By Carrie Valiant, Epstein Becker Green
(Carrie Valiant is a Member of the Firm in Epstein Becker Green’s Heath Care and Life Sciences practice in the firm’s Washington, D.C., office. Carrie is also the Founder and President of the Health Care Industry Access Initiative.)
In the national election's continuing controversy over health reform, Governor Mitt Romney commented on the television show "60 Minutes" in early October that there is no need for health reform because "we do provide care for people who don't have insurance. 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," he said. "Different states have different ways of doing that. Some provide that care through clinics. Some provide the care through emergency rooms," he said.
He added, "Look, it doesn't make a lot of sense for us to have millions and millions of people who have no health insurance and yet who can go to the emergency room and get entirely free care, for which they have no responsibility. Particularly if they're people who have sufficient means to pay their own way."
President Obama, on the other hand, recently pronounced the Affordable Care Act as the "cure."
These words from both presidential candidates highlight a number of misconceptions about health care access in the United States, both under the current health care regime as well as what we can expect under health reform.
Myth #1: People can get picked up in an ambulance and get free care in the Emergency Department for which they have no responsibility.
The care people receive in emergency departments is far from free, either to the hospitals that provide it or to the patients who receive it.
It is true that, for over twenty years, under the Emergency Medical Treatment and Labor Act (EMTALA), hospitals are required to provide emergency medical screenings and stabilization services to people who come to the hospital. And it is also true, under EMTALA, that hospitals are not permitted to delay furnishing required care while they inquire about the individual's method of payment or insurance status.
However, this does not mean that the hospital furnishing the care considers it to be "free" nor that the people receiving it bear no financial responsibility. Typically, uninsured people seeking care in hospital emergency departments are billed directly by the hospital for the care they receive, and, because of payer charge structures, often at rates far in excess of the rates that insurance companies can negotiate and obtain on behalf of their insureds. If a patient does not pay the hospital or negotiate a payment plan, hospitals often engage collection agencies to collect payment.
Ambulances aren't free either, even if you call in a 911 emergency. A ride in an ambulance without health insurance can result in a personal bill of hundreds of dollars, and can reach well over $500 depending on the level of service provided or requested. Just like hospitals, ambulance companies will charge uninsured patients directly, and, like any business, may attempt to collect unpaid bills.
Indeed, the majority of personal bankruptcies in the United States are due to unpaid medical bills. Many of those bankruptcies involve people who had employer-sponsored health insurance but lost it when they fell ill and could no longer work. Others involve people who were "underinsured" and hit lifetime limits, or whose coinsurance obligations became unmanageable in the face of serious illness.
Myth #2: Emergency rooms provide treatment for the uninsured
What emergency departments provide, while important, isn't really health care "treatment", it is only what is known as "stabilization." All EMTALA requires hospitals to do is stabilize people with emergency medical conditions, not care for the underlying medical condition. This means that, if you go to the emergency room, EMTALA requires that the hospital provide a medical screening to determine whether you have an emergency medical condition. If you don't have an emergency medical condition, the hospital's legal obligation ends there. If you do have an emergency medical condition, the hospital is legally required only to stabilize it.
What is an emergency medical condition? The law defines it as a medical condition with acute symptoms of sufficient severity, including severe pain, that the absence of medical attention could result in serious jeopardy to an individual's health, serious impairment of a bodily function, or serious dysfunction of a bodily organ or part.
As a practical matter, this emphasis on "acute" symptoms means that you will get immediate care if you suffer a heart attack, but hospitals are not legally obligated to provide any follow up procedures, pharmaceuticals or other treatment for the chronic conditions that caused the heart attack in the first place or that may prevent you from having another. Upon discharge from an emergency department, you may get a prescription for medication (but not the medication itself) or a plan for follow up care (but not the care itself.)
Myth #3: The uninsured have the means to pay for insurance or care, since Medicaid covers the poor.
Contrary to popular belief, Medicaid, the joint federal/state health care coverage program for the poor, does not provide a consistent safety net for the poor. Many states have not expanded coverage beyond the mandatory eligibility categories of pregnant women and children under age 6 with incomes under 133 percent of poverty, older children under 100 percent of poverty, and their parents only if below 1996 welfare eligibility levels (often below 50 percent of the federal poverty limit and certain other elderly and disabled.
