In 1986, Ronald Reagan signed the landmark legislation known as EMTALA (Emergency Medical Treatment and Labor Act) which mandated that hospitals who accepted payments from the federal government (Medicare, Medicaid, etc.) had to provide emergency medical treatment until their condition is stabilized. This widely popular mandate is often cited as a guarantee that every patient regardless of ability to pay gets the emergency treatment they need. In one of his speeches, George W. Bush even proudly declared, “people have access to health care in America. After all, you just go to an emergency room.”
The intent of this legislation was to prevent a practice called “dumping” in which hospitals turned away patients who were unable to cover the medical costs they incurred. Pre-1986, this manifested itself as doorstep baby deliveries, unfinished surgeries, and patients frantically scrambling to find a hospital to keep them alive. EMTALA put an end to this but there was an unintended consequence. It gave individuals who could not afford care a basic, last-ditch care option, making it an attractive option for young, low-income, and undocumented populations.
Since 1986, the number of visits to emergency departments has greatly increased partially because of this emergency care mandate. Many of these patients are insolvent of the care they receive due to inability to pay; in fact, according to the Department of Health and Human Services, 55% of emergency medical care goes uncompensated. The costs of this uncompensated medical care are mostly borne by the hospital itself reflected as increased charges for the care of insured patients. Moreover, this emergency medical care is often much more cost-intensive than that of regularly insured patients who are able to avoid complicated health issues later on through regular check-ups with their primary care physician.
Even with its flaws, EMTALA still stands today 31 years after its passage. A 2017 survey by the Morning Consult found that 95% of Americans wanted insurance for emergency medical care and strongly supported provisions in the ACA meant to protect it. Since the 1940’s when the US government allowed a temporary tax break for health insurance and accidentally created America’s employer-based health insurance market, America has held to its tradition of expanding health coverage for Americans. From Johnson’s Medicare and Medicaid to Reagan’s legislation, COBRA, which mandates health coverage after retirement, American government has created and protected powerful institutions to address this objective.
Given this, how did the American Health Care Act, a bill projected to increase the uninsured population by twenty-two million mainly due to cuts to the Medicaid expansion program, come one vote away from passing? The bill dangerously proposed to cut Medicaid without any replacement to reinsure low-income populations. These newly uninsured patients would’ve gone back to seeking emergency medical care instead of regular checkups imposing an undue burden on the medical system.
The big question is this: do we as a country believe that all Americans deserve equitable access to health coverage? I think we do. Even though the bill came harrowingly close to approval, there was clearly a disconnect between the policy and the message. When asked in public to defend the bill, Republican legislators were at a loss for words and often less than enthused about the process overall. John McCain famously said, “They’re just trying to get to 51 votes.” They themselves had concerns about how the legislation would affect their own state’s health insurance markets and were holding out for later corrections. Overall though, it seems as if legislators got caught up in party politics over policy.
Regardless, the AHCA almost set a dangerous precedent, making access to health coverage a partisan issue. How to achieve this vision of equitable access to health care is still divisive with different legislators rightfully having different views on how to best achieve this. But America’s future legislation will be tied to the profound influence that EMTALA has on the health care system today and the country’s own history in steadily increasing access for all Americans. The AHCA was simply a poor misstep in the wrong direction.
In the quickly changing landscape of health policy, it is important that the desire to increase coverage remain one of the tenets of policy-making in the area. A world where increasing health coverage becomes a partisan issue is one which risks losing much larger, more fundamental institutions of American medicine than Medicaid expansion. It begs the moral question of who deserves health coverage rather than the more political question of how this health coverage should be administered. When policymakers across the political spectrum can agree upon this premise, we can continue to make progressive change toward an improved health care system which works better for all Americans. If the conservative legislators of the past so strongly stood by this guiding principle, then the conservative legislators of today should do the same.
Ishaan Shah ‘20 studies in the College of Arts & Sciences. He can be reached at email@example.com.