Several times over the course of his campaign, Mitt Romney has suggested that emergency care in America is a form of universal healthcare coverage. I first heard the reference during his 60 Minutes interview with Scott Pelley last month.
Pelley: Does the government have a responsibility to provide health care to the 50 million Americans who don't have it today?
Romney: Well, we do provide care for people who don't have insurance, people – we – if someone has a heart attack, they don't sit in their apartment and die. We pick them up in an ambulance, and take them to the hospital, and give them care. And different states have different ways of providing for that care.
Then, a few weeks ago, in a meeting with the Editorial Board of the Columbus Dispatch he said basically the same thing.
“We don’t have a setting across this country where if you don’t have insurance, we just say to you, ‘Tough luck, you’re going to die when you have your heart attack.,’ No, you go to the hospital, you get treated, you get care, and it’s paid for, either by charity, the government or by the hospital. We don’t have people that become ill, who die in their apartment because they don’t have insurance.”
What he’s referencing, of course, is the Emergency Medical Treatment and Active Labor Act (EMTALA) which was passed in 1986. This unfunded mandate stipulates that hospitals are required to provide care to anyone needing emergency treatment regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. As an unfunded mandate, the cascading consequences of EMTALA are significant.
- Since there is nowhere to send these bills – hospitals use a bookkeeping entry called “uncompensated care.” According to the American Hospital Association – uncompensated care has grown to almost $40 billion per year - just through hospitals.
- These costs aren't just "magically" written off – they're “shifted” to all of us in the form of higher rates for both health insurance and services.
- Many hospitals have elected to simply shut their Emergency Department (ED) altogether. According to a JAMA study released last year, from 1990 to 2009, the number of hospital Emergency Departments (EDs) in metro areas declined by 27% – representing a net loss of 667 EDs.
- During that same period, ED visits have increased by 30% (from 95 million to 123 million visits annually). Only 4% of US Physicians work in hospital EDs but it’s estimated that they provide more acute care to Medicaid beneficiaries and the uninsured than the rest of US Physicians – combined.
- Feeling the squeeze, Hospitals are also getting much more aggressive in their collections. This often forces people into personal bankruptcy. Medical expenses remain the leading cause of personal bankruptcy in the U.S.
- Over a five year period (2005 to 2010), a group of North Carolina hospitals (most of which are tax-exempt non-profits) filed more than 40,000 lawsuits against patients with overdue bills. Most of these were uninsured patients.
All of which increases the cost of healthcare and the cost of health insurance. In turn, this fuels the downward spiral of more uninsured (or under-insured) patients and more ED visits for the decreasing number of emergency departments.
So, how does all of this relate to Romney’s cavalier comments? He’s factually correct that EMTALA exists (although he never referenced it outright) and he is factually correct that people don't die based on their insurance status alone. The real issue, however, and the one he completely avoided, is premature death from lack of health insurance. More importantly – it was either a calculated avoidance or a naiveté on the part of someone who has lived (and continues to live) a life of wealth and privilege. Did he earn that life? Sure. But that doesn't include the right to completely dismiss thousands of people who die prematurely every year from lack of basic healthcare insurance.
According to data from the Institute of Medicine, 26,100 people between the ages of 25 and 64 died prematurely due to a lack of health coverage in 2010.
The data was compiled by Families USA for a report called Dying For Coverage. According to that report, between 2005 and 2010:
- 2,175 people died prematurely every month
- The number of people who died prematurely each year due to a lack of health coverage rose from 20,350 to 26,100
- The total number of people who died prematurely due to a lack of health coverage for the 5-year period was 134,120
Factcheck.org ran a more detailed review of various studies and summarized their opinion this way:
A committee headed by Dr. John Z. Ayanian of the National Academies’ Institute of Medicine reviewed nearly 100 such studies released since 2002. And in March [of 2009] he summed up the findings for Congress this way:
Ayanian’s testimony to Congress, March 2009: Uninsured Americans frequently delay or forgo doctors’ visits, prescription medications, and other effective treatments, even when they have serious disease or life-threatening conditions. … Because uninsured adults seek health care less often than insured adults, they are often unaware of health problems such as high blood pressure, high cholesterol, or early-stage cancer. Uninsured adults are also much less likely to receive vaccinations, cancer screening services such as mammography and colonoscopy, and other effective preventive services.
Earlier this year, Dr. Otis Brawley – the Chief Medical Officer of the American Cancer Society – released his scathing indictment of the healthcare profession – How We Do Harm. The opening chapter is called simply: "Chief Complaint." It chronicles the arrival of Edna – a trim, middle-aged black woman to the emergency room of Grady Memorial – a “safety net” hospital in Atlanta.
She walks through the emergency-room doors sometime in the early morning. In a plastic bag, she carries an object wrapped in a moist towel.
She is not bleeding. She is not in shock. Her vital signs are okay. There is no reason to think that she will collapse on the spot. Since she is not truly an emergency patient, she is triaged to the back of the line, and other folks, those in immediate distress, get in for treatment ahead of her. She waits on a gurney in a cavernous, green hallway.
The “chief complaint” on her chart at Grady Memorial Hospital, in downtown Atlanta, might have set off a wave of nausea at a hospital in a white suburb or almost any place in the civilized world. It reads, “My breast has fallen off. Can you reattach it?” She waits for at least four hours – likely five or six. The triage nurse doesn't seek to determine the whereabouts of the breast. Obviously, the breast is in the bag.
The medical term is automastectomy – which is when the breast falls off by itself. According to Dr. Brawley, this is seen a "couple of times a year" at places like Grady, "often enough to be taken in stride." Edna had insurance through her employer – the phone company – but the cost kept escalating. At $3,000 a year it became too expensive to keep. Edna had actually lived the trajectory so carefully outlined by Mr. Romney – almost to the letter. She went to the hospital. She got treated. It was somehow paid for. Trouble is – emergency care isn't health care. Edna Riggs didn't survive the cancer that caused her breast to fall off. She died about 20 months after walking into Grady Memorial. She was 55.
