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EMTALA and our cruel health care system in Texas

There’s much that is being lost in the hyperventilating over the mistake-riddled roll out of the Patient Protection and Affordable Care Act, or ACA.  But the discussion of our health care system comes down to a few simple things.  Before this law was passed our health insurance system was a disaster.  The ACA was not designed to “fix” our health insurance system.  It’s a plan that is palatable enough for the health insurance corporations,  and was therefore allowed to pass through our corrupt political system.  And yes, Obama and the Democratic Party own it.

To show what a cruel disaster the former system was, and will continue to be in Texas – because of the decision not to expand Medicaid – please read this article, Texas’ Other Death Penalty, A Galveston medical student describes life and death in the so-called safety net. The description of how the emergency room law, Emergency Medical Treatment and Labor Act (EMTALA), works is shocking and it’s despicable that we allow this to continue.

There’s a popular myth that the uninsured—in Texas, that’s 25 percent of us—can always get medical care through emergency rooms. Ted Cruz has argued that it is “much cheaper to provide emergency care than it is to expand Medicaid,” and Rick Perry has claimed that Texans prefer the ER system. The myth is based on a 1986 federal law called the Emergency Medical Treatment and Labor Act (EMTALA), which states that hospitals with emergency rooms have to accept and stabilize patients who are in labor or who have an acute medical condition that threatens life or limb. That word “stabilize” is key: Hospital ERs don’t have to treat you. They just have to patch you up to the point where you’re not actively dying. Also, hospitals charge for ER care, and usually send patients to collections when they cannot pay.

My patient went to the ER, but didn’t get treatment. Although he was obviously sick, it wasn’t an emergency that threatened life or limb. He came back to St. Vincent’s, where I went through my routine: conversation, vital signs, physical exam. We laughed a lot, even though we both knew it was a bad situation.


But UTMB is no longer the state-subsidized charity hospital it used to be. The changes began before Hurricane Ike in 2008. But after the storm, UTMB administrators drastically cut charity care and moved clinics to the mainland, where there are more paying patients. The old motto “Here for the Health of Texas” was replaced by “Working together to work wonders.” Among those wonders are a new surgical tower and a plan to capitalize on Galveston’s semi-tropical charm by attracting wealthy healthcare tourists from abroad. Medical care for the poor is not, apparently, among the wonders. Whereas UTMB accepted 77 percent of charity referrals in 2005, it was only taking 9 percent in 2011.

UTMB ascribes these changes to financial strain from Hurricane Ike, the county’s inability to negotiate a suitable indigent-care contract and loss of state funding. The state blames budget shortfalls. The Affordable Care Act, better known as Obamacare, could have been a huge relief. However, Gov. Rick Perry rejected billions of dollars in federal funding to expand Medicaid, funding that should have brought access to more than a million Texans, including many St. Vincent’s patients.

Perry’s refusal is catastrophic health policy. For patients, it means that seeking medical care will still require risking bankruptcy, and may lead nowhere. For doctors, the message was not only that our patients’ lives don’t matter, but also that medicine—our old profession, so full of people who genuinely want to help others—will continue to be part of the economic machine that entrenches poverty. When the poor seek our help, they often wind up with crippling debt.

Because they can no longer count on UTMB to accept their patients, UTMB doctors now refer many to St. Vincent’s. They’ll treat someone for a heart attack (because that’s an emergency covered by EMTALA), then refer them to us for follow-up, even though we don’t have a cardiologist. They’ll stabilize a patient after her third stroke, put her on blood thinners and send her to us. They once sent us, from the ER, a man with a broken arm. They put the arm in a splint and referred him to us. What did they expect us to do—orthopedic surgery? Put on a cast? We don’t even have an x-ray machine.

