The ER as a substitute for health insurance ?

When candidate for President Mitt Romney, channeling George W. Bush, implied that access to ER care under EMTALA mandates was equivalent to having ‘health insurance’ for those who could not afford or purchase it; he was roundly criticized by the media and even members of his own party’s leadership.   This is but one of many misperceptions about ER care that are commonly held, but it was odd to see this one politically naive blunder from a presidential candidate stimulate so many comments from so many others who likewise seem to have very little clue what emergency department services, and the EMTALA obligation to provide emergency care to everyone, regardless of insurance status or ability to pay, are all about.

Many commentators chose to take Mr. Romney’s comments out of context, and ignore the fact that he followed the now infamous blooper with some references to state-supported charity care clinics that may or may not be available to the poor and uninsured to provide the care that ERs are not designed to provide.  However, even if you acknowledge these references, it does not mitigate Mitt’s presumption that ER care is ‘free’ to the uninsured, or that hospitals and physicians who provide this care will not at least attempt to pursue payment, some even all the way through bankruptcy court.  The fact that emergency physicians provide an average of $145,000 dollars worth of charity care every year does not mean that every uninsured ER patient gets a pass, or irresponsibly ignores the bills they receive for this care.  Clearly, Mr. Romney has never had to personally deal with such mundane issues.  ER care is neither a substitute for health insurance nor an open-ended guarantee of free care for the uninsured.

Furthermore, as many emergency physicians have already said in response, ERs can only do so much:  they don’t provide screening colonoscopies, or prenatal care, or cancer chemotherapy, or genetic screening, or rehab therapy after the heart attack or the car accident.  For that matter, the state-run charity care clinics Romney alluded to often are unable to provide this kind of care either.   Mr. Romney could have pointed to the health reform program he instituted in Massachusetts in response to the question about providing health insurance to the 50 million uninsured in the US, but predictably he chose to stumble over his party’s newly minted not so compassionate conservatism and try to break his fall by leaning on the open door of the ER.

What happened next is what really got my attention.  All sorts of talking heads in the media immediately pointed to Romney’s comments from two years ago citing his criticism of ‘ER socialism’: “”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”.  Curiously, this concept was accepted as a truism by nearly everyone who used it to suggest that the candidate had flip-flopped on the issue.  Believe me when I say that you can’t get entirely free care in an ER for which you have no responsibility.  In some cases, you can duck this responsibility, in other cases you will absolutely be held responsible, and it may have nothing to do with whether or not you can afford to pay.

Then came all the allusions to the ‘inefficiency’ of the ER.  I even saw one comment to the effect that ERs are ‘the worst possible place to get health care’!   If ERs are so ineffective and inefficient, why do so many ER patients come to the ER at the recommendation of their primary care physicians when the patients need urgent diagnostic evaluation and timely management?     And how about this one from Bob Confer of the Tonawanda News (and about a dozen other bloggers and commentators):  “Never mind the fact that ER care is the most expensive form of medical treatment there is.”  Really?  I guess they never spent any time in an operating room, or an ICU, or a cardiac cath lab.  He (and they) also had comments like:  “ER treatment is not health care. It’s death prevention.”  Reducing even the most painful shoulder dislocation really can’t be considered a life-saving procedure, can it?

Then we got the economic arguments deriding ER care, like the following from Robert Bowen in Examiner.com:  “Government data shows that the average emergency department visit cost $922 in 2008. The average office visit, meanwhile, came in at $199. Here’s another way to put it: Emergency room visits accounted for 4.4 percent of doctor visits but 14.4 percent of doctor visit costs.”  Yes, when you are talking about comparing treatment for a simple urinary tract infection, care in the ER is much more expensive than care in the doctor’s office; but when we are making comparisons like this, can we at least agree to compare apples with apples, and do some acuity adjusting while we are at it?  How many UTIs in the doctor’s office are bordering on sepsis?  How many visits to the doctors’ office include the cost of the x-ray done in the radiology suite, or the blood tests done at the lab?  How many such comparisons consider that it sometimes takes three visits over five days to arrive at the same result that one visit to the ER accomplishes?  Some would call that ‘efficiency’, but I guess one’s perspective depends on who is paying the bill, and who is receiving the care.

The list of inane comments about the ER in response to Romney’s gaff go on and on, and it makes me think that emergency physicians have not been as effective in getting the real story about ER care out as we hoped, though not for lack of trying.   These blogs are my contribution to the effort, and there are lots of other EM bloggers out there who do a much better job of conveying the truth about emergency medicine.  And of course, ACEP’s leadership puts many thousands of hours in to try to get the message out.  You would think 130 million visits a year and one of the best rated shows ever on television would give us plenty of opportunity to demonstrate the value proposition for ER care.   Perhaps being the poster child for what is most right and what is most wrong with health care in this country portrays such a mixed message that conveying an accurate picture of the role of the ER and emergency physicians is nearly impossible, especially in an election year.

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