Emergency departments will remain a safety net for decades to come

Former South Carolina Senator, and current Heritage Foundation president, Jim DeMint recently angered supporters of the Affordable Care Act by stating that uninsured patients will “get better healthcare just going to the emergency room,” than they will receive through Obamacare.

That’s a sweeping assertion.  However, the ACA supporters offended by Sen. DeMint need to understand the supreme irony that without America’s emergency departments and their dedicated personnel, the ACA will fall apart even if it is adequately funded and enacted.

The American College of Emergency Physicians pointed out some relevant information in response to Sen. DeMint’s statement.  Their information, based on data from the RAND corporation, reveals that emergency departments are already strained, accounting for 11 percent of all outpatient healthcare visits in the US and 28 percent of all acute care visits.  They also see half of the acute care visits by Medicaid and CHIP (Children’s Health Insurance Program) beneficiaries and 2/3 of all acute care visits by the uninsured.

In addition, the number of hospital admissions from emergency departments has increased by 17 % over the last few years, even as many hospitals and emergency departments have closed over the past three decades due to lack of funding and increased volume of uninsured patients.  (Uninsured patients that emergency departments must evaluate and treat according to federal law.)  And emergency physicians, by the way, constitute only 4% of the physicians in America today.

Buried in those numbers is the reality that all too many of America’s mentally ill, and drug or alcohol addicted, have precious little access to care outside of trauma centers and emergency departments.  Even if they obtain insurance via the ACA, they are sadly non-compliant and difficult to manage in the offices and clinics of outpatient medicine.

Sen. DeMint may have been speaking prophetically.  You see, not only are we facing a vast shortage of primary care physicians in America, those in practice are reacting to changes in new, creative ways that ultimately direct more patients to emergency departments.  For instance, many physicians don’t admit their patients to hospitals; their patients are admitted by hospitalists who do only inpatient medicine (and who are also facing the Herculean task caring for a tidal wave of patients with new insurance, or no insurance, and no physician of their own). However, accessing the hospitalist almost always means first visiting the emergency department.

In addition, many primary care physicians no longer accept Medicaid or Medicare; some have abandoned insurance altogether in favor of a cash model.  This is often because the reimbursement for the care they provide under those plans is inadequate to cover their practice costs; and because the labyrinthine regulations and requisite forms make private or government insurance unpleasant and costly for providers.

In many communities, those with Medicare or Medicaid, or even commercial insurance, simply won’t find primary care physicians.  When they become ill or need prescription refills, local emergency departments or urgent cares are the only options.

To complicate things, there are simply fewer primary care physicians.  Frankly, with average medical student debt around $160-170,000, young physicians can scarcely afford to practice lower-paying specialties; at least not if they hope to have children or own a home.  And current practitioners are retiring early.

The answer, some say, is to allow mid-level providers, nurse practitioners and physician assistants, to fill the gap in primary care.  This idea has merit. But when the problem becomes too complicated or the patient deteriorates, the patient will still need the nearest emergency department.  It’s also true for those treated in outpatient surgery centers by specialists who (reasonably) don’t want the burdens of call coverage.  Their after-hours patients are often directed to the ER.

These factors have caused emergency department visits to increase for decades.  And they will likely skyrocket if amnesty passes, with a sudden influx of ever more patients without physicians.

The fact remains, however, that the ACA cannot create physicians where there are none; nor will it suddenly change decades of physician or patient behavior anymore than it will magically erase the uninsured from the medical and economic landscape of America.

Intentionally or inadvertently, the Sen. DeMint brings up a relevant fact.  The emergency departments of America, where anyone and can receive healthcare anytime, will remain a critical healthcare safety net for decades to come; whether Obamacare stands or falls.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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