I remember when politicians, (and their minion pundits, hacks and operatives), could not get away with the false claim that there was universal coverage and access to health care in the US because everyone could go to the emergency room.

As I recall, there was pushback against that false claim, and the guilty had to eat some crow after saying dangerous, offensive and absurd things to the whole country. Those were the good old days.

It seems times have changed. The claim that we are all covered and all have access to ‘health care’ through the emergency room seems to be the fashionable new talking point of political operatives who oppose health care reform. They say this in the national media, and no one corrects them anymore! I have heard it several times just in the last week, usually in opinion pieces that remain uncorrected, and on TV segments during which obscure political operatives babble ignorantly.

I think such absurd claims are irresponsible and unethical. I do not believe any normal person with common sense would agree that access to an emergency room care is access to ‘health care’ if they knew the facts.

Access to emergency medical care regardless of ability to pay was made federal law in 1986 with the Emergency Medical Treatment and Active Labor Act (EMTALA). Here are the basics of what the act does:

1) If you go to an emergency room with an emergency medical condition (EMC) you must be examined, and treated if an EMC is determined to exist, without any test for ability to pay.

2) The emergency room and any associated hospital or clinic, must provide appropriate care for you until you are stabilized and can care fro yourself, or must transfer you to a facility that can provide continued care.

3) The emergency room must refer you to an outpatient facility to which you have ‘reasonable access’ for any needed non-emergency care, that is willing and able to care for you.

At first glance, that may sound like ‘health care’ but on closer examination, it is not. Let us go through each point in more detail and see why it is not.

1) You have to have an EMC, which is defined as 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 … in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.” (1)

In actual practice, that definition does not even cover things that most people would consider an ‘emergency’. Examples of conditions what have not been deemed to be emergencies include small head insuries, sprains, small abscesses, foreign objects in the ear canal, toothache, and even abnormal discharge from the urinary tract. (2)

2) The EMC for which you came in, or is discovered during examination, must be stabilized. No cure, no long term tratment of chronic conditions. Just, stabilized, that is all.

Other health problems are not treated unless they directly contribute to the emergency. So, if you come in for malignant hypertension (an acute episdoe of blood pressure so high it threatens to kill you or permanently damage an organ), your malignant hypertension episode will be stabilized. If you have underlying chronic high blood pressure that caused the malignant hypertensive episode, that will not be treated. This distinction is not clear cut, and determined by clinical judgment of the staff, under pressure to minimize financial and legal liability for their institution.

Examples can be multiplied endlessly. A diabetic coming in for a diabetic complication will not be treated for the underlying chronic condition of diabetes. A person coming in for an asthma attack will not be treated for the underlying chronic condition of asthma, only the acute episode caused by that asthma.

The emergency room only has to treat you for life-threatening, limb-threatening, or organ threatening conditions. They are not responsible for any other aspect of your health care.

I know one doctor who quit emergency medicine because s/he could not accept the ethical dilemmas of providing that kind of medical care. It was just too difficult for that doc to ‘push ‘em through the doors’ as soon as stabilized even though the patient still had serious and unaddressed health problems, but that the emergency room was not legally obligated to treat. And depending on circumstance, the emergency room might make decisions based on a very strictly financial and legalistic basis, having nothing to do with the overall welfare of the patients, just as long as they follow the letter (but often not the spirit) of the law.

3) In practice, the referral process, and finding a provider who is willing and able to care for you has been flexible. Reports from 2006 say that in some places this consists of giving patients a directory or contact sheet of public clinics that provide care for the uninsured, and getting patient’s agreement that they have found a suitable provider’s name on paper. I have heard doctors and residents since 2006 say that this ‘referral’ process in some places consists of simply badgering a relative, or friend, or someone who can be interpreted to be a guardian or emergency contact of some sort, until they pick up the patient.

Furthermore, hospitals and doctors attempt to game the system to avoid financial and legal liability. For example, in some areas, doctors, particularly specialists, severely limit their availability (they will not be ‘on-call’) to avoid or reduce exposure to what they consider (sometimes reasonably) excessive burdens of EMC treatment duties. This means that specialist care may not be available for treatment, and this may in many cases limit your access to any appropriate and needed treatment at all. (3)

And finally, EMTALA has had the side effect of encouraging the proliferation of purely private urgent patient care centers and hosptials that do not accept Medicare or Medicaid reimbursement. This relieves them of any obligation under EMTALA. This means that even if you can get into an emergency room, there may be no nearby hospital that is required to admit you.

Lack of health insurance increases the risk of death by 25% even after adjusting for differences in insured and uninsured populations such as age, sex, education, current smoking,.and income (4) In view of the limits of emergency room care, is that tragic statistic any surprise at all?

How can these ruthless pundits and hacks sleep at night after spouting that access to an emergency room is the same as access to ‘health care’?

If you feel so moved, contact the media and tell them to stop their unethically misleading, incompetent, and irresponsible coverage of health care reform.

News site contacts below:

ABC News
http://abcnews.go.com/Site/page?id=3068843

CBS News
http://www.cbsnews.com/htdocs/feedback/fb_news_form.shtml?tag=ftr

CNN
http://www.cnn.com/feedback/

NBC and MSNBC news shows
http://www.msnbc.msn.com/id/10285339/
Chris Matthews
http://www.thechrismatthewsshow.com/html/contact.html

Sources

(1) Emergency Medical Treatment and Active Labor Act article, Wikipedia.
http://en.wikipedia.org/wiki/EMTALA

(2) Robert. Bitterman. EMTALA and the Ethical Delivery of Hospital Emergency Services. Emergency Medicine Clinics of North America 24 (2006) 557–577

(3) Hospital emergency on-call coverage: is there a doctor in the house? Issue brief (Center for Studying Health System Change) 2007 Nov;(115):1-4.

(4) Umut Sarpel, Bruce C. Vladeck, Celia M. Divino, and Paul E. Klotman. Fact and Fiction: Debunking Myths in the US Healthcare System. Annals of Surgery 2008;247: 563–569