The Emergency Department as Health Insurance

It was bad enough when George W. Bush told us the poor have access to health care because they can just go to the ER.  We had come to expect W to say dumb things.  But Mitt Romney?  I expected better.  Yes, I know, I piled on when the Brits called him a "wazzock" for ill-considered remarks he made last summer in connection with the Olympics.  And, in fairness, he didn't say the ED is a substitute for health insurance.  He merely pointed out that the poor are not dropping dead of heart attacks in the streets for want of health insurance, because our EMS colleagues pick them up and take them to hospitals, where they receive care.  But, for those with little depth of understanding of the consequences of being uninsured, Romney's remark reinforces a very foolish notion.

Earlier this month I addressed the Council of the American College of Emergency Physicians.  My subject was the problem of the uninsured.  Here is an excerpt of that address.

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Today I want to talk to you about a woman I met in August.  I’ll call her Nancy.  Nancy came to see me in the emergency department.  She was coughing up blood.  I took a quick look at her records.  Fifty-seven years old.  Diagnosed in July with lung cancer.  

Wait a minute.  That was July of 2011.  Not a month ago, but thirteen months ago.  She must be going somewhere else for her cancer care.

“Where?” I asked her.

“Nowhere.  I lost my job and my health insurance.”

I asked about COBRA, or the possibility that she might have become eligible for Medicaid or Medicare.  She looked at me blankly.  Everyone else she knew who had lost health insurance simply went without health care.  She assumed that was her lot.  She focused on finding a new job.  She was still working on that.

I ordered a CAT scan of the chest and compared it with the old one.  I explained the difference to her.  She told me she had a grandson who was about to start twelfth grade.  She looked into my eyes, through her tears, and said, “I’m not going to get to see him graduate, am I?”

ACEP has long had a policy position advocating universal coverage.  So have several other medical professional organizations: the AMA, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American College of Surgeons among them.

Harry Truman sought universal coverage.  We made some progress in the 1960s with Medicare and Medicaid.  But we have fifty million uninsured.  And even with the passage of the Affordable Care Act, we stand to make only modest inroads.  Those newly covered under Medicaid are supposed to have equal access, but that is true only if you accept an Orwellian vision in which some are more equal than others.

Why can’t we get there?  Because most Americans have health insurance.  In the abstract they support universal coverage, just as we do.  But when you get down to particulars, they don’t want any changes that will affect what they have. And they balk at the prospect of higher taxes, even when they are told that access to longitudinal primary care for those with chronic diseases can save money.

The public must understand that the uninsured are everyone’s problem.  This is partly a matter of social justice.  It is also a matter of providing health care to all in the most cost-efficient way possible.

It is not enough to adopt this as an advocacy position if doing so does not influence the national debate. There are 850,000 licensed physicians in the United States.  If we all tell the public in a loud, clear, united voice that the status quo is unacceptable, we can transform public opinion.

Why should ACEP take the lead on this?

Emergency physicians provide more uncompensated care than doctors across all specialties by a factor of ten.  We can stand up and say this.  We can say we do this because we have always believed it is our ethical duty.  We wear this as a badge of honor.

But when the wealthiest nation in the history of the world has fifty million uninsured, that is a badge of shame.

We must take the lead in carrying this message to the public, and we must get all of our colleagues across all specialties to join us.

How do I know this is what we must do?

I know what Nancy’s grandson would say.  Shout it from the rooftops - and the studios of CNN.  Go tell it on the mountain - and the pages of the Wall Street Journal.  With strong physician leadership,  America can solve this problem. 

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So, Romney is right.  If you're having a heart attack, you don't have to sit at home and wait to die because you have no health insurance.  You can call 9-1-1, and you will be taken to a hospital ED and receive excellent health care.

But you might never have gotten to that point if you'd had health insurance and primary care to manage your high blood pressure, high cholesterol, or diabetes. Sometimes an ounce of prevention is worth ... well, you know what it's worth. And so does Mitt Romney.  We all do.  So why are we being penny wise and pound foolish?