The federal mandate that hospital emergency departments (EDs) and the physicians who staff these departments provide medical screening and emergency care to all people who present to the ED for care (the Emergency Medical Treatment and Active Labor Act) ensures that everyone in our country has guaranteed access to emergency care when they need it, regardless of insurance coverage or ability to pay. Everyone. Regardless. With the last twist on the failed ‘repeal and replace Obamacare’ effort in the Congressional House (the American Healthcare Act), the conservative wing of the Republican Party coerced House leadership to include language that would have eliminated requirements that heath insurers include coverage for emergency care and any hospitalization or surgery that was required to resolve the medical or traumatic emergency. EMTALA has always been an ‘unfunded mandate’, meaning that Congress mandated this service but declined to allocate funding to pay the physicians and hospitals that provide these services. It should be fairly obvious that if no one paid for these services, and there was no funding to support them; mandated or not, there would be hardly any one providing them. You cannot expect hospitals, or physicians, to offer emergency care unless most of the costs incurred are covered, somehow.
It is true that Medicare does pay for these services, though at rates that fail to cover the cost of providing them. If States were allowed to modify or eliminate coverage for emergency care under State-operated Medicaid programs, as might have been the case under block-grants or waivers proposed by Republicans; Medicaid programs would no longer cover emergency care. As it is, the rates paid by Medicaid are in many cases way below the cost of providing these services. The Veterans Administration is supposed to cover emergency care, though in many cases claims go unpaid or inappropriately denied, and the rates, when the claims are paid, are likewise borderline. The fact is that government sponsored health care coverage programs do not begin to cover the costs of providing emergency care for all. In fact, the 40% of emergency care patients who are insured under commercially operated health plans cover close to 70% of the total revenues collected to cover these costs. In many hospitals, the number of commercially insured patients is so low that operating emergency departments represents millions of dollars in unreimbursed services, huge losses for a business that typically operates with extremely thin margins.
If the House Freedom Caucus had their way in Congress, not only would Medicaid enrollment have fallen and many more emergency care patients have been uncovered and unable to pay for their care; but in addition may commercially insured patients would have ended up with insurance plans that failed to cover emergency care as a part of their benefit package. As ACEP and every one else familiar with the economics of emergency care warned, passage of this flawed plan would have most certainly trashed the emergency care safety net. This in turn would have guaranteed that, despite protestations to the contrary, patients would be ‘dying in the streets’ for lack of access to emergency care, because loss of coverage would translate directly into loss of access for many Americans, despite the EMTALA mandate. What these very conservative Republicans may not have considered was that this would not just impact the poor, it could just as well result in the richest campaign finance donor dying in the street as well. That’s the thing about medical emergencies: they happen at the most inconvenient of times. Your rich person might just find himself in desperate need of an ED only to discover that the nearest hospital has closed (as many already have), and the next closest ED that is still open is miles away, understaffed, underfunded, and overcrowded. Poor people have that experience now all the time, even though Obamacare had stemmed the tide of uninsured and helped to shore up many failing hospitals. Medical emergencies have a way of leveling the playing field, often putting rich and poor in ED gurneys side by side. In fact, if that very conservative Republican congressman suffered major trauma, a hospital ED serving mostly the poor might be the best place for him to get trauma care. Gutting funding for emergency care, from a purely self-preservation point of view, might well have been the dumbest thing the House Freedom Caucus ever espoused.