate in Medicare must provide a screening exam and treat emergency medical conditions. It requires this regardless of the patient’s ability to pay.
[00:02:53] Also the hospitals can’t consider insurance status, national origin, race, creed, or color in their decision to provide treatment.
[00:03:01] And it also defines an emergency for this purpose. And I’ll quote the definition: “a condition manifesting itself by acute symptoms of sufficient severity including severe pain such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health or the health of an unborn child in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.
[00:03:27] So this sounds like a great idea right? Well yeah but it does have its issues.
[00:03:33] How so?
[00:03:34] Well primarily it’s an unfunded mandate.
[00:03:38] Bingo! But that’s OK. If all hospitals have to provide this care the cost would be spread across the board and shared.
[00:03:44] Well yes but one group kind of gets the shaft here. Emergency Physicians. Many of these doctors aren’t employees of the hospital and they bill their services separately. So they simply don’t get paid for work they perform under EMTALA.
[00:03:56] Right. And the American Medical Association estimated back in 2003 that ER Docs provided about 138 thousand dollars per year per E.R. doc worth of charity care because of EMTALA and other specialties provide some of the telecare as well. But the burden really does fall disproportionately ER Docs.
[00:04:17] Yeah. Now they can bill the patients, to be clear, and they do – same as the hospitals do. But that doesn’t mean they’re going to get paid for their work because I mean these patients can’t pay. That’s the whole point.
[00:04:26] Well they’re filthy rich doctors they can take it right?
[00:04:29] That’s right. They can cry about all that money they’re losing from their second home in the Caribbean.
[00:04:34] Dear ER friends we hope you know we’re being extremely sarcastic.
[00:04:39] There is a general point to be made here though. We the People pay for this emergency care one way or another. The hospitals absorb the cost of EMTALA and they raise their prices to compensate. Insurance companies then raise their premiums to cover higher costs of medical care.
[00:04:53] And the ER docs probably charge more for the same reason causing a ripple effect leading to increase insurance premiums.
[00:04:59] So funding that federal mandate from a federal level could actually lower insurance rates.
[00:05:04] Yeah. OK. But back to the initial question we were asking. Hospitals do you have to provide emergency coverage. So we don’t really need universal coverage we already have it.
[00:05:14] For emergencies. We have it for emergencies. But once the patient is stabilized nobody has to give them any care.
[00:05:22] OK. Can you give an illustration of how that would work.
[00:05:25] Yeah. OK so let’s say an uninsured individual comes to the ER with stomach pain and vomiting and they’re dehydrated.
[00:05:30] And through the course of their work up a tumor is found that’s blocking their small bowel. And they have cancer.
[00:05:37] So they get rehydrated and they have surgery to remove the bulk of the tumor that’s pressing on the bowel. They feel better they get discharged from the hospital. And now they’re stabilized, but they have cancer for which they can’t afford treatment.
[00:05:53] Yeah. So the next care they may get maybe for the next emergency the cancer causes because the tumor is growing again.
[00:06:00] Right. Yeah. Well maybe the patient had Crohn’s disease which is a lifelong illness. Maybe that was what’s causing the problem. And again once they’re stabilized they still don’t have health care for Crohn’s disease.
[00:06:14] Yeah. And I mean you can think of any number of emergencies that would fit the same pattern.
[00:06:18] It goes on and on and I have seen this so many times.
[00:06:21] Yeah. And and that after the emergency. What about before the emergency?
[00:06:26] Yeah. The person with cancer may have been able to have it detected prior to the emergency but they just couldn’t get any treatment.
[00:06:33] Yeah. If you can’t afford preventive medicine. Yeah. And what about somebody who’s having a heart attack. Maybe they could have prevented the heart attack with an affordable medication for high blood pressure, but because they were uninsured they weren’t getting regular care until the emergency came up.
[00:06:49] So let’s state this clearly, instead of receiving emergency care to prolong their lives. they could have received preventative and outpatient care that saved their lives. They should have.
[00:06:59] Yeah they should have. And so EMTALA is a safety net but it’s certainly not the ideal from a medical standpoint. It’s also more expensive.
[00:07:09] Right, a prescription for blood pressure medications is a lot cheaper than treatment for a heart attack.
[00:07:15] And remember those costs end up inflating our insurance premiums. That’s a higher cost to all of us.
[00:07:20] So yes we have universal coverage for emergencies but we don’t have universal health care by any shot.
[00:07:25] No. Now the Affordable Care Act tried to address this by expanding Medicaid. Expanding in this case means increasing the income level necessary to qualify for it and also lifting some of the other restrictions to qualify for it. So for example before the Affordable Care Act it was up to individual states how they wanted to handle low income people – adults under age 65 who were not disabled and who didn’t have children. So some states provided them with Medicaid and some didn’t but there was no federal rule governing that.
[00:07:56] Right. In our great state of Texas for example low income adults without children under the age of 65 who are not disabled are not covered by Medicaid. That’s a mouthful. In fact we’re going to be talking about Medicaid and the following podcast here. Yeah. So a lot of this will go into a little bit more depth here.
[00:08:15] Now some states did expand Medicaid and with that expansion comes the mandate that they provide Medicaid services for everybody based on their income level. But if they didn’t expand Medicaid they don’t have to. So even after the Affordable Care Act, for example in Texas, certain people don’t get Medicaid coverage. So it’s a complicated and tricky. But the Affordable Care Act attempted to solve the problem but it didn’t completely solve it.
[00:08:43] More on that later.
[00:08:44] So anyways so let’s say now universally parents of children with under a certain income level do get some Medicaid help but it’s not much. They have to make 18 percent or less of the federal poverty level. How much is that. Well it varies by families. But let’s take a single parent with one child. The federal poverty level is sixteen thousand two hundred forty dollars per year and 18 percent of that two thousand nine hundred twenty three dollars to make less than $250 a month to qualify for Medicaid. Yeah. So if you’re a working full time minimum wage job single parent with one child and you make eleven hundred sixty dollars a month at that minimum wage job you would have to be in real trouble. Something really bad would happen to have to happen to you to qualify for Medicaid because you’re way over the minimum or the maximum income level there.
[00:09:38] The limits are higher for children but still there are a number of kids in states that didn’t expand Medicaid whose families make too much for Medicaid but not enough to buy insurance on the exchange.
[00:09:48] Yeah. So what’s our take away on this. We don’t have universal coverage in the United States. EMTALA is a safety net with a really big mesh size.
[00:09:55] That’s right. Lots of stuff getting through that net.
[00:09:57] So if you’re making the argument that we have EMTALA so we don’t need better health care policies in the U.S. Your’re going to have to come up with a better argument.
[00:10:06] So that’s our show for today.
[00:10:07] We hope you enjoyed it and can use the information well.
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[00:10:21] Hey, You know I’ve got a craving for French onion soup.
[00:10:23] Topped with Emmentaler cheese I presume?
[00:10:25] You got it.
[00:10:26] That’s really bad.
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