I was pleasantly surprised when, a couple weeks ago, a Wesleyan alumnus wrote in with some comments on my first health care column. I was reminded of two interesting things – one, that people who show up injured at an emergency room cannot be refused treatment under the Emergency Medical Treatment and Active Labor Act (EMTALA), and two, that alumni actually read the Argus.
I was tempted to use this column to explore the implications of that second revelation – namely, that our sophomoric wespeak verbo-brawling is readily available to prospective students, our parents, possible employers, etc, – but then I realized that the real world, as usual, trumps self-referential angst hands-down in intrigue and relevance.
The person who wrote in mentioned EMTALA in response to my opening question about rights and privileges. She acknowledged that “follow-up care or any continuity of coverage are two very different subjects,” but made the completely valid point that we all have the right to be provided ER care for serious medical emergencies, free from any questions about the ability to pay.
While this is legally the case, the uninsured poor experience on average twice as many delays in obtaining hospital care. In addition, research from the Robert Wood Johnson Foundation indicates that the poor are (obviously) more likely to be uninsured, and less likely to have a regular source of care. Poverty is correlated with ill health in almost every index. But regardless of income level, infant mortality and death rate statistics are worse for African Americans than white Americans. All this goes to show that, as is probably obvious, EMTALA resolves the ethical problem of health care delivery only when the patient is present in the ER and denial of care would constitute an outright harm. Care is by no means equally available on a societal level.
This probably doesn’t come as a surprise. We can all easily imagine why the stresses of poverty and racism, for instance, lead to lower health scores. We’ve certainly heard enough about diabetes and fast-food diets to understand the more concrete correlations between wealth and health. But one of the most troubling parts of the big picture is that the populations most in need of health care are those least likely to have it.
Private insurance companies have a responsibility to their shareholders, like all corporations. This means the priority is always on profit. It’s no mystery why premiums are higher for smokers or even innocent people with a family history of heart disease. These people are “high risk” and on average cost the insurance company more money. But the contradiction here is almost lunatic in its obviousness. Not only in insurance coverage, but in almost every area of a market-based health care system, care will be cheapest and most readily available to the people who need it least, while those most at risk will pay more. And risk, as we saw above, is correlated with poverty.
Having AIDS is a category that exists regardless of our interests. Being “uninsurable” is not – “risk” and “uninsurable” are artifacts of a profit-based insurance system. Nowhere is it written that AIDS patients should pay more for health care – except in the account books of an HMO or private insurance company.
The crazy part is that it’s not their fault. There’s no law against charging high prices for insurance. But there is one against defrauding stockholders. So private companies, bound by competition in the market, act to minimize their losses and maximize their gains. This isn’t novel – we see it in every facet of our capitalist society. But when health care is the product, rationing its distribution in the interests of profit becomes problematic. When an HMO manages a team of doctors, their salaries depend on efficiency and patient turnover. The results are obvious – just enough face-time, just enough care, to keep the customer. Discourage or simply refuse to take on high-risk patients. Situate the practice in a wealthy area where the nagging health problems of the poor can be avoided. Refer patients to the least expensive surgeons. Spend on advertising.
The result is nothing less than an inexorable slide past mediocrity, but just short of utter negligence. And again, you can’t blame the provider – it’s how the market works, and in almost every other application, we enjoy the fruits of its labors.
The sad part is that legislation like EMTALA, written with the best of intentions, merely band-aids the problem, and may even exacerbate different aspects of it. Free access means inner city emergency rooms are crowded and care is hugely delayed, despite its legal availability. Meanwhile, approximately one third of hospital beds lie empty because laws like EMTALA, obviously, do not extend beyond the ER, and those who need those beds simply can’t pay for them. A system that extended EMTALA’s admirable rationale to non-emergency care would change everything about American health care, however, which is precisely why it’s politically unpalatable. Next edition we’ll talk about why, and I’ll also try to answer some of the practical questions about health care for college grads.
Comments, criticisms, and suggestions can be emailed to Nick at ngerrybullar@wesleyan.edu
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