Editore"s Note
Tilting at Windmills

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December 21, 2010

THE GOP'S EMERGENCY-ROOM ARGUMENT LIVES.... I'd hoped we would hear the argument much less after the Affordable Care Act became law, but the notion that the uninsured can just rely on emergency rooms hasn't gone away quite yet.

Here, for example, was Virginia Gov. Bob McDonnell (R) on Fox News the other day:

"The fact is a lot of people that don't have insurance are getting [care] right now. They're not denied in the emergency rooms. They're generally not denied by doctors. It's not a pretty system, but the idea that people are not getting health care particularly for critical needs is just -- is just not the case."

This is strikingly wrong. For one thing, doctors in private practice nationwide tend to take on patients with insurance. For another, all McDonnell has to do is spend a few minutes at a free clinic someday to realize all kinds of families in need go without much-needed care every day, in Virginia and elsewhere.

But it's that darn emergency-room argument that needs the most help.

Let's set the record straight. It's true that under the previous system -- before the Affordable Care Act passed -- if you're uninsured and get sick, there are public hospitals that will treat you. But it's extremely expensive to treat patients this way, and it would be far cheaper, and more medically effective, to pay for preventative care so that people don't have to wait for a medical emergency to seek treatment.

For that matter, when sick people with no insurance go to the E.R. for care, they often can't pay their bills. Since hospitals can't treat sick patients for free, the costs are passed on to everyone else.

In other words, it's the most inefficient system of socialized medicine ever devised.

And yet, Republicans keep praising it. McDonnell was repeating this talking point over the weekend, but he's hardly alone. Rep. Steve King (R-Iowa) was touting it late last year, and Sen. Jim DeMint (R-S.C.) was thinking along the same lines a month prior. In July '09, Senate Minority Leader Mitch McConnell was asked about the 47 million Americans who go without health insurance, McConnell replied, "Well, they don't go without health care," because they can just go to the emergency room.

In 2008, the conservative who shaped John McCain's health care policy said anyone with access to an emergency room effectively has insurance. The year before, Tom DeLay argued, "[N]o American is denied health care in America," because everyone can go to the emergency room. Around the same time, George W. Bush said the same thing: "[P]eople have access to health care in America. After all, you just go to an emergency room." In 2004, then-HHS Secretary Tommy Thompson said our healthcare system "could be defined as universal coverage," because of emergency rooms.

It's a dumb argument. That it's been a staple of Republican rhetoric for so long only adds insult to injury.

Update: Aaron Carroll has a related post on this, which emphasizes a few points I'd overlooked. Worth a read.

Steve Benen 3:00 PM Permalink | Trackbacks | Comments (42)

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hmmm, maybe my wife can get her cancer treatments at the ER.

Posted by: rmp on December 21, 2010 at 3:09 PM | PERMALINK

of course they leave out the part where the "free" Emergency care bills you and takes every last nickle you've got before it's "free". oh, and it acts as triage as sends you on your way the minute they know you don't have a way to pay.

Posted by: KK on December 21, 2010 at 3:11 PM | PERMALINK

I think you're missing the main point about using ER's for healthcare. They are for emergency care only. Once they've addressed the problem that brought you in they're done with you. They may find that you have life threatening chronic diseases like high blood pressure or diabetes but they won't do anything to address that problem. If you have high blood pressure they'll administer meds to bring the BP down enough to release you. If you have diabetes they'll tell you to consult with your doctor, if you have one. In neither case, or any other chronic disease will there be any followup or even a prescription for meds to carry you through a reasonable time to get long term treatment.
ER treatment is not health care!

Posted by: wordtypist on December 21, 2010 at 3:17 PM | PERMALINK

It's worse than that. "They're generally not denied by doctors." is completely false.

In 2000 when I switched jobs, I promptly broke my arm. I didn't have a lapse in employment and I didn't have a lapse in insurance. I had money. I *still* could not get non-critical care.

I got my arm taken care of in an emergency room and my previous insurance covered it. But they would not cover my follow-up appointments. Fair enough, but when I went for that appointment, a letter from my current employer saying "he has insurance, trust us" was not good enough. Neither was my Visa card. My doctor WOULD NOT see me until I could produce an insurance card proving I had coverage.

