Not One Thin Dime: Republican Health Advisor Says the Uninsured Can Just Go to an Emergency Room

John Goodman is president of the National Center for Policy Analysis, a conservative think tank. He has proposed a novel solution to the uninsurance crisis. I'll let the Dallas Morning News tell the story:

Mr. Goodman, who helped craft Sen. John McCain's health care policy, said anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort. (Hospital emergency rooms by law cannot turn away a patient in need of immediate care.)

Some, um, real reporters tell me that it's not clear Goodman is an official advisor to the McCain campaign. He's apparently part of that cloud of informal advisors who helped produce and market what we know of the McCain health plan. The Wall Street Journal, modestly cited on Goodman's own website, describes him as "the father of medical savings accounts." He's an important Republican on healthcare concerns.

An even more important Republican beat him to it. Here is President Bush from last year:

"The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America," he said. "After all, you just go to an emergency room."

The Washington Post's Dan Froomkin aptly called this one "Clueless Quote of the Day."

Let's all stop and wrap our minds around Goodman's comments. Many health policy experts are trying. Their unanimous verdict isn't pretty.

I have noted before that emergency departments (EDs) are increasingly overcrowded, with many in danger of closure. Between 1995 and 2005, ED visits increased by 20 percent, while the number of emergency care facilities declined by 38 percent. Almost every level 1 trauma center is operating at or above capacity. Why is this happening? The crush of uninsured and underinsured people makes these facilities very unprofitable for many hospitals that run them. Many hospitals are actively considering closing their emergency departments.

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These problems affect everyone. Median waiting time for emergency care exceeds four hours and is rising. Last year, Edith Rodriguez lay on the floor of the ED waiting room at Los Angeles's Martin Luther King Jr.-Harbor Hospital. She was suffering from a painful abdominal problem. Her boyfriend, trying in vain to get medical attention, became so desperate that he called 911. . The paramedics refused to come, and Rogriguez died an agonizing death from a perforated bowel.

Less egregious tragedies are common. Medical surveys reveal a disconcerting number of ED doctors and nurses with first-hand knowledge of patients death due to delayed care. As Ramon Johnson of the American College of Emergency Physicians told Congress,

Emergency physicians and nurses are dedicated to saving lives. But in a system struggling with the closure of hundreds of emergency departments in the last 10 years because of huge amounts of uncompensated care, and in which ambulance diversions and the 'boarding' of patients in ER hallways for hours and sometimes days at time have become commonplace, we simply can't always get to everyone. And if we can't get to you, we can't save your life.

Goodman (and Bush) are right that the ED has to treat your emergent problem. Of course that hospital can then kick you out once your immediate crisis is addressed. If you are a 58-year-old woman with hypertension and diabetes, no one is under any legal obligation to help you stabilize your blood pressure or to make sure you receive your medications. A hospital is within its legal rights to stabilize you, load you into your car or an ambulance, and ship you off to the county whatever when they don't like your insurance card.

And of course both hospitals can send you a whopping bill and then sue you if you cannot pay. Jonathan Cohn's prizewinning Sick describes Dickensian conditions at the Cook County courthouse. Its docket is clogged with medical debt cases in which hospitals sue low-income patients.

A trainload of studies indicate that uninsured people suffer serious harm because they are less likely to receive preventive care, get blood pressure checks, or fill needed prescriptions. They also receive substandard care.

Given President Bush's comments, Mr. Goodman may be accused of shameless copying. Given Goodman's academic pedigree, I'm not surprised that he adds a little more. Here is Goodman's solution to the healthcare crisis:

"So I have a solution. And it will cost not one thin dime," Mr. Goodman said. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American - even illegal aliens - as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care.

Facts are stupid and embarrassing things. Maybe we can find the same guys to do the census who found no gay people in Iran.

Many people drop their health insurance for the cheaper path of using the ER.

I've heard this someplace before ... but where? Oh yeah: Herbert Hoover: "Many persons left their jobs for the more profitable one of selling apples."

There is a mentality at work here, whereby the comfortable and complacent regard the suffering of others with undue equanimity. You can't afford regular healthcare, but you can always go down to the County Hospital and hibernate in the ER.

One thin dime, indeed.

Update: Jonathan Cohn has been killing this story over at New Republic. And so have many others. Seth Michaels has a great piece. Steve Benen adds that it isn't just Goodman and Bush.

This nonsense is surprisingly common in Republican circles. Last year, Tom DeLay argued, "[N]o American is denied health care in America," because everyone can go to the emergency room. Around the same time, George W. Bush said the same thing: "[P]eople have access to health care in America. After all, you just go to an emergency room." In 2004, then-HHS Secretary Tommy Thompson said our healthcare system "could be defined as universal coverage," because of emergency rooms.

In a way, they're right. If you're sick, there are public hospitals that will treat you.

One might wonder how these public hospitals are supposed to keep the lights on. Goodman and McCain have little to offer on that score, too.

