Skip to main content

Why emergency rooms don't close the health care gap

By Aaron Carroll, Special to CNN
May 7, 2012 -- Updated 1321 GMT (2121 HKT)
That
That "free" emergency room treatment isn't nearly as "free" as you might think, Dr. Aaron Carroll writes.
STORY HIGHLIGHTS
  • Aaron Carroll: Opponents of health reform say emergency rooms give health care to all
  • Not true, he says. ERs can't refuse emergency care but not required to give other care
  • He says other misconception is treatment costs easily written off; in fact, billers will pursue
  • Carroll: Yes, hospitals need money; important to realize ER care no substitute for reforms

Editor's note: Dr. Aaron E. Carroll is an associate professor and vice chair of health policy and outcomes research in the department of pediatrics at the Indiana University School of Medicine. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll.

(CNN) -- For decades, the attempts at health care reform have aimed to increase access. The United States is one of the few industrialized nations in the world that does not provide universal health care to its citizens. And repeatedly, those who oppose it have been forced to argue that access isn't the problem some make it out to be. Why?

The emergency department, they say. After all, it is a commonly held belief that no one can be denied care there. So -- in essence -- everyone can get free health care if they need it. We have a universal system after all.

That, of course, is not true.

It's not even close. Let's start with the idea that emergency rooms must provide you care.

What's important to remember is that you can't be refused emergency care. That's because the Emergency Medical Treatment and Active Labor Act (EMTALA) requires that any hospital that takes Medicare or Medicaid must check you for emergent conditions and treat them if they exist. Since nearly every hospital in the country takes federal funds from one of these programs, nearly all hospitals are subject to EMTALA.

But "emergency medical condition" has a pretty narrow definition. It includes active labor for women and acute conditions that would cause death, serious bodily organ harm or serious bodily function impairment if they were not treated right away.

Aaron Carroll
Aaron Carroll

Follow @CNNOpinion on Twitter and Facebook.com/cnnopinion.

If politicians are meaning to say that women have universal access to delivery care, then I suppose there's an element of truth to that. But there's no guarantee of prenatal care in the emergency department.

If they are saying that we have universal access if we're acutely having a heart attack, then I suppose there's truth to that as well. But there's no such access for lipid panels, stress tests or prescriptions for cholesterol medications that might help you avoid the heart attack in the first place.

If you're acutely obstructed by massively advanced colon cancer, it's likely you can get emergency surgery to end the blockage. But your cancer is likely too far advanced to cure at that point. Moreover, you're not going to get chemotherapy in the emergency department nor could you have gotten the colonoscopy that might have detected the cancer far earlier.

You can't get preventive care in the emergency department. You can't get screened for a host of disorders. You can't get treatment for your depression there or really for any chronic mental disorders. You can't get help with your child's autism, ADHD or developmental delay.

And even if you could, it wouldn't be free.

That's the second and perhaps more misunderstood part of this emergency department misconception. The costs of treatment in the emergency room are not quickly dismissed or written off. You'll get that emergent care, but you'll also be charged for it.

And hospitals aren't going to let that go easily. A recent article in the New York Times detailed how Accretive Health, a medical debt collector, is using aggressive tactics such as confronting patients in their hospital beds to collect the money owed for even emergent care. The article also describes how collection agencies have long been used to go after patients after they've left the treatment facility. In some cases, patients were even confronted and stalled by debt collectors as they entered the emergency department on some later occasion so that the company could collect on old bills before more care was offered.

An even more recent story covered by Kaiser Health News and NPR reported on a family of four sued by its local nonprofit hospital. The family earned about $25,000 a year -- below the poverty line -- but the parents did not qualify for Medicaid in Ohio. It seems that the hospital had sued almost 1,600 people for unpaid medical bills from 2009 to 2011. Further, the piece reported, "[w]hile Ohio has a law that prevents foreclosures based on medical debt alone, it is legal for hospitals to garnish patient wages, attach bank accounts and get a lien on any future earnings, including from the sale of a house."