So to say that people who genuinely don't have coverage have all these options is complete B.S.

Posted by: Vondo on December 21, 2010 at 3:20 PM | PERMALINK

This is how "death panels" work in the Republican view by the default of blinders. Don't you dare cut my granny off, but screw the invisible yours! How Christian of these righteous!

Posted by: lou on December 21, 2010 at 3:22 PM | PERMALINK

I think O'Donnell makes a great argument, because it proves why "Obamacare" [one way to beat a perjorative is to own it] was such a smart idea.

It's not like we're adding on a costly economic burden with Obamacare. All we're doing here, is finding a smarter and more efficient (i.e., cheaper) way to pay for something that we're all already paying for.

No such thing as a free lunch, as Milton Friedman might have said.

Posted by: Obamacare on December 21, 2010 at 3:23 PM | PERMALINK

For conservatives like McDonnell to point to the emergency room as a source of healthcare is not only idiotic, it betrays the principles of business and economics they always claim to champion. Any fourth grader could explain that forcing emergency rooms, with all their high priced apparatus, to act as a family doctor is the most expensive way to provide health care that exists. It is much cheaper to adress preventive care than it is to wait until an emergency situation occurs. And finally, if you have ever gone to an emergency room on any night of the week, with a legitmate condition you know that those who are there because they have no insurance create a wait time of many hours. I took my wife to the mergency room because she was having severe pain just a day or two after major surgery. We arrived at the emergency room at 10:00 pm and finally got treated at 4:30 in the morning. My advice - if you need to go to the emergency room, make sure you get there in an ambulance. They'll treat you immediately.

Posted by: Vandal on December 21, 2010 at 3:25 PM | PERMALINK

Hospitals are required by the Emergency Medicine Transport and Active Labor Act (EMTALA) to stabilize emergencies and deliver women in active labor without regard for whether the patient in question can pay. That does not mean that they can't send a bill. They can and they do. Stabilizing an emergency, however, is not the same as providing chronic care or non-emergency treatment.

Yes, there are a lot of physicians who provide free care. If, for instance, you are my patient and you lose your insurance, I will charge you a nominal amount to come in to my office. However, if you need hospital care (which involves a whole bunch of non-physicians who need to be paid, too), you are pretty much out of luck.

An American born patient of mine, working full-time, lost her insurance when her employer dropped it. She was too young for Medicare and had several pre-existing conditions (multiple myeloma and asthma), so she was unable to purchase insurance. She had an asthma attack. Rather than going into debt to go to the ED, she promised her daughters that she would come see me in the morning. She died that night of an entirely treatable condition. She was a mother, grandmother, and daycare worker, not a Wall Street financier, so Repuliconfederates and a few Blue Dogs will tell you that that was just fine.

Posted by: Stella Barbone on December 21, 2010 at 3:28 PM | PERMALINK

Everybody is missing the most obvious of problems with the mandated ER care:

Under the law, the ER is ONLY obligated to provide stabilizing treatment (stop the hemorrhage), NOT to fully treat the patient.

If you have cancer, you are out of luck, as for many other problems that take multiple MD visits to treat. They won't fix a hernia.

If you can't pay for treatment, they put you in a wheel chair, call the ambulance, and take you home.

Posted by: JimPortlandOR on December 21, 2010 at 3:28 PM | PERMALINK

My niece needs her gall bladder out but the ER won't touch it until it is life threatening. It is ludicrous for these Republicans to call this health care. You get the bare minimum, and definitely not what you need....more shameful lies.

Posted by: sherrybb on December 21, 2010 at 3:29 PM | PERMALINK

wordtypist and everyone else are absolutely correct: emergency room treatment is a terrible way to deal with medical and other health problems for all kinds of reasons.

It's hard to know whether King, DeMint, McDonnell and McConnell are really as clueless as they appear to be or whether this is just intellectual dishonesty. I think that a lot of these guys--particularly the Southern Republican Senators and Congresspeople--live a very parochial existence and have no real sense of the difficulties faced by the poor, the working poor and families with incomes only slightly above the poverty line. On the other hand, if these guys had put any effort at all into learning about the health care problems this country faces, they should understand how inadequate a solution emergency room care is.

So, ignorant/clueless or dishonest? Either way, these guys are really a disgrace.

