The ethics of access: Comparing two federal health care reform efforts

February 20, 2013

Two major health reform laws, enacted 25 years apart, both try to meet an ethical standard to provide broad access to basic health care. Neither quite gets there—but it's not too late for modern health care reform to bring the nation closer to a goal of comprehensive and coordinated care for all.

That's the conclusion of a commentary published in the new issue of the by a team of University of Michigan Health System physicians.

The authors – a family physician, an and a primary care pediatrician/internist – take a hard look at the implications of the ethical standard set in 1986 by a law that mandated universal access to emergency care. They assess the ability of both that law, and the Act of 2010, to meet the standard of providing access to basic to all who live in the United States. They conclude that both laws fall short of that standard.

But, by learning from the quarter-century of the nation's experience with the emergency care law – called EMTALA – they say the current Congress and administration may still be able to implement and tweak the ACA so it comes closer to the public's ethical expectations.

The crux of the issue, they write, is that the ACA doesn't ensure access to preventive care for all, nor coordination among all types of health care. An estimated 30 million people will still be without insurance even after all of its provisions take effect.

"Health care in the U.S. is sometimes treated as a right and sometimes as a privilege," says U-M health care policy researcher Katherine Diaz Vickery, M.D., a Robert Wood Johnson Foundation Clinical Scholar who also sees patients at U-M's Ypsilanti Health Center. "When we compare EMTALA and the ACA, we see that while emergency care is treated as a right, primary care, it seems, is treated as a privilege."

EMTALA focused on taking care of individuals in urgent or emergent situations, and did not address how to make all people in the U.S. healthier, say the authors. They cite the need for a balanced health care system that focuses on both illness and wellness, and allows patients and providers the chance to work together to prevent illness and save money.

Co-author and U-M emergency medicine physician Kori Sauser, M.D., notes that while the ACA comes closer to changing that perspective, it does not go far enough.

"As the provisions of the ACA kick in, millions more people will have access to primary care providers and preventive services like vaccinations and routine screenings for high blood pressure and cancer," says Sauser, who is also a RWJF Clinical Scholar. "Even so, demonstration projects haven't convinced us that patients will choose primary care offices over the emergency department for their acute care. A major missing piece in the ACA is in failing to determine how to connect emergency care with primary care resources in ways that meet patients' needs."

EMTALA, which requires hospitals and providers to evaluate, stabilize and provide basic lifesaving treatment to any patient who comes to an emergency department or is in active labor, was passed during President Ronald Reagan's administration. It does not allow a patient's ability to pay to be considered during emergency care.

Its ethical core, to ensure access to care in medical emergencies, includes an acknowledgement of "community responsibility" and "historic standards" in health care.

But in the years since, it has led patients who do not have insurance or the ability to pay for care out of their pocket to rely on emergency rooms for care. That in turn has burdened hospitals and led to spending that doesn't take advantage of potentially cost-saving primary and preventive care.

The authors note that ACA does not expressly lay out the way to integrate the emergency and primary care worlds in a way that ensures access to care—what the authors call a major oversight.

And, at the same time that the ACA is being implemented, payments to hospitals to fund care for the uninsured are being decreased—in spite of estimates that 30 million people will remain uninsured in 2020.

The authors conclude: "Ultimately, the ability of the US health care system to satisfy the ethical obligation to ensure access to care—first codified in EMTALA—will be a core measuring stick for the success of the ACA and for any future reforms."

The article grew out of discussions that Vickery and Sauser had with Matthew Davis, M.D., M.A.P.P., who is co-director of the RWJF Clinical Scholars program at the University of Michigan and holds faculty positions in the U-M Medical School and U-M Gerald R. Ford School of Public Policy.

Vickery, who had previous experience treating undocumented immigrants at a Federally Qualified Health Center, notes that the issue of access to for that population, and for others who will not become insured under the ACA, still needs to be addressed. She recalls instances where patients had to be hospitalized for severe complications of diabetes that had never been diagnosed or controlled, because their only health care access came through emergency rooms.

On the flip side, Sauser notes that not having to consider someone's insurance status in the ER feels like a "luxury" – but that every day she sees a need for better ability to coordinate the care of a patient who has been seen for an .

Both say that the accountable care organization, or ACO, model of care encouraged under the ACA may help patients within ACOs get access to more coordinated care.

By looking back at lessons from EMTALA – which will continue to be the law of the land even under the ACA – they hope to inform policy makers and health leaders who are working to implement or introduce potential changes to the ACA.

Explore further: Rising barriers to primary care send many Americans to the emergency department

More information: JAMA, Vol. 309, No. 7, pp. 665-666 jama.jamanetwork.com/article.a … px?articleid=1653529

Related Stories

Rising barriers to primary care send many Americans to the emergency department

August 9, 2011
A shortage in the number and availability of primary care physicians may continue to mean rising numbers of emergency department visits, despite the expanded health insurance coverage required by the 2010 Patient Protection ...

New project examines medical safety net for undocumented patients

October 11, 2011
The Hastings Center is exploring the ethical challenges that clinicians and organizations face when providing medical care to undocumented immigrants in the United States. The project is supported by a grant from the Overbrook ...

ER referral ups specialist access for publicly insured

February 4, 2013
(HealthDay)—Specialists are more willing to see publicly insured children if they are referred from an emergency department, according to research published online Jan. 10 in the Annals of Emergency Medicine.

Young adults allowed to stay on parents' health insurance have improved access to care

February 13, 2012
Researchers from Mount Sinai School of Medicine have found that laws permitting children to stay on their parents' health insurance through age 26 result in improved access to health care compared to states without those ...

Comprehensive guidelines needed for young adult preventive care

March 6, 2012
With no specific clinical preventive care guidelines targeting young adults, health care providers are missing key opportunities to improve the health of this population through preventive screening and intervention.

Change in health insurance status linked to greater emergency department use

March 26, 2012
Recent changes in health insurance status were linked to greater emergency department use by newly insured and newly uninsured adults, according to a study published Online First by Archives of Internal Medicine. The article ...

Recommended for you

High-fat diet in pregnancy can cause mental health problems in offspring

July 21, 2017
A high-fat diet not only creates health problems for expectant mothers, but new research in an animal model suggests it alters the development of the brain and endocrine system of their offspring and has a long-term impact ...

To combat teen smoking, health experts recommend R ratings for movies that depict tobacco use

July 21, 2017
Public health experts have an unusual suggestion for reducing teen smoking: Give just about any movie that depicts tobacco use an automatic R rating.

Opioids and obesity, not 'despair deaths,' raising mortality rates for white Americans

July 20, 2017
Drug-related deaths among middle-aged white men increased more than 25-fold between 1980 and 2014, with the bulk of that spike occurring since the mid-1990s when addictive prescription opioids became broadly available, according ...

Aging Americans enjoy longer life, better health when avoiding three risky behaviors

July 20, 2017
We've heard it before from our doctors and other health experts: Keep your weight down, don't smoke and cut back on the alcohol if you want to live longer.

Parents have critical role in preventing teen drinking

July 20, 2017
Fewer teenagers are drinking alcohol but more needs to be done to curb the drinking habits of Australian school students, based on the findings of the latest study by Adelaide researchers.

Fresh fish oil lowers diabetes risk in rat offspring

July 19, 2017
Fresh fish oil given to overweight pregnant rats prevented their offspring from developing a major diabetes risk factor, Auckland researchers have found.

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.