The proposed changes to Medicaid and Medicare by Congressman, and Republican Vice Presidential candidate, Paul Ryan will undoubtedly change the landscape of 24/7 emergency care. U.S. emergency rooms, with 123.8 million visits per year, are a staple in many communities, especially inner city and rural areas.
As ER physicians, we are the relative safety net for certain aspects of health care, so anything and everything that affects health care, affects us in the ER. That rolls over to our patients, including how long they wait to be seen and the services we can offer.
A Medicare proposal of premium support — a government payment to each Medicare recipient to cover health care expenses — seems on first glance promising, but leaves holes. Many seniors can barely afford their daily expenses on a fixed income; so keeping up with additional costs if their health expenses exceed the payment will be challenging.
“Ryan’s Medicare vision would shift the burden of cost from the federal government to seniors, which for African-Americans could be deadly,” says Dr. Cedric Dark, an emergency medicine physician at Saint Agnes Hospital, an urban, community, teaching hospital.
“Eventually, health care inflation will outpace the [premium] support and thus, seniors will have to dip into their savings to make up the difference if they opt for a private plan,” he says.
Dark, who also runs a health policy website called Policy Prescriptions, stresses how important Medicare and Medicaid are for many of his African-American patients.
Changes to Medicaid — the health program which insures persons and families under the poverty line — will include capping grants to a certain amount per Medicaid patient, regardless of services provided, leaving each state to fill in the gap or make cuts. This potentially means even less healthcare services for Medicaid patients.
“Ryan basically proposes to turn Medicaid over to the states and let states decide what to do for low-income people,” says Dr. Wes Fields, an emergency physician and chairman of the Emergency Medicine Action Fund. “You have to wonder what states like Texas would do. Look at their uninsured rate. It doesn’t bother them. Their biggest priority is to hold down costs and hold down taxes.”
Dr. Alden Landry is frustrated with the present system.
“It’s hard to practice medicine in an environment where hospitals and physicians see patients as dollar signs as opposed to individuals with needs,” says Landry, who is director of community outreach in the department of emergency medicine at Beth Israel Deaconess Medical Center in Boston. “I see my career evolving beyond practicing medicine because I know more work will need to be done in health policy.”
Outside of the ER, Medicaid yields many woes. We often see the patients who cannot find follow-up for months, so they return to the ER looking for help. We also see the family who can’t afford Medicaid co-pays to see outpatient physicians. Worse, because of how little Medicaid pays doctors, fewer and fewer doctors accept the insurance plan now.
However, without Medicaid, the number of insured would have been much more than the nearly 50 million that existed before the Affordable Care Act. Medicare, as opposed to Medicaid, insures the oldest, sickest patients, especially of those seen in the emergency room.
Even without Ryan’s cuts, “seniors end up sitting around the emergency department longer [than other patients],” Fields says. “One effect [of the changes] for Medicare beneficiaries is that they’re likely to wait even longer to get an inpatient bed if they require hospitalization,” he continues. “Hospitals feel like they lose money on them.”
Regardless, the emergency room is still the portal for healthcare for many patients, especially those with nowhere else to turn.
“[The ER] is the only place in the health system where you have a right to health care,” says Fields.
Lower income, non-Hispanic black patients and those aged 75 and over are seen in U.S. emergency rooms more than other groups, according to a CDC report. In the same report, as family income increased, the number of emergency room visits went down.
“Hospitals would never have been able to subsidize 24/7 care for the poor and the elderly without the federal programs [Medicare and Medicaid] to cover the costs of their care.”