I do not think that these referrals are an official policy. Rather, they are the work of doctors and nurses trying to do something for patients who have been refused care through the financial screening process at the hospital. Former St. Vincent’s leader Dr. Merle Lenihan has described the clinic as a “moral safety valve.” It protects UTMB from confronting the consequences of the state’s refusal to provide care. [Emphasis added]

What’s being missed about the hyperventilating over the ACA’s current problems is that many who didn’t have insurance will get it. Except in places like Texas where Medicaid expansion is not happening.

My first patient, the one who died in hospice, might have lived if his cancer had been treated before it had spread from the kidney. But without the Medicaid expansion, the Affordable Care Act wouldn’t help him: As an adult with no dependent children, he wouldn’t qualify for Medicaid now.

In a better medical system, he’d have had a chance at a more dignified experience of illness. He wouldn’t have had to wait for hours in a crowded free clinic, and assume the posture of gratefulness that charity seems to require. He wouldn’t have had to be treated in part by an earnest, but unskilled, first-year medical student. He, like so many Texans, deserved better.

There is much wrong with the ACA. The least of which is that some people who had “junk” health insurance will lose it and have to buy actual health insurance. If we wanted to fix health care in our country there’s an easy way to do it, Expanding Medicare to all can solve health care disaster.

The ACA was an effort to preserve a private health insurance market, using regulation to achieve a better result. As we see, this is very complicated.

There is a third option. If everyone is in the same, large, pool, everything medically necessary is covered, insurers are paid merely to process claims, and premiums are scaled to income, there is enough money to cover everyone at reasonable cost without elaborate, expensive, error-prone computer programs and geniuses to run them. People will be able to choose their doctors and hospitals. (And the rich can always buy more if they want.)

A crazy, wild-eyed socialist nightmare? No, this is Medicare, a familiar, popular, competently-run public insurance system that everyone’s parents or grandparents rely on. Person-for-person, disease-for-disease, Medicare is the cheapest, most efficient health insurance program in the country. (There is virtue in simplicity.)

Medicare already controls health care costs better than private insurers, and with a few tweaks, could do much more, forcing prices down to the level citizens of every other advanced democracy pay, with no sacrifice in quality.

Given the alternatives, maybe Medicare-for-all deserves a second look.

Everyone must understand that the ACA is the Heritage Foundation’s fix for health insurance.  The health care debate never should have been an insider discussion about how best to safeguard health insurance corporation profits. It should have been about how best to take care of the needs of the American people. That discussion almost always leads back to a single-payer, Medicare for all solution. One day, we will get there. Until then expect much more hyperventilating.

But this is a moral issue. For a wealthy country like ours to be allowing this kind of outcome for our citizens is an outrage. We should not allow our corrupt political system to keep us from reforming our cruel health care system, into one that allows our citizens to live and die with dignity.

Further Reading:
Medicaid enrollments surging under Obamacare, and that’s a good thing.
Check out, Health Care for All -Texas.
Via Kaiser Health News, Medicaid Enrollment Progresses Under Health Overhaul.


4 Responses

  1. […] Eye On Williamson is still blogging at our temporary home. There’s much that is being lost in the hyperventilating over the mistake-riddled roll out of the Patient Protection and Affordable Care Act, or ACA. Part of which is EMTALA and our cruel health care system in Texas. […]

  2. […] Eye On Williamson is still blogging at our temporary home. There’s much that is being lost in the hyperventilating over the mistake-riddled roll out of the Patient Protection and Affordable Care Act, or ACA. Part of which is EMTALA and our cruel health care system in Texas. […]

  3. […] Eye On Williamson is still blogging at our temporary home. There’s much that is being lost in the hyperventilating over the mistake-riddled roll out of the Patient Protection and Affordable Care Act, or ACA. Part of which is EMTALA and our cruel health care system in Texas. […]

  4. […] again about how government can do things for people, to help them. One place they could start is by showing how cruel the Texas GOP’s decision not to expand Medicaid and withhold health insurance for more that 1 Million Texans is. It’s […]

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