The emergency department is not health insurance

September 24, 2012

In a Sunday night interview with "60 Minutes," Republican presidential candidate Mitt Romney suggested the emergency department as a place where those without coverage could seek treatment

"Well, we do provide care for people who don't have insurance," Romney said. "If someone has a heart attack, they don't sit in their apartment 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."

That's how the federal system is supposed to work:  A federal law called EMTALA, or the Emergency Medical Treatment Active and Labor Act, requires emergency rooms to stabilize a patient with a life-threatening condition. Since 1986, hospitals have had to comply with that provision to receive federal funding - thanks to Medicare, they play ball.

A few recent studies, however, suggest that's not exactly what happens on the ground. They underscore how hospitals can sometimes shirk this responsibility and why emergency care doesn't work like a regular health insurance plan.

The first comes from George Washington University's Sara Rosenbaum, who looked at how well hospitals in Denver actually complied with that EMTALA requirement to treat. 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 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."

Aggressive debt-collection has shown to be another obstacle, with some hospitals demanding upfront payment prior to treatment. Medical debt collector Accretive Health recently paid a $2.5 million settlement over charges it was not complying with EMTALA. A few patients at Minnesota hospitals, which worked with Accretive, recounted their experiences in court documents reported in the New York Times:

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.

In the hospitals that do accept uninsured patients, recent studies raise questions about whether they receive care equal to those with coverage. Uninsured children in the emergency department tend to get less care than those with coverage, a team of researchers at the Children's Hospital in Boston recently found. Their results, published in the Journal of Pediatrics, showed that uninsured kids were 22 percent less likely to receive tests, undergo procedures or receive prescription medication.

Federal law does indeed require that hospitals accept all patients regardless of insurance status. In practice, though, that does not seem to mean they will receive equally good care. 

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Ezra Klein · September 24, 2012