Earlier this year, Congress passed a spending bill through the process known as reconciliation, which means that the majority party does not need any votes from the minority and the bill is not subject to filibuster in the Senate. The bill was wide-ranging. One of the things it did was change Medicaid eligibility rules in a way that is predicted to result in millions of people losing their Medicaid coverage and the closure of many, mostly rural, small hospitals. The bill also cut the Covid-era subsidies given to people purchasing private insurance in the Affordable Care Act (ACA) marketplaces. Many of these people will see their premiums double or triple and will drop their coverage as a result. If you have health insurance you did not buy in an ACA marketplace and live in a metropolitan area, you may think these changes won’t have much of an effect in your life. You are probably mistaken.
The United States is the only major industrialized nation that does not have universal health care for its citizens. The system we have of private insurance for those able to afford it and Medicaid, a government program for the poor, leaves many of us who are not Medicare eligible without insurance. There are many people who cannot afford private health insurance but are not poor enough to qualify for Medicaid. Now many of those who are poor and on Medicaid will not be able to meet all of the new requirements for Medicaid coverage and will lose it. Cutting poor people off from Medicaid is not a bug of the spending bill but a feature. It is only by cutting billions from Medicaid spending that the authors of the bill were able to justify the tax cuts they wanted to enact or continue. The bottom line is that over the next year the number of Americans without health insurance will increase greatly. This will have a ripple effect that will be felt by all of the rest of us.
Just because a person does not have health insurance does not mean that the person does not get sick and need medical care. What it does mean is that the uninsured person does not go to the doctor for check ups and does not get preventative care. When they get sick, they usually wait until they are really sick and then off they go to the one place they know must provide them care even if they are not insured. They go to the local emergency department.
Today, the local emergency department is the medical care provider of last resort. The usage of emergency departments for primary care has been increasing at an alarming rate. According to the New York Times, In 2018, there were 130,000,000 emergency department visits in the United States. Last year, that number increased to 155,000,000. Our emergency medicine system was never designed or intended to handle that volume of visits. It cannot effectively handle that volume. As crowded as you may have thought the emergency department was the last time you visited, hold on to your hat because it is going to be far more crowded the next time you go.
Crowded emergency departments don’t just mean longer waits for the care you need, they mean a greater chance you will get an illness from a sick person coughing nearby. Just what you don’t need.
Crowded ER’s also greatly increase the risk that a medical mistake will be made. Not everyone can be seen the moment they arrive at the emergency department. The sickest people must and should be seen first. This means that everyone who arrives must be assessed, almost always by a triage nurse, to determine just how sick they are and in what order they should be seen. This is the first place a major error can be made. Patients arriving at the ER may not look as sick as they are. There may be a language barrier that prevents them from explaining just how sick they really are. Even if there is no language barrier, the patient or the patient’s friend may not do a good job of explaining just how sick they are. The triage nurse may be busy, tired, overworked or all of the above. I have had cases in which a patient having a heart attack was made to wait until they collapsed onto the floor in the waiting area.
Even when you get back to see the doctor, the effect of the overcrowded ER is not yet behind you. The larger the crowd, the greater the chaos, the greater the urgency doctors and staff will feel to “move the meat” and to get you diagnosed, treated and on your way home or to a hospital bed. If you have a simple illness, even a hurried diagnosis will probably be accurate. But if you have a difficult presentation with symptoms that are coming and going, there is a greater chance of a mistake when the doctor feels pressured to move you along.
Whew! You got in to see the doctor, were properly diagnosed and treated and sent home. You dodged the bullet. You were not affected by the cuts to Medicaid or the ACA subsidies. Not so fast. Here comes the hospital bill and it is a whopper. Who did you think was going to pay for the care for all those uninsured people in the ER with you? They don’t have the money to pay for the care they received and yet the hospital has to collect enough of that money from somewhere, if it is going to keep its doors open. If the federal government is not going to pay, that leaves you and all of the other patients who use that hospital and have insurance or assets. Your bill covers not only your care, but the hospital’s other expenses, including the care given to people who cannot pay.
You are going to be affected in other less direct ways as well. Economists tell us that when people don’t receive regular care, they miss more work than they otherwise would, which is a drag on the overall economy. The production of the ill worker is lost. The ill worker’s income is reduced and his contribution to the local economy is lost or reduced. Even if they cannot pay their hospital bills, families with members that visit the ER may be hounded by bill collectors and have their credit downgraded. Some will be forced into bankruptcy. They may be evicted and join the ranks of the homeless. They may show up at an underpass near you.
The consequences of an increase in the uninsured population may not always be obvious, but it is present and it is substantial. You should care.
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