What’s Actually Wrong with Romney’s Emergency Care Comments.
I’m late to this party, but I wanted to make a comment about Mitt Romney’s comments from a week ago about emergency care. First of all, there’s absolutely nothing wrong with this quote, from his “60 Minutes” interview:
“Well, we do provide care for people who don’t have insurance. If someone has a heart attack, they don’t sit in their apartment and die. We pick them up in an ambulance, and take them to the hospital, and give them care. And different states have different ways of providing for that care.”
It is entirely appropriate to provide emergency care for people in cardiac distress, in emergency rooms, regardless of insurance status. So people freaking out about that aspect seem to me to be grasping at straws with which to condemn someone they already dislike. However, I think the broader context of health care delivery and emergency care is deeply important here, and this quote suggests that Romney either hasn’t thought about the issue, or simply gets it wrong.
That’s this: while it is appropriate to provide emergency care to people in life-threatening distress regardless of insurance status, if that is the manner in which you are providing care then the system has already failed. And the care we provide for those patients in acute distress will be severely compromised. Because it’s a system. And the system has to respond to more than just those in acute distress.
The lack of insurance causes many millions of people to treat the emergency department as if it is primary care. Because they cannot afford to see a primary care physician, they go to an emergency room when they are suffering from any illness. There are enormous numbers of patients who simply don’t need to be at emergency rooms. Many ED docs refer to them as the “gofer” patients: “Get out of the fucking ER”. This swelling of patients in the ED leads to a number of serious consequences.
When the ED is crowded, wait times go up. The triage process of sorting patients into resuscitation, emergent, urgent, etc., is not a perfect science (these are generally captured in the US by the Emergency Severity Index)[1]. As patients wait longer, their outcomes degrade[2]. As wait times increase, more patients leave without being seen (LWBS)[3]. These patients are generally the same distribution of illnesses as patients who do not LWBS[4,5]. This suggests that they are equally likely to suffer subsequent adverse events, only now, they are not receiving care.
Treating the emergency department as the overflow bin for the health care system has disastrous consequences for patients. First, EDs are designed to perform resuscitation and stabilization. That’s how the physicians and nurses are primarily trained. However, as EDs are currently used, they are essentially performing as souped-up family practice facilities, which degrades their central mission, and may prevent them from providing those services when they are needed.
Additionally, when large numbers of the uninsured rely on the emergency room for primary care, they receive no preventive care. Which means that treatable conditions progress until they become emergencies. That heart attack Romney references? In many cases, insurance would have allowed that individual to be aware of and control hypertension, or arrhythmia, or what-have-you, which would have delayed or prevented that life-threatening event.
When the ED is a large segment of the population’s primary access to medical care, because they cannot be turned away for failure to pay, we have all failed. We have failed economically, in providing adequate opportunity for people to afford medical care. We have failed philosophically, in promoting the idea that it is reasonable for a class of health care providers to be forced to work without remuneration (meaning they must raise the fees for those who can pay). We have failed medically, because the great majority of patients are in the wrong venue to receive appropriate care for their conditions. We have failed politically, in pitting industries and individuals against one another rather than collaborating to maintain a healthy populace and thriving medical engine.
So, Romney is right: it is appropriate that a person who is having a heart attack goes to the emergency department regardless of ability to pay. But he’s literally dead wrong about the system’s ability to handle the crisis he’s promoting with that sentiment.
I’m not endorsing any particular health care/coverage plan. I haven’t seen one yet that I think addresses our systemic problems. I’m not sure there is one. Some of the inequities in the health care system are, I think, insurmountable. And I’m actually kind of ok with that. I don’t think the goal should be to provide all persons with the most possible health care.
But the emergency room is for emergencies. And that is, by my own unpublished data, less than one-third of what goes on there. People are dying because too many people who aren’t dying are presenting for emergency care.
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[1] Emergency Severity Index: A Triage Tool for Emergency Department Care, Version 4,
Implementation Handbook. Agency for Healthcare Research and Quality. http://www.
ahrq.gov/research/esi/esi1.htm.
[2] Ackroyd-Stolarz S, Read Guernsey J, Mackinnon NJ, et al. The association
between a prolonged stay in the emergency department and adverse events in older
patients admitted to hospital: a retrospective cohort study. BMJ Qual Saf
2011;20:564e9.
[3] Fernandes CM, Daya MR, Barry S, et al. Emergency department patients who leave
without seeing a physician: the Toronto hospital experience. Ann Emerg Med
1994;24:1092e96.
[4] Monzon J, Friedman SM, Clarke C, et al. Patients who leave the emergency
department without being seen by a physician: a control-matched study. CJEM
2005;7:107e13.
[5] Rowe BH, Channan P, Bullard M, et al. Characteristics of patients who leave
emergency departments without being seen. Acad Emerg Med 2006;13:848e52.
Infactorium 
I work with street involved and homeless kids and the only access to health care for them is the emergency room because of bureaucracy that prevents them from showing up at doctors office….health care is a basic human right and even in Canada we haven’t got it right in my view!
and just to add to that – we have to address social exclusion that is responsible for accessing emergency services!
We have this problem in the UK even with our free at point of access model of the NHS. People still don’t go to their GP early enough etc. and then end up in A&E when a treatable condition becomes acute.
The NHS has brought in some “walk-in” centres where you don’t need to make an appointment and are good for minor issues where A&E is not appropriate. One of the real issues is getting people to take control of their health issues, constant monitoring and encouraging them in the correct treatment options… that heart attack due to hypertension – change diet, exercise more etc. a CCB might relieve the symptoms but there are bigger underlying causes at times
I certainly agree that the primary job of any emergency room should be the triage and stabilization of emergent (duh) patients, so that they can go home to be seen by their own physicians later, or be admitted as needed for further treatment. However there are any number of situations which, while not “emergencies” in the true sense of the word, are nonetheless best suited to the emergency room.
For example – Hope, as a three year old, fell down and bit almost all the way through her lip. It was about 7 pm, no other option than the emergency room. She is bleeding like crazy, and in my judgement (which is that of an RN) probably needed a stitch or two. This kind of thing happens hundreds of times every day in any big city. Putting in a couple of stitches falls into the category you call “souped up family practice” – which I like, by the way. Other things that fall into this category are possible broken bones, mild concussions, severe food poisoning requiring IV hydration, severe allergic reactions …
In the absence of 24 hour walk-in clinics, the E room is the only option for all of these and many similar issues. In Hope’s case, we took her in, blood all down the front of her shirt, and waited over three hours. Again, as an RN, I know that the window of opportunity for stitches is closing rapidly. After 4 hours, you might as well not bother. We left, and she has a scar to this day. Ok – big deal. But it might be, if the bleeding is just a bit worse. Or the concussion not quite so mild. Or the dehydration a little worse than you thought.
I don’t see how any of the proposals addresses this “in-between” situation. There have been suggestions that people who arrive at the E room with problems that are, after triage, deemed not to be true emergencies, should have to pay in full, that insurance shouldn’t cover it. Where does that leave the kid with a maybe-broken arm after a night football game? The broke single mom is weighing whether or not to bring in her kid who has been vomiting violently…. the infected hangnail with stripes going up the arm?