Posted by: DRF on December 21, 2010 at 3:33 PM | PERMALINK

Missing angle to this is that as the number of patients without insurance (self-pay) increases, there is a direct correlation in price increases by the hospital, which are passed on only to those with insurance through higher premiums. Basic hospital math is that you lose money on self-pay patients, you lose money on Medicaid, you might break even on Medicare, leaving the only place for margin on those with insurance. When hospitals raise prices in part to offset the uncompensated care, the only payer it matters for is commercial insurance, as government payers are fixed payments regardless of charges. So, one aspect of the ACA hospitals are counting on is fewer uninsured/self-pay patients. Even reimbursement less than cost is better than writing it all off.

Posted by: RollaMO on December 21, 2010 at 3:38 PM | PERMALINK

So the Republicans expect the poor in Arizona to go to the emergancy room for transplants?

Posted by: J. Frank Parnell on December 21, 2010 at 3:39 PM | PERMALINK

Once the TeaParty House gets sworn in, we'll be hearing lots more of this type rhetoric...it proved very successful in derailing public opinion of the Healthcare package and will continue to be used to turn public opinion against funding the HCR package...which is the expressed goal of the next GOP/TeaBag House. Making up lies, spreading them without any Media pushback is always successful for the GOP and they won't stop.
Palin's already back to the "Death Panel" mantra and the rest of the propaganda, such as this by McDonnell, will be front and center come January.

Posted by: T2 on December 21, 2010 at 3:39 PM | PERMALINK

You can't get fucking chemo at a fucking ER.

Posted by: dob on December 21, 2010 at 3:40 PM | PERMALINK

"It's a dumb argument." -Steve Benen

Yes, but if you repeat it often enough a large percentage of people will believe it.
-Same goes for "global warming", "welfare queen", and "trust me".

Posted by: DAY on December 21, 2010 at 3:45 PM | PERMALINK

@dob, 3:40

Eloquently put.

So it is more than just a matter of emergency rooms being more expensive. There are treatments they just won't do.

There was a story about a month or two ago about a Detroit woman who shot herself in the shoulder so she could get her non-emergency frozen shoulder fixed in the emergency room. They patched her up and sent her home once the bleeding had stopped.

Posted by: patrick II on December 21, 2010 at 3:46 PM | PERMALINK

The lie that "anyone can get free health care" is necessary to keep the real system palatable for the nice, middle-class, white people who are Republican voters.

Posted by: Stella Barbone on December 21, 2010 at 3:49 PM | PERMALINK

I took my son to the emergency room in February, and I have a bill for $749 on my desk. And I have health insurance.

Posted by: Rick Massimo on December 21, 2010 at 3:56 PM | PERMALINK

Since the cost of ER care for the uninsured impacts hospitals as well as those with insurance, this is a true example of the fact that those without insurance are involved in the economic activity of the healthcare system. Since the healthcare system is nationwide, the uninsured are involved in interstate commerce. The GOP is impliciity making the point that the individual mandate included under ACA is constitutional under the Interstate Commerce clause. They need to be hit very hard with this.

Posted by: skitso on December 21, 2010 at 4:02 PM | PERMALINK

This infuriatingly false argument - that emergency rooms will take care of the uninsured -discredits the honesty, and maybe even the brains, of the Republicans who use it.

Here is a partial list of diagnoses that my emergency room will not treat, and should not treat, except to stabilize an emergency exacerbation: cancer, chronic airways disease, valvular heart disease, hypertension, diabetes, ulcerative colitis, chronic renal failure, rheumatoid arthritis, sacro-iliac joint dysfunction, a torn meniscus, a torn rotator cuff, spinal stenosis, carpal tunnel syndrome, plantar fasciitis, hyperlipidemia, glaucoma, partial complex seizure disorders, non-miliary tuberculosis, endometriosis, hypothyroidism, hepatitis B and C, HIV, and many others.

So, my Republican friends, where should uninsured patients with these problems be treated? - an increasingly Grumpy Family Doctor, who is wondering . . .

Posted by: Paul Papanek on December 21, 2010 at 4:05 PM | PERMALINK

And R's wonder why their medicaid budgets have gone through the roof.

Idiots. Let's see - what would be more economical - treating someone for high blood pressure or treating their eventual heart attack at an emergency room?

