11A024 ER Blues by Jim Davies, 1/24/2011    

During the Health Care Repeal debate last week, someone made a passing comment to the effect that if all care was provided "free" (at taxpayer expense) then emergency rooms would no longer be overcrowded and mis-used.

Back when the Earth was still cooling and I was a lad, the emergency room was just that: a place where health emergencies could be treated; an injury, a heart attack. Even as late as 1969, I recall an incident in which access to emergency treatment was not blocked by lines of people who "ought" to have been in the offices of their primary physicians. Since the 60s, things have changed.

Doctors' office visits are so expensive that rather than make an appointment and pay the fee, ever more people go instead to the ER. Why so? - because payment for services rendered there are optional. I can hardly take this in, but last time I was in one, the notice hung on the wall in plain sight: treatment will not be denied for want of ability to pay. Go to the ER, don't bother about the bill. I exaggerate, but that seems to be the bottom line resulting from a 1986 law. There are a few caveats, and I don't know how they work out, but American Demographics found that only about 17% of ER patients end up paying the bill.

There's another effect of this silly law. Since costs can be passed on to third parties such as payers of taxes and premiums, the resulting bills have become grotesque, and that in turn causes people who recognise an obligation to pay, not in fact to do so; we can't afford it. In other words, the cycle is vicious. A couple of years ago a blood clot formed in my leg at the weekend so I ended up in the ER; for if the bloodstream had swept it North you might not be reading this. The subsequent bill was obscene, and though I could (just) manage to pay the deductible after Medicare paid the majority, I declined to do so. I wrote the hospital to explain why the bill was unacceptable, and offered a smaller payment based around the fact that my barber also gives treatment on demand without appointment; I made generous allowance for much higher rates of pay for the higher skills, and more costly capital equipment and 24/7 availability, but still ended up with a small fraction of the total they were billing. The hospital declined to engage me in that reasoning (no surprise there) so I declined to pay it a dime. No doubt my credit record is stained as a result, but heck, credit is greatly over-rated anyway.

So in effect and to a considerable degree, we already have universal health care underwritten by government - but it's funneled through the ER, whose genuine raison d'Ítre is thereby impeded. The choice is to extend it fully so as to resemble Canadian and European systems, or to scrap it - to get government altogether out of the industry; that debate centers around whether or not people have a "right" to such care, presumably at someone else's expense. Both sides of that are explored quite well in a 2007 article in Business Week - where Onkar Ghate reasons clearly and a Harvard insider founders on a false premise. If they won't scrap it now, we shall have to await the coming zero government society, which certainly will. The result will be a good system, with prices so dramatically reduced that even I will be able to pay them.

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