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So often I see the working poor in the emergency department.  They come because they don’t have physicians, or because when they do the office is often too busy to see them.  They come because they’re anxious, or because their social situations are horrible.  (That’s another discussion.)
They also come because they don’t have insurance; or money.  The co-pays in their own physician’s offices, or in urgent cares or minute clinics may be prohibitive.  They know, for better or worse, that in the emergency department they will be seen and evaluated. 
EMTALA (The Emergency Medical Treatment and Active Labor Act) came into existence under President Reagan in 1986 to allow even the poorest access to healthcare. It was meant to prevent ‘dumping,’ wherein the sick and injured, and those in labor, were transferred from private, for profit hospitals to charity hospitals for financial reasons. 
Not entirely a bad thought as it might have saved the patients money too, but it was done when patients were in labor, or in the process of dying.  Patients who were ‘unstable’ were sent to other facilities and bad outcomes resulted.  EMTALA was a compassionate idea.
I have said before that while compassionate, its results were also deleterious.  Because every hospital had to see everyone, no matter what, costs rose dramatically.  It’s a simple concept really.  If your business has to give one third of its services or products to anyone, for no guaranteed compensation, you can’t stay afloat.  Likewise, trauma centers and busy hospitals were crushed by uncompensated care and closed.  Communities lost care in the attempt to be compassionate towards all. 
The ugly truth is also that some people understood the law.  Emergency departments attract some bad actors in the mix of people in true need.  Those who are seeking narcotics, those who are violent, those who are manipulative often show up. These folks can be extremely expensive for hospitals when their bills will never be paid. 
I was thinking about this on a busy ED shift a few days ago.  Every day emergency departments care for those with head colds, cough, minor injuries and other conditions not truly emergent.  Also, those whose employers said ‘you have to go to the hospital for your chest pain (or dizziness or whatever), no matter how young and healthy.  Those who are compelled to get ‘return to work’ notes, or whose children have to be ‘cleared’ because the school nurse required it.  Even young, strapping individuals who are arrested have to be ‘cleared’ to go to jail.  What’s the problem?  Well, all of that takes staff and material.  All of that costs time. And all of that costs the patients.
But it’s worse now.  First of all because our poor patients learned the lesson.  They have been well and truly conditioned to go to the ED, a thing sometimes very appropriate and others very unnecessary. 
Second of all, EMTALA now allows the poorest access to care to something unintended in the original iteration of the law.  EMTALA allows our poor patients access to care that is driven by metrics and treatment algorithms, is wildly overpriced, micromanaged, run by MBAs and driven by investors and corporate bonuses, and for which the poor will face aggressive, often financially devastating collections efforts.
Is it a win? Not so sure.
When I was in a fee-for-service group, my partners and I had a little orange form in the drawer by our desk.  It was a discount form, which we sent to our billing company.  If we knew a patient couldn’t pay, or was having a tough time (or was a friend or co-worker or public-servant for that matter), we could simply check off the 100% discount box. Sometimes we did it when there was a process problem or inconvenience. Sometimes when there was a death.  We didn’t want them to get that bill as a reminder.  Subsequently no ED bill would be generated.  We couldn’t stop the hospital portion, but it was that much less for them to pay.
We could also offer a percentage discount, which we often did.  And the the insurance companies figured out that we were doing it to the insured and demanded that we offer them the same discount we gave the patient.
Ultimately, as so often happens, the hospital was purchased, the group employed by the larger system, and discounts were no more.  After all, you have to pay for all that administrative staff, for that shiny new EMR/billing tool, the expansion, marketing the branding. Those things don’t pay for themselves!  (They’re paid for by interactions between patients and clinical staff, by the way.)
As physicians increasingly lose control of our practices, as large contract management groups and hospitals (and minute-clinics) take up more of the space of medicine, the remote possibility of a lower price or discounted bill fades into the distant past.  Corporate investors expect returns.  CEOs expect bonuses.  (Physicians, nurses and others, consequently, expect less security and respect…also another discussion for another post.)
Let’s bring this rambling discussion home.  The way we currently do emergency (and thus much primary) healthcare ambushes poor patients and subjects them to inflated prices (without transparent pricing, which is coming at last).  It traps them in costly algorithms like sepsis pathways, it bludgeons them with defensive medicine and redundancy of efforts (‘guess you need another CT scan just to be safe!)
Small hospitals often being limited after they are purchased, poor patients end up being transferred an hour, two or three from home because the small town physician ‘isn’t comfortable’ with that problem, because they might deteriorate and generate a lawsuit, because the large center took away the surgeon or the OB or the intensive care unit.  Thus, more cost for travel, for another ED visit before admission (goodness knows you can’t be a direct admit…a second set of costly test is essential since the first hospital might have missed something).
Travel itself is costly, especially in ambulances or worse, helicopters.  And families of limited means can barely afford the gas for work, much less to visit loved ones.
Sure, EMTALA guarantees that everyone can be seen and stabilized.  But in this corporate heavy, billing intensive world, EMTALA can almost guarantee bankruptcy for the very people it was designed to help.
Pity.  I knew it was a mixed bag; but I had no idea it would turn into a financial assault in the end.
Edwin
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