God but R's are fucking stupid.

Posted by: fourlegsgood on December 21, 2010 at 4:07 PM | PERMALINK

anyone who argues that emergency rooms provide an alternative health care system for those without health insurance is an idiot. period. end of argument. it is wrong from a humanitarian standpoint, and it is wrong from a practical standpoint.

Posted by: mudwall jackson on December 21, 2010 at 4:11 PM | PERMALINK

The consciences of Republicans are so tiny, only the thinnest of balms are necessary to soothe them when they bother them.

"The uninsured can go to the ER, the existence of want ads proves unemployed people are lazy and massive tax cuts for rich people cut deficits."

"Well that's a load off my mind. Thanks. Let's hit the links."

Posted by: Another Steve on December 21, 2010 at 4:13 PM | PERMALINK

It's not only expensive, it overloads ERs past the breaking point. Two years ago I went into the bedlam at Bayonne Medical Center on a Monday (a bad day to be sick, try to avoid it), and because of the crush it took ten hours to get me into a bed (I had pneumonia, and at my age then, 69, that is not trivial). And I have plenty of insurance (Medicare + a good retirement package). I was told by my pulmonologist (I also have a chronic lung condition) that I was lucky...that he had elderly patients who had waited as long as a day in an ER. And Bayonne is well run!

I find it ever ironic and worthy of note that many of the same people who object to Darwinism in the classroom seem to love it in the marketplace. Or is that Hobbes' (Thomas, not Calvin &) World?

Posted by: jrosen on December 21, 2010 at 4:21 PM | PERMALINK

The other element is that people generally hate to ask for care when they don't have coverage. They often will wait until a condition has progressed before seeking care. This also does not make it cheaper, although cost should not be the primary concern in this situation.

Posted by: jb on December 21, 2010 at 4:28 PM | PERMALINK

THE ARGUMENT is also rubbish because many people, like AIDS patients and Diabetics, require daily MEDICINE to keep them alive. Emergency rooms are not equipped to handle long term care for patients or repeat visits. This is why the plan to eliminate AZ's version of Medicaid by AZ's Governor Jan Brewer is so callous, thousands of patients who need daily meds will DIE if the program is cut.

BUT, Arizonans can take comfort in knowing that Jan Brewer will create thousands of new prisoners out of undocumented workers at $64,000 a year and cut taxes for businesses in exchange for the tens of thousands of lives eventually cut short because of her Medicaid policy.

Posted by: KurtRex1453 on December 21, 2010 at 4:29 PM | PERMALINK

A hospital's responsibility under EMTALA is to evaluate and stablize. So a patient with a broken leg requiring surgery will be put in a splint, given a pair of crutches and some pain killers and sent on their way. This is not a frivolous example.

Posted by: Jose Padilla on December 21, 2010 at 4:35 PM | PERMALINK

ERs will stabilize you period. My son injured his hand and they made sure blood was flowing, that it was wrapped and handed him a script for pain pills. They did not do the surgery he needed to actually use his hand again. For that they referred him to a surgeon and my husband and I took out an equity loan on our home for 10K and paid cash so our son wouldn't be a cripple. Oh and we live in Virginia. Bob McDonnell has had socialized medicine all his adult life as he was a military man and then a politician.

Posted by: bohica on December 21, 2010 at 4:40 PM | PERMALINK

Congress doesn't deserve health care. They should be stripped of that privilage completely.
Every one of those people deserve to get a big swallow of reality so they can learn to govern a nation fairly, instead of being allowed to govern and to make laws from the rarified point of reference of the wealthy.

If you don't hurt, you can't understand pain.

And Congress should have their retirement stripped as well. That too is a privilage. Or just reduce their retirement to my level as a government employee, where I get 1% of my highest paygrade for every year I work; 30 years = 30%. No full benefits after six years bullshit.

Then lets see how many of them stay in those Congress jobs when the perks are gone. I imagine, like Palin, some nasty GOP trash would be out the door and on the Fox payroll before you could say "how's it feel?"

Fuckers. All of them.

