Monday, August 18, 2008

Fifteen days of blogging for health care reform: Unfunded mandates

Guest post by Skylanda.

The arrival of my intern class at the university hospital was occasioned by the opening of the brand spanking new emergency department. I never had the pleasure - or the horror - of seeing the old department, though its mythology remains. Occupied beds lining the hallways, bleeding patients begging as you passed anonymously on your way to find the one you were assigned to admit, and dingy, always dingy in those old war stories. No, by the time I arrived and rotated through there on the first month of the academic year, the old one was shut and gutted, and the sparkling new ED was up and open and running at such a constipated pace that most nights we had half a dozen beds moving patients, a dozen or so beds in each wing housing admitted patients waiting for real rooms upstairs, and nothing to do but twiddle our thumbs while some forty to sixty patients lay triaged but unseen in the waiting room. Except for a few Friday nights when the frenetic shuffle between the ambulance docks, the resuscitation bays, and the trauma-surgery ICU kept the whole lot of us running, it made for an eerily quiet month in the busiest emergency department in the state.

On one of the quieter nights, I got an earful out of one of the ED attendings. The topic was universal health care; the tone was at a low yell. I didn’t ask about it because I know better than to talk politics at work - someone else set off the spark, I was just in the line of sight when he started to breath fire.

“What do you think,” some poor, unsuspecting resident rotating from another department asked, “are you for or against universal health care?”

“We already HAVE a system of socialized medicine in this damn country,” the attending snarled back, all afire all of a sudden, “people just refuse to f’ing admit it.

I thought for a moment before contributing anything to a clearly sensitive topic, then I ventured forth. “You mean things like Medicare?” I asked and then ducked back. People over 65 and enrolled tribe members under the Indian Health Service are often cited as the only two demographics in the US with entitled access to health care - that is, they have it and cannot lose it through change in circumstance; the former was the first one into my head and out of my mouth.

“No,” he said tightly. “The emergency room. Look around you. How many of these people can pay? How many will pay? How many handed you a fake name and a social security number that doesn't exist because they can't afford to have this bill coming to their residence, if they even have a place they call a residence? But we take care of them anyway. Not that we wouldn't if we did have the choice, but we are mandated to. The great unfunded - and unspoken - mandate of the American health care system. Anyone who cannot pay comes to us. You primary care people can turn them away, but we cannot. No one pays for this, no one reimburses us for this, we eat most of these bills, if we‘re lucky the billable visits covers the write-offs in any given year. And if something goes wrong, they can sue us even though no one has paid us a dime for the time and effort spent on their care. We already HAVE socialized medicine in the US. We just need to start acting like we have it, and start f’ing paying for it.

We digested this for a moment while he went back to scribbling orders. But he wasn‘t done just yet.

“You know about EMTALA, right?”

Oh yes, EMTALA: The Emergency Medical Treatment and Active Labor Act. This is the law that mandates that anyone who is hurt or in labor can show up to almost any ED and has the right to be seen by a provider, no matter if they can pay or not (not that this stops private hospitals from owning ambulance companies and directing their fleet to triage their cargo to various hospital, including or not including their own, based on their gestalt assessment of the patient's ability to pay). It always seemed to me - as it probably seems to most - that emergency departments, merely by their nature, have some kind of cosmic obligation to treat emergencies. But this is not the case. There is actually an American law that states that all emergency departments - at least all those who receive any reimbursement from the Medicare/Medicaid axis - must triage, stabilize, and at least transfer to an appropriate facility (if not treat in house) anyone who presents ill, injured, or in labor. Without this law, you can bet that certain emergency departments would not accept certain patients…of that you can be certain.

EMTALA, it turns out, is a mixed blessing for the uninsured and underinsured folks of America. On one hand, it provides the final and definitive safety net for those without any other means of access to health care. You can be undocumented, on the lam from a felony charge, hopped up on meth, without a cent to your name (and believe me, this constellation of demographic niceties is not a rare story at the university ED), and if you walk into any almost emergency department in America, they have to address your chest pain, your diabetes, your stab wound, your disease du jour. EMTALA is what stands between care and disaster for a large number of American citizens and others living and working inside our borders.

EMTALA is also - in my opinion - one of the primary stumbling blocks between America and concrete health care reform. However noble in intent, it is entirely possible that without EMTALA, pressure would have mounted so high on the health care system from so many quarters by now (from so many people dying, being turned away from the ER doors with no insurance) that something would have had to give. The stitching on real safety nets might have begun. No one can say for sure, of course - Americans are breath-taking in our ability to bury heads in sands when tough but feasible answers are available to nasty problems - but EMTALA has become both a curse and godsend to every uninsured person in the country. If worst comes to worst, the ER always has to take you. It makes us all sleep a little better at night. And because we all sleep a little better at night, we don't bother to get up the next morning and do something concrete to solve the problem of lack of health care access.

Would I revoke EMTALA now? No, of course not - the ferrets are already loose in the chicken house, it would do far more harm than good. But if I could go back two decades to the year that EMTALA was passed - to a time when the health care crisis was just peaking around the corner and not brewing in forty million-plus American homes - I might have thought twice and hard about whether it was such a good idea. By providing half a safety net full of holes, we have put off the weaving of a strong social fabric to take care of the nation‘s health.

The attending’s diatribe ended with a declaration that he already provides universal health coverage, and that it is just up to America to start ponying up the cash for the services we demand of his profession. Moreover, wider coverage would prevent the sort of drain-clogging ER crowds that drive doctors trained in the medical heroics of trauma and resuscitation to spend their time fixing primary care issues that cost a pennies on the dollar to treat in clinic versus the emergency department. Universal coverage would empty the ERs of the earaches and the bellyaches and the headaches and leave way for the car crashes and the heart attacks and the knife wounds - the things that ERs were built to handle, the things that ER docs were born to revel in.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.