Emergency Rooms Busier Since Obamacare: Why?

If you are in the United States and you are sick, the one place that has to treat you is the emergency room (ER). Strictly speaking, there is no law that absolutely requires hospitals to offer treatment regardless of ability to pay. However, since the passage of the Emergency Medical Treatment and Active Labor Act in 1986, any hospital that accepts Medicare or Medicaid payments (which make up 42 percent of hospital income nationally) is also required to treat any patient who comes in for treatment through the ER.

Every ER patient has certain basic rights:

• Patients are seen in order of their medical needs, not on the basis of their ability to pay.
• Patients cannot be refused care just because they do not have medical insurance. However, the hospital can send the patient a bill, sue for non-payment, and get non-payment noted on a credit report.
• Patients who are unable to care for themselves must be admitted to the hospital. All patients must receive the same level of care.
• If the hospital does not have the facilities to treat the patient's condition, the patient must be transferred to an appropriate facility that does. This includes long-term care and rehabilitation services. "Dumping," refusal to treat people because of anticipated high costs, is prohibited by the act (but still sometimes occurs).
• Treatment can only be delayed to keep the patient from harming himself or herself or others.
• Treatment cannot be denied on the basis of an outstanding bill not yet paid to the hospital.

The rights of ER patients as ER patients stop when they become "stable." Stable patients may have serious conditions that are "non-emergent." Who is a stable patient?

• The patient must be conscious, awake, and alert.
• The cause of any symptoms reported by the patient must be ascertained.
• The cause of any other symptoms that may be life-threatening, limb-threatening, or organ-threatening, even if not reported by the patient, must be ascertained.
• Any condition that is immediately life-threatening, limb-threatening, or organ-threatening must be treated to the best of the hospital's ability.
• No patient can be released to self-care who does not have the ability to move, dress, eat, go to the toilet, attend to personal hygiene, take medicines, and communicate, unless another person is available to help the patient after discharge.
• Any patient who has an emergency while already admitted as an in-patient is not covered by this law.

The standards of emergency care, however, are not the same as the standards for care in your doctor's office. Emergency care only treats "emergent" conditions. Pregnancy is not an emergent condition. Cancer is not in itself an emergent condition. If you have diabetes, for example, and you need insulin, and even if you don't get insulin you will have to come right back to the ER a few hours later, the hospital is not required to provide it to you. If you have extreme high blood pressure, so high that you are likely to have a stroke, the ER is not required to give you medicine. However, you will probably at least get a prescription so you can buy medicines on your own.

READ The Americans Obamacare Forgot

Why would even more Americans come in for a system that doesn't promise to keep them well even after health insurance has become much more widely available?

What Is Happening in American ER's, and What Can Be Done About It

To find out how the Affordable Care Act has affected ER use, American College of Emergency Physicians invited 24,427 member physicians to complete a poll. About 2,000 did. Of those 2,000 emergency room doctors:

• 47 percent report a slight increase in the number of patients they see.
• 28 percent report a large increase in the number of patients they see.
• 41 percent are concerned that patients who come to the ER are still not able to get follow-up care anywhere else.
• 70 percent fear that their emergency departments are not equipped to handle any more patients.

In states that have rejected Medicaid expansion (making health insurance available for the working poor, not just the very poorest of the poor), new penalties for patients that have to come back to the ER after treatment have made the financial problems faced by hospitals even worse. Hospitals still have to provide care whether they are paid or not, but also have to pay a penalty if patients do not get appropriate follow-up care. The writers of the Affordable Care Act failed to anticipate that many states would reject hundreds of billions of dollars of federal assistance to care for patients only in order to object to President Obama.

When Massachusetts adopted a system of coverage very similar to Obamacare, providing health insurance to nearly the entire population, death rates actually went up. People who were used to going to emergency rooms for their medical care suddenly had the option of seeing a regular doctor for an affordable fee. As a result, they put off getting treatment for conditions that had been neglected for years or even decades and at least for a few years, death rates went up by as much as 12 percent.

When Oregon ran a pilot program of Medicaid expansion, making it possible for many more people to get insurance, emergency room use went up rather than down. Some detractors of the Affordable Care Act opined that this was due to the "laziness" of "poor people," and took this result as a justification for denying care to the working poor in their own states. However, another explanation is that the working poor of Oregon took their obligation to pay their bills seriously. They did not want to incur emergency room charges that they could not pay. Once they had insurance coverage, they were not as hesitant to go to the ER when needed, because the cost of care had become affordable. They could pay their share when they had at least some insurance coverage.

READ Why Silver May Be Better Than Gold (Or Platinum) For Obamacare

If you have a medical emergency and you are in the United States, don't hesitate to go to an emergency room. No matter whether you have the ability to pay, you must be treated. Beware, however, of doctors who note that you are "unusually alert," or you have "declined treatment." These are ruses designed to deny you the care to which you are legally entitled. Be especially careful not to allow do-gooders and would-be friends to go into the ER and say they are there to pick you up and take care of you, unless you are very sure they will. A would-be friend can make it impossible for you to get the medical care you need.