Posted by: Skip on December 21, 2010 at 4:41 PM | PERMALINK

A senior staffer at our local, community-based, not-for-profit hospital told me last week they are carrying $73 million in written off emergency care and recognized charitable care. They are still operating in the black and are solvent, largely because, as a nonprofit, they have some endowment funds and charitable donations for the care. If they were part of an investor-owned, for profit hospital chain, I wonder if they would still be open.

I believe part of this distorted perspective grows out of the "doctor as selfless hero" mindset. Which, of course, has no relationship to reality in the early 21st century.

Posted by: jpeckjr on December 21, 2010 at 4:45 PM | PERMALINK

Actually everything McConnell said is wrong. He may know that, on the other hand he may believe his own BS. Who knows. OBRA '86 (the federal patient anti-dumping law) applies only to hospitals that have emergency rooms (some do not and it is not a requirement). The American Hospital Association made sure this was the case, and then they spent the next 24 years trying to weaken and bypass the original law using every technicality imaginable. Private physicians can refuse care to anyone they please. Most hospitals are in the business of making money any way they can, and most physicians, especially surburban physicians in specialty areas, have a very strong sense of entitlement and expensive tastes. Greatest health care system in the world, just not this particular world.

Posted by: max on December 21, 2010 at 4:49 PM | PERMALINK

""They're not denied in the emergency rooms. They're generally not denied by doctors.""
This is one of the most vicious lies ever to enter the political game. The thrust of medicine today is prevention. Try going to the ER and asking for a colonoscopy or mammogram. Not happening. Now, when you are passing blood or feel a lump..you might get seen only to be give a bad prognosis. ER's are not a place for "health care" in its modern definition. They are a place for treatment. You have to be sick to go there.

Posted by: Richard on December 21, 2010 at 4:57 PM | PERMALINK

At this time of the year, it seems appropriate to quote Mr. Dickens:
“At this festive season of the year, Mr Scrooge,” said the gentleman, taking up a pen, “it is more than usually desirable that we should make some slight provision for the Poor and destitute, who suffer greatly at the present time. Many thousands are in want of common necessaries; hundreds of thousands are in want of common comforts, sir.”

“Are there no prisons?” asked Scrooge.

“Plenty of prisons,” said the gentleman, laying down the pen again.

“And the Union workhouses?” demanded Scrooge. “Are they still in operation?”

“They are. Still,” returned the gentleman, “ I wish I could say they were not.”

“The Treadmill and the Poor Law are in full vigour, then?” said Scrooge.

“Both very busy, sir.”

“Oh! I was afraid, from what you said at first, that something had occurred to stop them in their useful course,” said Scrooge. “I’m very glad to hear it.”

“Under the impression that they scarcely furnish Christian cheer of mind or body to the multitude,” returned the gentleman, “a few of us are endeavouring to raise a fund to buy the Poor some meat and drink, and means of warmth. We choose this time, because it is a time, of all others, when Want is keenly felt, and Abundance rejoices. What shall I put you down for?”

“Nothing!” Scrooge replied.

“You wish to be anonymous?”

“I wish to be left alone,” said Scrooge. “Since you ask me what I wish, gentlemen, that is my answer."

'Nuff Said - Ted

Posted by: Ted Lehmann on December 21, 2010 at 5:14 PM | PERMALINK

My Fox-News-listening sister used that line on me when I worried about my son's lack of insurance. She was actually surprised when I told her that, yes, the ER will treat him, but then they send a bill. Really?

Posted by: Gretchen on December 21, 2010 at 5:34 PM | PERMALINK

Conservatives are simple-minded people who don't want to be troubled by facts and care only about dogma and not human consequences. Thus, government is always wrong in their mind, the "free market" is always right and it is always better to spend tax dollars on guns than butter- human consequences be damned. This situation is just one more validation of that fact pattern.

Posted by: Sam Simple on December 21, 2010 at 5:38 PM | PERMALINK

That people without health insurance don't refuse treatment because they can't afford it, but rather rely on emergency care, the cost of which must be born by others, seems to be an admission by the Senator that the uninsured are engaged in an economic activity (of passing the costs of emergency care on to others), thereby proving that the failure of the uninsured to purchase insurance falls within the Congress' powers to regulate interstate commerce.

