Skip to main content

Why emergency rooms don't close the health care gap

By Aaron Carroll, Special to CNN
updated 9:21 AM EDT, Mon May 7, 2012
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
updated 5:01 PM EDT, Wed October 22, 2014
Paul Callan says the grand jury is the right process to use to decide if charges should be brought against the police officer
updated 12:19 PM EDT, Thu October 23, 2014
Theresa Brown says the Ebola crisis brought nurses into the national conversation on health care. They need to stay there.
updated 6:35 PM EDT, Tue October 21, 2014
Patrick Hornbeck says don't buy the hype: The arguments the Vatican used in its interim report would have virtually guaranteed that same-sex couples remained second class citizens
updated 9:36 AM EDT, Fri October 24, 2014
Paul Begala says Iowa's U.S. Senate candidate, Joni Ernst, told NRA she has right to use gun to defend herself--even from the government. But shooting at officials is not what the Founders had in mind
updated 6:08 PM EDT, Thu October 23, 2014
John Sutter: Why are we so surprised the head of a major international corporation learned another language?
updated 5:54 PM EDT, Thu October 23, 2014
Jason Johnson says Ferguson isn't a downtrodden community rising up against the white oppressor, but it is looking for justice
updated 12:21 PM EDT, Fri October 24, 2014
Sally Kohn says a video of little girls dressed as princesses using the F-word very loudly to condemn sexism is provocative. But is it exploitative?
updated 4:06 PM EDT, Tue October 21, 2014
Timothy Stanley says Lewinsky is shamelessly playing the victim in her affair with Bill Clinton, humiliating Hillary Clinton again and aiding her critics
updated 10:14 AM EDT, Thu October 23, 2014
Imagine being rescued from modern slavery, only to be charged with a crime, writes John Sutter
updated 12:00 PM EDT, Tue October 21, 2014
Tidal flooding used to be a relatively rare occurrence along the East Coast. Not anymore, write Melanie Fitzpatrick and Erika Spanger-Siegfried.
updated 7:35 AM EDT, Tue October 21, 2014
Carol Costello says activists, writers, politicians have begun discussing their abortions. But will that new approach make a difference on an old battleground?
updated 9:12 AM EDT, Tue October 21, 2014
Sigrid Fry-Revere says the National Organ Transplant Act has caused more Americans to die waiting for an organ than died in both World Wars, Korea, Vietnam, Afghanistan and Iraq
updated 2:51 PM EDT, Tue October 21, 2014
Crystal Wright says racist remarks like those made by black Republican actress Stacey Dash do nothing to get blacks to join the GOP
updated 6:07 PM EDT, Tue October 21, 2014
Mel Robbins says by telling her story, Monica Lewinsky offers a lesson in confronting humiliating mistakes while keeping her head held high
updated 9:29 AM EDT, Mon October 20, 2014
Cornell Belcher says the story of the "tea party wave" in 2010 was bogus; it was an election determined by ebbing Democratic turnout
updated 4:12 PM EDT, Mon October 20, 2014
Les Abend says pilots want protocols, preparation and checklists for all contingencies; at the moment, controlling a deadly disease is out of their comfort zone
updated 11:36 PM EDT, Sun October 19, 2014
David Weinberger says an online controversy that snowballed from a misogynist attack by gamers into a culture war is a preview of the way news is handled in a world of hashtag-fueled scandal
updated 8:23 AM EDT, Mon October 20, 2014
Julian Zelizer says Paul Krugman makes some good points in his defense of President Obama but is premature in calling him one of the most successful presidents.
updated 10:21 PM EDT, Sun October 19, 2014
Conservatives can't bash and slash government and then suddenly act surprised if government isn't there when we need it, writes Sally Kohn
updated 8:05 AM EDT, Wed October 22, 2014
ISIS is looking to take over a good chunk of the Middle East -- if not the entire Muslim world, write Peter Bergen and Emily Schneider.