Absent from mandatory eligibility altogether are childless adults, who frequently do not qualify for Medicaid coverage no matter how low their incomes or few their assets. And while some states provide optional coverage to 100 percent or more of the poverty limit (approximately $22,000 last year) many do not.
Myth # 4: States have their own ways of dealing with the uninsured.
Beyond the matter of Medicaid eligibility, a few states, like Massachusetts, have enacted comprehensive health reform. For others, the provision of care through hospital emergency rooms and clinics is largely by default, not by state design. Nor is it the optimal means of health care delivery for either the patient or the health care system as a whole.
Hospital emergency rooms are the most expensive venue for the provision of health care services, and hospitals that care for the uninsured have to absorb the costs and pass along to others, if they can (and the safety net hospitals often can't.) Federally qualified health centers and privately run free clinics may take the uninsured on a sliding fee scale basis in a particular state, but these private or federally funded organizations that may exist in a particular state can hardly be described as the states "dealing with" the uninsured.
Moreover, the services provided by federal qualified health centers and free clinics are typically primary care services, not the comprehensive, coordinated specialty care typically available to insured patients.
Myth #5. The Affordable Care Act is "the Cure."
But there are myths as well as to what President Obama's health reform plan will accomplish with respect to health care access. The success of health reform is based on the triple assumption that employers will continue to provide employer-sponsored coverage to their workforce, that states will expand their Medicaid programs to 133% of the poverty limit, and that, if you build the state insurance exchanges, people will come and purchase health insurance. But some of these assumptions may not hold true.
Already, a number of states are declining federal subsidies to expand their Medicaidprograms to everyone under 133% of poverty, one key component of health reform. And there have been various reports of employers considering whether to drop health insurance coverage and instead pay the associated employer penalty.
And just because private health plan coverage will be available on the exchanges for people not eligible for Medicaid, does that mean that people will sign up? Despite the financial penalties from the "individual mandate" for people who don't purchase health insurance, the coverage itself will be costly, and individuals buying exchange coverage won't be paying with the after-tax dollars and employer subsidies that typically save individuals covered by employer group health plans up to two thirds of the total price of coverage. And although federal subsidies will be available to help low income people purchase insurance, the subsidies will cap out at 400% of the poverty limit (which is now $88,000 for a family of four.)
The experience with health reform's high risk pools -- expected to take care of people with pre-existing conditions before health reform's expanded, "guaranteed issue" coverage comes on line in 2014 -- illustrates the problem. Originally expected to cover 200,000 to 400,000 uninsured who tried to buy and were denied coverage, few signed up for coverage. Why? Some found the price of hundreds of dollars a month too costly, some could not obtain the required documentation of insurance denial, and others simply did not know that the program existed. After eliminating the insurance denial documentation requirement in favor of a physician's note, taking steps to increase visibility of the program, and finally contracting with private agents and brokers to promote the program, ultimately 50,000 signed up for the coverage.
The question remains -- if it is so difficult to enroll for health care coverage people who have preexisting conditions and are likely to need the care and coverage, how will we be able to convince young, healthy Americans, who are critical for the economic viability of health reform, to sign up?
And just because people sign up for coverage doesn't mean that they will be able to access the care they need. There is a substantial physician shortage, with many physician practices closed to new patients, so some will have no choice but to seek care at costly emergency rooms. Most plans will have high deductibles, meaning that individuals may have to pay a few thousand dollars out of pocket before insurance will pay for any health care services leading to the possibility that many newly insured individuals may not seek care at all.
These challenges to health care access, with or without health reform, are why I founded the Health Care Industry Access Initiative, a nonprofit, tax exempt organization, www.healthindustryaccess.org. Our mission is to promote collaborative action across the health care industry to improve access to health care coverage and services in the United States. We focus on best practices, including effective ways to get people to sign up for coverage, and, once covered, to obtain convenient and accessible health care services. We invite senior health care executives to participate in our Access Summit to be held in Washington, DC on February 13 and 14, 2013, focused on capturing and promoting the next generation of thought leadership on how to accomplish health care access, whether or not there is health reform.