The Uninsured: Access To Medical Care

Main Points

  •  Emergency care is the safety net of the entire national health care system, caring for everyone, regardless of ability to pay or insurance status.
  • The effects of the nation’s current financial crisis are playing out first in the emergency department, where the newly unemployed and uninsured are turning for care.
  • Inadequate coverage of the uninsured, cutbacks in Medicare, declining payments by health plans and a medical liability crisis are threatening the ability of emergency physicians to continue to provide high-quality care to everyone.
  • ACEP advocates for expansion of health care coverage for the uninsured and underinsured and has taken a leadership role in building a national consensus for universal health coverage.
  • The Institute of Medicine in 2006 recommended that Congress consider providing greater reimbursements to large, safety-net hospitals that bear the burden of taking care of uninsured patients.
  • Everyone is only one step away from a medical emergency.

Who are America's uninsured?

The federal government estimates 46 million Americans are uninsured in the United States. Nearly 20 percent (8.7 million) of the uninsured are children.

  • 8 in 10 are in working families that cannot afford health insurance, and most are not eligible for public programs.
  • 66.7 percent live in households with a full-time worker and 20.2 percent with a part-time worker
  • 20.4 percent of African-Americans are uninsured
  • 33.5 percent of Hispanics are uninsured
  • Most elderly are covered by Medicare, so nearly all the uninsured are under age 65.

What is the nation's health care safety net?

Health care safety net providers are those that have a legal mandate or mission to offer medical care to all patients, regardless of their ability to pay, and have a substantial number of patients who are uninsured or on Medicaid.

  • Health care safety net providers include emergency departments, community health centers, public hospitals, charitable clinics, and in some communities, teaching and community hospitals—organizations that people turn to when faced with barriers to obtaining medical care elsewhere.
  • Emergency departments have the only legal mandate to provide health care ??the Emergency Medical Treatment and Labor Act (EMTALA). This law ensures that anyone who comes to an emergency department, regardless of their insurance status or ability to pay, must receive a medical screening exam and be stabilized. According to a 2009 ACEP survey on the financial crisis, 66 percent of emergency physicians polled have seen an increase of uninsured patients in their emergency departments during the current financial crisis.

Are uninsured patients with nonurgent medical problems causing overcrowding?

No. According to ACEP’s survey of emergency physicians released in March 2003, many of the uninsured people who arrive in America’s hospital emergency departments are in terrible shape. Emergency physicians say they have delayed needed care, live with more serious medical conditions and are more likely to die before their time than those with health insurance. Besides, patients with nonurgent medical conditions may wait longer for care, but once seen, they are treated quickly and released. Dangerous overcrowding is caused when a lack of hospital resources results in acutely ill patients being "boarded" in an emergency department, because no hospital inpatient beds are available, and ambulances must be diverted to other hospitals. The Centers for Disease Control and Prevention classified only 12.1 percent of hospital emergency department visits as non-urgent in 2006.

What are the costs of providing health care to the uninsured?

Hospitals and physicians shoulder the financial burden for the uninsured by incurring billions of dollars in bad debt or "uncompensated care" each year. Fifty-five percent of emergency care goes uncompensated, according to the Centers for Medicare & Medicaid Services Health care costs for both the full-year and part-year uninsured will total $176 billion dollars this year - $86 billion of which will be incurred when they are uninsured.

In the past, hospitals shifted uncompensated care costs to insured patients to make up the difference. However, cost shifting no longer is a viable option because managed care and other health plans have instituted strict price controls, leaving little margin to shift costs. More than one-third of emergency physicians lose an average of $138,300 each year from EMTALA-related bad debt, according to a May 2003 American Medical Association study.

With projections that health care costs will double and the number of uninsured will increase, the nation is faced with how it will continue to provide care for all Americans, not just the disadvantaged. Emergency departments provide an essential community service, similar to fire departments, police departments, and public utilities. The nation cannot afford to allow the emergency care system to collapse because of a lack of funding. It is too high a price to pay in terms of public health effects and human suffering.

What is the SCHIP program and how has ACEP promoted it?

ACEP supports expansion of the State Children’s Health Insurance Program (SCHIP) to cover more low-income American children. SCHIP is the largest expansion of health insurance coverage to children since the enactment of Medicaid in 1965. Like Medicaid, the program is a partnership between federal and state governments. Enacted as part of the Balanced Budget Act in 1997, SCHIP was designed to expand health insurance coverage to working families that earn too much for traditional Medicaid, yet not enough to afford private health insurance.

  • ACEP has worked to educate emergency physicians about this program as a partner in the Covering Kids campaign. Many ACEP state chapters have partnered with local SCHIP programs to identify eligible children and promote the program by providing information and resources to uninsured families during emergency department visits.
  • A study published by Annals of Emergency Medicine in December 2004 found emergency departments are an effective place to enroll children in government health insurance programs, and that these enrollment program can generate enough revenue for the hospital to pay for the program costs and then some.

What does ACEP propose as solutions?

ACEP advocates for universal health care coverage that builds on the strengths of the nation’s current health care system.

  • ACEP is asking Congress to pass the "Access to Emergency Medical Services Act 2009" (H.R. 1188 and S.486) to reduce the dangerous trends that are limiting the public’s ability to receive high-quality, lifesaving medical care and leaving emergency departments unable to respond to disasters.
  • ACEP’s Task Force on Health Care and the Uninsured developed six principles to be used as a framework for expanding health care coverage to all.
  • The public’s desire for health care reform has shifted over time from wholesale reform to more targeted, incremental strategies. Among the options are: shoring up Medicaid, offering vouchers to buy insurance, offering tax credits to help small employers and individuals, and providing tax relief to those who buy insurance on their own.
  • Numerous polls show that most Americans support the idea of access to universal coverage, and the plight of the working uninsured clearly resonates with most of the public. But support starts to wither when people are asked whether they would be willing to pay more taxes to cover more people.

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