It might even be worse in North Carolina, where a group of nonprofit hospitals sued 40,000 patients from 2005 to 2010. This is problematic because nonprofit hospitals are supposed to provide a certain level of charity care in exchange for their tax-exempt status. A recent review found that three hospitals in Illinois were providing a very small amount of care for free or at discounted rates. This has led to a number of facilities losing their nonprofit status and legislators to try to pass new laws requiring specify charity care minimums for nonprofit status.

Before you get all riled up, I understand that hospitals need money to run. The American Hospital Association reports that hospitals lost upward of $40 billion in unpaid bills in 2010 alone. I'm not suggesting care should be given out freely or that hospitals should be forced to operate at a loss. But let's acknowledge that patients will be held accountable for the costs of their care, even in the emergency room. If they can't pay those bills, their credit can be ruined. Medical bills are a very significant cause of bankruptcy in this country.

So it's true that an emergency room won't let you die if you show up at the door, but short of that, you can't get care for a host of medical issues. And, while they will provide that lifesaving care to you even if you have no insurance and no money, they will send you a bill. And if you can't pay, it may cause you, and your family, financial ruin.

That's a far cry from universal health care, and nothing to brag about.

Follow us on Twitter @CNNOpinion

Join us on Facebook/CNNOpinion

The opinions expressed in this commentary are solely those of Aaron Carroll.

ADVERTISEMENT
Part of complete coverage on
September 18, 2014 -- Updated 1914 GMT (0314 HKT)
Ruben Navarrette says spanking is an acceptable form of disciplining a child, as long as you follow the rules.
September 18, 2014 -- Updated 1950 GMT (0350 HKT)
Steven Holmes says spanking, a practice that is ingrained in our culture, accomplishes nothing positive and causes harm.
September 18, 2014 -- Updated 1831 GMT (0231 HKT)
Sally Kohn says America tried "Cowboy Adventurism" as a foreign policy strategy; it failed. So why try it again?
September 18, 2014 -- Updated 1427 GMT (2227 HKT)
Van Jones says the video of John Crawford III, who was shot by a police officer in Walmart, should be released.
September 18, 2014 -- Updated 1448 GMT (2248 HKT)
NASA will need to embrace new entrants and promote a lot more competition in future, argues Newt Gingrich.
September 16, 2014 -- Updated 2315 GMT (0715 HKT)
If U.S. wants to see real change in Iraq and Syria, it will have to empower moderate forces, says Fouad Siniora.
September 18, 2014 -- Updated 0034 GMT (0834 HKT)
Mark O'Mara says there are basic rules to follow when interacting with law enforcement: respect their authority.
September 16, 2014 -- Updated 1305 GMT (2105 HKT)
LZ Granderson says Congress has rebuked the NFL on domestic violence issue, but why not a federal judge?
September 16, 2014 -- Updated 1149 GMT (1949 HKT)
Mel Robbins says the only person you can legally hit in the United States is a child. That's wrong.
September 15, 2014 -- Updated 1723 GMT (0123 HKT)
Eric Liu says seeing many friends fight so hard for same-sex marriage rights made him appreciate marriage.
September 12, 2014 -- Updated 2055 GMT (0455 HKT)
David Wheeler wonders: If Scotland votes to secede, can America take its place and rejoin England?
September 12, 2014 -- Updated 2036 GMT (0436 HKT)
World-famous physicist Stephen Hawking recently said the world as we know it could be obliterated instantaneously. Meg Urry says fear not.
September 11, 2014 -- Updated 1721 GMT (0121 HKT)
Sally Kohn says bombing ISIS will worsen instability in Iraq and strengthen radical ideology in terrorist groups.
September 11, 2014 -- Updated 1327 GMT (2127 HKT)
Artist Prune Nourry's project reinterprets the terracotta warriors in an exhibition about gender preference in China.
September 10, 2014 -- Updated 1336 GMT (2136 HKT)
The Apple Watch is on its way. Jeff Yang asks: Are we ready to embrace wearables technology at last?
ADVERTISEMENT