Aug 21 2013
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Pros and Cons of Federally Mandated Comprehensive Care

Italo M. Brown, MPH, is a rising third-year medical student at Meharry Medical College. He holds a BS from Morehouse College, and an MPH in epidemiology and social & behavioral sciences from Boston University, School of Public Health. He is a Health Policy Scholar at the Robert Wood Johnson Foundation Center for Health Policy at Meharry Medical College. Read all the blog posts in this series.

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In 1986, Congress took a step in the direction of patient advocacy by passing the Consolidated Omnibus Budget Reconciliation Act (COBRA). One part of this act, the Emergency Medical Treatment and Labor Act (EMTALA), has served as the precedent for federally mandated care and has largely shaped our understanding of urgent care delivery in America. While some have touted EMTALA as a public health victory, many have scrutinized the federal mandate, citing its imperfection and labeling it as a strong contributor to the current ailments of our emergency medical system.

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However, 27 years after EMTALA became law, a greater emphasis is placed on preventive measures and comprehensive care, rather than urgent care, as a means to reduce negative health outcomes. Naturally, champions of cost-efficient comprehensive care have suggested that a federal mandate should be explored.

Making the Case

During a conversation with a financial advisor who specialized in entrepreneurship, I learned three very important things that must be addressed before launching any product/service/enterprise. First, one must demonstrate "proof of concept;" in other words, one must prove that the grand idea is worthy of acclaim, and feasible enough for investment. Second, a business case must be made that justifies the product/service/enterprise from an economic standpoint. Finally, one must gauge the scalability of such a grand idea/service/enterprise (or rather, why it has not gone to scale already).

This thought process can be applied to the idea of a comprehensive care mandate, and used to formulate a substantial rationale in its favor.

Here, the proof of concept is evident; in the U.S., the leading causes of death (related to illness) are rooted in chronic conditions, many of which can be addressed through preventive care and consistent disease management. In making the business case for a comprehensive care mandate, cost-efficiency is the theorized economic trump card. Many believe that increasing access to needed services (think preventive care plus managed care), will reduce negative health outcomes over time, potentially abridge emergency room visits, and shift the cost-curve in a favorable direction. Scalability, however, is controversial, making it the most difficult tenet to troubleshoot.

A Moral Hazard Application

The insidious counter-argument against a comprehensive care mandate (and its scalability) can be made simply by exploring moral hazard. This concept describes the unrestricted utilization of a given service by an individual who is not aware of, or not affected by, the consequences of such utilization. In fact, moral hazard can be offered as a potential rationale for the overuse of emergency services occurring in hospitals across the U.S. (as one of my professors put it, this is the "Million-Dollar Murray" debacle author Malcolm Gladwell warned about). The same minds that attribute the "overburdened, underfunded, and fragmented" nature of emergency care to EMTALA anticipate a similar outcome if a federal mandate for comprehensive care were to be passed. In short, the mass effect wouldn't be cost-saving but rather a shift of uncompensated care from the urgent care setting to the clinic/ambulatory care setting.

The Bottom-Line

We are far removed from common ground in this dialogue. Modern political currents in the health care debate have created an undertow that seemingly complicates the idea of a comprehensive care mandate that goes beyond bare bones. For example, certain fundamental principles, such as "health care for all (regardless of citizenship)" or obligating public and private hospitals to treat patients (both of which are features of EMTALA), are likely to invoke fierce opposition.

Further, the expansions in preventive care made possible through the Patient Protection and Affordable Care Act may be framed in a way that pacifies champions of a federal mandate. Perhaps the most pronounced gray-area in the discussion is federal funding. While most broad-reaching mandates (enacted in the past 15 years) are begrudgingly written into the federal budget, EMTALA (an unfunded mandate) remains a crop circle in the field.

Ultimately, in this debate supporters of a federally mandated comprehensive care model must recognize that an "apples to apples" comparison is difficult to assume. Universal coverage and emergency care may both appear as fruits, but grow on different trees. Domestically, a comprehensive care mandate is a unique and unprecedented idea/care model; as such, it should be given a degree of consideration free from the confounding of our previous successes (or failures—depending on your vantage point).

Tags: Center for Health Policy at Meharry Medical College, Disease Prevention and Health Promotion, Emergency Care, Voices from the Field