Aug 12 2013
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Drawing a Line in the Sand: Where Do We Stand on Universal Health Care?

Kori Sauser, MD, is an emergency medicine physician and a Robert Wood Johnson Foundation (RWJF)/U.S Department of Veterans Affairs Clinical Scholar at the University of Michigan (2012-14). In February, she coauthored a commentary in the Journal of the American Medical Association that asked, to paraphrase: Why does the United States ensure universal access to basic, life-saving treatment in emergency rooms but not to more cost-effective, comprehensive, and preventive treatment, and how can it achieve the latter? The RWJF Human Capital Blog asked Sauser and her coauthors, both affiliated with the RWJF Clinical Scholars program, to respond. Sauser’s response follows. Read all the blog posts in this series.

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I am struck by the fact that we are still discussing whether health care is a right or a privilege, because it has been long-determined that the medical care that I provide is a right. As an emergency physician, I am held to the standards of the Emergency Medical Treatment and Active Labor Act (EMTALA), which mandates that I provide basic, stabilizing treatment to all who present to the emergency department (ED), regardless of ability to pay.

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So when a patient presents to the ED when I am working a shift, I take care of the patient appropriately and without a thought to their payment status. When “Juan,” a young Mexican day laborer without insurance presents with an advanced toe infection as a consequence of his undiagnosed diabetes, I am able to start his diagnostic work-up and treatment, and to admit him to the hospital for continued antibiotics and definitive care of the toe.

And I do this without worrying about what type of insurance he does or does not have. It is a luxury, of sorts, to know that we are not turning people like Juan away, to know that we provide care to all comers without consideration of payment status, to know that we are a place where all are welcome to seek medical care.

Yet, why is this a luxury enjoyed almost exclusively by the ED? The background to this question dates back to the 1980s—to a time before smartphones, before widespread gluten intolerance, before EMTALA.

Prior to the passage of EMTALA, there were no federal requirements for universal provision of health care. Then, in the early 1980s, there were a handful of highly publicized incidents of “patient dumping”—unstable patients dying during inappropriate transfers between hospitals—and EDs denying treatment to patients because of inability to pay.

The ensuing public outrage led to a congressional response and the 1986 passage of EMTALA. In this act, Congress requires EDs to provide medical care and stabilizing treatment to all patients regardless of ability to pay.

Congressional reaction to the public outrage at the time affirmed the popular sentiment that “all Americans, regardless of wealth or status, should know that a hospital will provide what services it can when they are truly in physical distress” (131 Cong Rec S13904).

In this way, the American public drew a line in the sand and declared a minimum basic standard: that nobody should be denied basic, life-saving or stabilizing treatment, regardless of ability to pay. We have affirmed that access to basic emergency medical care is a right for all U.S. citizens, and it strikes us as cruel, cold, and inhumane to attempt to assert otherwise.

It seems to be a profound jump, though, to move from asserting the universal right to basic, life-saving treatment to now move forward and consider the right to more comprehensive, preventive care.

Here, we come to a place of varying opinions and disagreement. But this strikes me as an odd place to draw the line. Perhaps it is because in the ED we see many patients like Juan—patients with gangrenous foot ulcers as a consequence of undiagnosed or poorly controlled diabetes; we care for patients with debilitating strokes after years of uncontrolled hypertension; and we diagnose patients with advanced malignancies because they didn’t have earlier access to appropriate screening.

On a regular basis we see patients with complications and advanced stages of diseases that could have been prevented or delayed with earlier, more comprehensive care. Could Juan’s infected toe and subsequent amputation have been prevented with earlier diagnosis and treatment of his diabetes, and regular access to primary care services?  Almost certainly.

But it isn’t until he has approached this point-of-no-return – then we feel compelled to intervene. Yet at this point, patients are often already to the point where their quality of life has fallen substantially, their ability to work and contribute to the economy has diminished dramatically, and their use of health care resources will be the most tremendous.

In this country we have the ability to ensure access to routine, high-quality, cost-effective primary care. To provide for the health of all Americans in a way that maintains their health, prevents or delays life-altering and expensive complications, and maximizes patients’ quality of life and ability to contribute to society.

We’ve established, with EMTALA, that we all agree on the incontestable importance of universal access to basic stabilizing treatment. The next step is to come together and critically evaluate the implication of how we draw this line, and to realize that we will all benefit if we can agree on the importance of universal access to basic preventive and primary care as well. 

Not only would this lead to improved efficiency in our use of health care resources, but more importantly, it would lead to the improved health of our population.

Tags: Clinical Scholars, Emergency Care, Health Care Access, Voices from the Field