Posted by: dan on December 21, 2010 at 7:34 PM | PERMALINK

I don't work in the ED, but I know several people who do. These physicians really do try to do the right thing within the constraints of the current system. Indeed, many of my colleagues treat patients for free. Even the hospital writes off a great deal for services it provides. Without that, many children in Tennessee, Arkansas, and Mississippi would go without adequate care. I believe that the charity of these physicians are keeping our current system afloat.

Of course, I have many Republican friends who regularly tell me that paying taxes to support the poor is unfair to them and that gives me an idea. If I follow their logic, it seems that forcing hospitals and physicians to treat a patient even if they might not get paid is unfair. We don't expect plumbers to fix broken pipes if they won't get paid. In fact, in the language of the libertarians, this law make the doctors slaves to the poor. I fully expect to see the Tea Party act to change the law so that the 911 operator begins the call by asking for a credit card or insurance card number.

Posted by: JustAnotherDoc on December 21, 2010 at 7:42 PM | PERMALINK

The big lie about this is that only public hospitals HAVE to treat someone in the ER. Private hospitals can turn people away in the ER if the person has no insurance without penalty.

Posted by: Bonnie on December 21, 2010 at 9:35 PM | PERMALINK

I'm very surprised that two things haven't come up in the discussion here: 1) the previous discussion of education, and 2) the recent election of Rick Scott as Governor of FL.

Here we have two other facets of the same argument. In the one case, as with the healthcare jabber, we have a segment of the political class who just don't want to be bothered about attending to the common weal: ignorant and untreated seem to be how they want to leave us, even though they tout both segments of the common sphere. They get the best of both worlds: a handful of state-of-the-art facilities they can showcase as proof their system works, and no real obligation to pay for any more than that.

In the second case we see exactly what part of the healthcare the G(n)O(B)P values. The former head of a major hospital chain, which was prosecuted and convicted of defrauding Medicare (among other programmes) is punished for his crimes - by being elected governor of a state with some of the most serious demands for healthcare in the country. Florida has been marketed as a retirement haven for generations now, and many have moved to Florida thinking that their quality of life would be better served living there. For whatever reason, then, voting blocs like the elderly seem to find a highly suspect figure like Scott, whose companies robbed the very federal funds many depend on for their healthcare and support, an attractive state leader. The head of a healthcare company which defrauded the government of billions thus becomes the hero of the wingnuts for being so clever and successful, rather than shamed for stealing from the citizens who paid into the funds and from the beneficiaries who were demonstrably mistreated by a greedy enterprise more interested in its bottom line than their well being.

This, then, is a summary of the great conundrum. The Right lauds the public sector of this country so long as they don't have to pay for it, and begrudge it every penny - when they're not actively robbing it for their own gain, which again is somehow laudable in their universe. They then paint those who would see the public sphere at least somewhat healthy as enemies of the state. And their base, thoroughly fooled, fall for the charade every time.

Posted by: boatboy_srq on December 21, 2010 at 10:27 PM | PERMALINK

Bonnie: "The big lie about this is that only public hospitals HAVE to treat someone in the ER. Private hospitals can turn people away in the ER if the person has no insurance without penalty."

Bonnie, if you aware that a private hospital is turning any patient away who presents in an emergency condition (it has to be a real emergency) then report it immediately to your State Department of Health. They have a contract with the feds to investigate patient dumping complaints, which are a very high priority. This is still against the law. If the complaint is valid Medicare can issue a 23-day termination letter (termination from Medicare) unless the hospital demonstrates they have fixed the problem. No hospital, including private hospitals want to be booted out of Medicare, even if they are owned by Republicans (likely). The comments by Governor Bob McDonnell (R) Virginia that started this thread are all untrue. He either doesn't know what he's talking about or he is deliberating conflating unrelated issues to play to his dumbed down constituents who watch Fox News and want to believe what he says.

Posted by: max on December 22, 2010 at 8:51 AM | PERMALINK

Ignoring for the moment the fact taht ER's provide only acute care, not chronic care, I find it interesting that the Republican Party is advocating a policy of what is essentially "shoplifting" by the uninsured. Think about that for a moment...rather than responsibly addressing the healthcar crisis in this country with policies that provide universal health insurance, Republicans are telling people to secure something with no intention of paying for it.

And they accuse Democrats of not respecting property rights!

Posted by: Chesire11 on December 22, 2010 at 9:29 AM | PERMALINK



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