The ACA, Urban Legends, and Data
For years an urban legend has circulated that the poor and uninsured use emergency departments as a substitute for a doctor visit because hospitals are non-profits and won’t turn these sick and injured patients away.
You don’t have to be in healthcare or public health to “know” that hospitals won’t or can’t turn anyone away. The overcrowded, underfunded “county” hospital is a common trope in television and movies; County General Hospital of “ER” fame is probably the most prominent example. The fictional doctors there routinely treated the indigent and homeless, and their outrage at greedy private hospitals dumping uninsured patients on their doorstep was a recurring plot point.
This practice of transferring patients who don’t have insurance and can’t pay for treatment has occurred, and has been covered by news outlets. It was one of the reasons for the creation of the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA), which instituted penalties for hospitals that denied emergency care to patients that required it. That law, and the fact that most institutions already practiced a policy of treating all emergency patients, likely contributed to the urban legend.
Even Snopes, the Internet clearinghouse for all urban legends, has weighed in on the topic, albeit indirectly. It addresses the specific question of a high profile hospital delivering more babies to illegal immigrants than legal residents. The recent political focus on immigration has brought that particular consequence of EMTALA and related legislation into the national consciousness.
But does this popular understanding of how emergency departments and EMTALA work reflect reality? Do the un(der)insured use emergency departments as a substitute for primary care providers, and do they do it because they can’t be turned away?
To begin with, let’s consider the implications of the EMTALA more closely. While it does protect patients who require emergency treatment and does include provisions for women in labor (making it relevant to the immigration conversation), the law does not mandate that all patients be treated for every complaint. If a qualified medical professional determines that there is no emergency, the patient can be turned away. This limits the ability to use emergency departments for preventive care, treating minor injuries and illness, and other primary care functions.
A recent report in JAMA by Raven et al would seem to bear this out. In an examination of nearly 35,000 emergency department visits, only 6% were found to be “primary care treatable.” Furthermore, of those 6%, nearly 90% had chief complaints identical to visits that did qualify as emergencies. Therefore, it may very well be that most nonurgent emergency department visits are not actually preventable by providing insurance to all individuals so they can get primary care. Instead, those visits may result from legitimate ambiguity on the patient’s part about the nature of their condition.
This was also corroborated in Massachusetts, where recent reforms improved access to insurance. A study by Smulowitz et al in the Annals of Emergency Medicine found that while low-severity visits to emergency departments were reduced after the reform, and the reduction was highest among the uninsured and those with newly subsidized insurance plans, only a small percentage of all low-severity visits were eliminated. Presumably other factors besides insurance were leading to the choice of the emergency department for healthcare.