Comments

[MNDoc]

In 30 years as an Emergency Physician, I have cared for patients regardless of their ability to pay. If an emergency department is not financially viable, the Board Certified Emergency Specialists leave. The care becomes sub par. Or the hospital closes the ER. This seriously limits the ability of our communities to respond to disasters. The government does not ultimately pay for the uninsured, doctors and hospital have to absorb the cost. Since retiring, I have volunteered in a clinic for the uninsured. On a regular basis I care for patients who get episodic care, with little preventive care, because that is all they can afford. The only medications they can afford are $4 generics at Walmart. High tech care is unavailable. Our system of health care delivery should be based on preventive primary care, with specialists for complicated medical problems, and emergency departments for the acutely ill and injured. It is absurd to think that we can exist as a society if we just send everyone without insurance to the ER. I am not a supporter of a government run health care delivery system. I am a supporter of universal health insurance so that everyone can choose their heath care provider, and have assurance that both preventative primary care and care for catastrophic illness is available for everyone. Nothing less will provide the health care America needs.

[XME]

Apparently this very lucky man who clearly has insurance has NO clue about all the scenarios under which ERs have the right to turn the uninsured away! Additionally, when I was only 30 years old, I had to file for bankruptcy because I had over $40,000 in medical bills due to no one being willing to insure me. Sure, I got service...but WITH insurance, that $40,000 would have been about $4,000!!! While it would have taken a long time to pay off $4K, there is no way I could ever have been able to pay it off, and attempting to do so would have meant never being able to have any savings and living paycheck-to-paycheck for the rest of my life, while barely even making a dent in that debt.

[QualityCounts]

Goodman's contention that emergency rooms provide all the health insurance Americans need rivals Jonathan Swift's modest proposal in its ironic beauty, except that Swift was a satirist and Goodman brandishes credentials as an authority in health policy. By similarly tortured logic, McCain is right about Obama raising taxes on the middle class, because according to McCain someone earning $4,000,000 a year is middle class. Then again, McCain's logic can't be tortured because McCain is an American and Americans don't torture. And so it goes. George Orwell, you should be living at this hour. Big brother has need of you.

[AllAboutHealthPolicy]

Hi Hal - This so called solution needs to be shared far and wide so that the American people understand that the Republican solution to the uninsured is to declare that no one is uninsured. Talk about double speak.

I guess if we change the label, we solve the problem! Wouldn't it be amazing if all such intrenched problems could be so easily solved? What about the homeless.? Hey, if you have a place to put your head at night, then you aren't homeless, right -- even if it is piece of concrete under an underpass. Voila! Problem solved. How about hospital acquired infections. If we don't count them, we can say there aren't any and again-- voila, problem solved.

And to think that the Republicans would be promoting ERs for basic primary and preventive care. The most expensive, most unhealthy way to deliver care. We need to get people who are not urgently ill out of emergency rooms. The program Michelle Obama started at the University Hospital at the University of Chicago reflects the real understanding of the problem. Make sure there is access to primary and preventive care in the community and triage the non-urgent patients out of the emergency room, making more time and space to care for true emergencies.

To solve a problem, define it away. Unbelievable. The American people are a lot smarter than that!

[cmnsntz]

Primary and preventive care comes from our PCPs. I'm uninsured, I make four appointments a year 80 dollars/appt (the dates and times are my choice), I get a three month script for all my preventive meds. My meds cost me 12 dollars a month (no insurance). Thats not bad healthcare. If you can't afford that then you should be on our current socialized medicine program called Medicaid. If you have another illness such as cancer,AIDS etc and can't afford treatment, take the time to register for Medicaid/Medicare/Disability. If people didn't abuse our current socialized programs (Medicaid) things would become increasingly easier for those who truly need it. Think about how abused the system will become if each person has free medical coverage. Then think about the Superbugs we will have on our hands. Obama's great, but socialized medicine is not what we need, especially with provider shortages and Baby Boomers retiring.

[Linda Bergthold - Huffpost Blogger]

So glad you're sharing this story with us, Harold. It's super important for people to know just how different the McCain and Obama approaches to health reform really are. If you care about your health care coverage at all, the "riskiest" vote you can ever make is for John McCain. His health plan leaves you to your own devices. Kind of like where you might be right now! There can be no starker difference in policies than the one on health care reform between Obama and McCain.

In addition to being just plain stupid, this comment from a McCain "supporter" or adviser or whatever he is, is callous and cruel. It will not solve one problem in the health care system. And worse, it helps to overcrowd allready stressed emergency rooms. Places we need when we have a real emergency.

[Harold Pollack - Huffpost Blogger]

Thanks Linda. The most amazing part is how many other Republicans from Bush on down say the same sorts of things.

[PhiloVance]

Well, in Canada or England you can wait a month or maybe a year. Which is better?

[arnray]

Surely there must be a special circle of Hell reserved for those who insist profits are more important than the health of their fellow citizens. That dollars in the pockets of the middlemen are more important than relieving pain and suffering. How christian of them.

[mommadona]

Republicans - Clueless
Republicans - Bubble Dwellers
Republicans - Pater Retro
Republicans - White Guys Falling Down

http://www.youtube.com/watch?v=yHUXKLpXLlo