updated 9:00 AM EDT, Mon October 20, 2014
The world's response to Ebola is its own sort of tragedy, writes John Sutter
updated 4:33 PM EDT, Fri October 17, 2014
Hidden away in Russian orphanages are thousands of children with disabilities who aren't orphans, whose harmful treatment has long been hidden from public view, writes Andrea Mazzarino
updated 1:22 PM EDT, Sat October 18, 2014
When you hear "trick or treat" this year, think "nudge," writes John Bare
updated 12:42 AM EDT, Sat October 18, 2014
The more than 200 kidnapped Nigerian schoolgirls have become pawns in a larger drama, writes Richard Joseph.
updated 9:45 AM EDT, Fri October 17, 2014
Peggy Drexler said Amal Alamuddin was accused of buying into the patriarchy when she changed her name to Clooney. But that was her choice.
updated 4:43 PM EDT, Thu October 16, 2014
Ford Vox says the CDC's Thomas Frieden is a good man with a stellar resume who has shown he lacks the unique talents and vision needed to confront the Ebola crisis
updated 4:58 AM EDT, Sat October 18, 2014
How can such a numerically small force as ISIS take control of vast swathes of Syria and Iraq?
updated 9:42 AM EDT, Fri October 17, 2014
How big a threat do foreign fighters in Syria and Iraq pose to the West? It's a question that has been much on the mind of policymakers and commentators.
updated 8:21 AM EDT, Fri October 17, 2014
More than a quarter-million American women served honorably in the Iraq and Afghanistan wars. Now they are home, we have an obligation to help them transition back to civilian life.
updated 4:27 PM EDT, Thu October 16, 2014
Paul Begala says Rick Scott's deeply weird refusal to begin a debate because rival Charlie Crist had a fan under his podium spells disaster for the Florida governor--delighting Crist
updated 12:07 AM EDT, Thu October 16, 2014
The longer we wait to engage on Ebola, the more limited our options will become, says Marco Rubio.
updated 7:53 AM EDT, Wed October 15, 2014
Democratic candidates who run from President Obama in red states where he is unpopular are making a big mistake, says Donna Brazile
updated 12:29 AM EDT, Thu October 16, 2014
At some 7 billion people, the world can sometimes seem like a crowded place. But if the latest estimates are to be believed, then in less than a century it is going to feel even more so -- about 50% more crowded, says Evan Fraser
updated 12:53 PM EDT, Mon October 20, 2014
Paul Callan says the Ebola situation is pointing up the need for better leadership
updated 6:45 PM EDT, Wed October 15, 2014
Nurses are the unsung heroes of the Ebola outbreak. Yet, there are troubling signs we're failing them, says John Sutter
updated 1:00 PM EDT, Wed October 15, 2014
Dean Obeidallah says it's a mistake to give up a business name you've invested energy in, just because of a new terrorist group
updated 7:01 PM EDT, Wed October 15, 2014
Fear of Ebola is contagious, writes Mel Robbins; but it's time to put the disease in perspective
updated 1:44 PM EDT, Tue October 14, 2014
Oliver Kershaw says that if Big Tobacco is given monopoly of e-cigarette products, public health will suffer.
updated 9:35 AM EDT, Sat October 18, 2014
Stop thinking your job will make you happy.
updated 10:08 PM EDT, Tue October 14, 2014
Ruben Navarrette says it's time to deal with another scandal involving the Secret Service — one that leads directly into the White House.
updated 7:25 AM EDT, Tue October 14, 2014
Americans who choose to fight for militant groups or support them are young and likely to be active in jihadist social media, says Peter Bergen
updated 9:03 AM EDT, Mon October 13, 2014
Stephanie Coontz says 11 years ago only one state allowed same sex marriage. Soon, some 60% of Americans will live where gays can marry. How did attitudes change so quickly?
updated 4:04 PM EDT, Tue October 14, 2014
Legalizing assisted suicide seems acceptable when focusing on individuals. But such laws would put many at risk of immense harm, writes Marilyn Golden.
updated 9:07 AM EDT, Mon October 13, 2014
Julian Zelizer says the issues are huge, but both parties are wrestling with problems that alienate voters
updated 6:50 PM EDT, Mon October 13, 2014
Mel Robbins says the town's school chief was right to cancel the season, but that's just the beginning of what needs to be done
updated 11:43 AM EDT, Sat October 11, 2014
He didn't discover that the world was round, David Perry writes. So what did he do?
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT
ADVERTISEMENT