Why Did We Get Obamacare?
One of the main arguments for the Affordable Health Act (Obamacare) was to reimburse Emergency Rooms for the cost of treating and/or stabilizing indigent patients. Yet, according to the American College of Emergency Physicians, "Emergency care represents less than 2 percent of the nation’s $2.1 trillion in health care expenditures while treating 136 million people a year." That yields an emergency care total industry value of less than $4.2 billion. One Congressional Budget Office estimate, published in an editorial by Money magazine, states that increases in expanded Medicaid due to Obamacare will cost taxpayers over $100 billion in 2016 alone. That amount of money would pay for every Emergency Room visit in the country 25 times over. I am certainly oversimplifying the case, but you get the picture.
What happens when indigent patients can't pay?
Should the ER turn them away? As it turns out, our US Congress passed a law in 1986 that requires Emergency Rooms to evaluate and stabilize indigent patients. That law is part of COBRA, named the "Emergency Medical Treatment and Active Labor Act (EMTALA)". It is an unfunded mandate, meaning that Emergency Rooms have to "eat" the cost of diagnosing and stabilizing patients if the patient can't pay. I am not taking sides for or against the objectives of EMTALA, but I am faulting Congress for not taking responsibility to reimburse Emergency Rooms for indigent care. So what happens? Emergency Rooms are businesses. They are responsible to their stockholders, owners, or sponsors and need to at least cover their expenses. So the cost of indigent care gets passed on to the bills of "paying" patients. It amounts to a tax levied on the people who use and can pay for the Emergency Room. According to the Centers for Medicare & Medicaid Services, 55% of U.S. emergency care (or about $1 billion) was uncompensated in the years leading up to the passage of the Affordable Care Act.
So what to do about it?
I propose two actions for Colorado that do not require any federal legislation:
- Move Emergency Rooms under the auspices of community emergency services. Because of EMTALA, Emergency Rooms are not free market services. Fire and police departments are not free market services and it is common for ambulance services to be part of the fire department. Why should emergency medical services be any different? I am not proposing that we add an Emergency Room to every firehouse, but rather that existing Emergency Rooms, including all staff and services become community services. This would remove the burden of EMTALA from hospitals. It would also remove emergency medical services from federal control and instead place them under community control.
- REQUIRE that medical providers give a written estimate for all non-emergency procedures, incorporating all costs. This provides two major benefits: first, that a primary care physician know all of the typical costs associated with a procedure or treatment so that they can measure the value of what they are recommending for their patients; second, so that patients can get not just a medical second opinion but a financial one as well for non-emergency procedures. This encourages free-market competition for all non-emergency medical care. Any such law would need to be fine-tuned to determine how close an estimate needs to be and what possible complications it needs to encompass before the estimate becomes legally binding.