A Spirit of Charity: Restoring the Bond Between America and Its Public Hospitals will be available in print from Secant Publishing in May 2016. This column is drawn from the author’s research.
You’re forgiven if you can’t quite make out the Republican front runner’s health care reform policy positions. Donald Trump is not one for articulating details. Yes, he brings up the usual talking points his party’s leaders have offered over the years — Medicaid block grants to the states, more tax breaks for health savings accounts. You’ve heard those many times. But his overall vision of what the post-Obamacare-Donald Trump policy would look life can be summed up with this oft-repeated assurance:
“I will not let people die in the streets.”
Why doesn’t make you feel better?
Well, for starters this country decided a long, long time ago (during Colonial times) that not letting people die in the streets was a worthy goal. In fact, this is why large public hospitals like Bellevue in New York City and Charity in New Orleans were created in 1736. It’s also why places like Grady Memorial in Atlanta and County Hospital in Chicago opened a century or so later while European nations embarked on a path toward tax-supported health care for their populations. In our country the Bellevues, the Gradys and the Countys and a few dozen others like them are more than safety net hospitals, they are the safety valves for a $3.2 trillion health care system that still hasn’t figured out how to care for the poor and uninsured.
When you really examine it, it’s more that a little embarrassing that of all the other comparable nations in the developed world, the U.S system remains so profoundly warped. Only here do we seem satisfied that when poor people develop chronic, treatable medical conditions they can at least get rescued by a public hospital when they finally get sick enough to need one.
Even now, even after the Affordable Care Act — the law Trump and his Republican colleagues want to repeal and replace (with what, no one seems to know for sure) — the continued existence of large, urban, public hospitals with charity missions make the unfinished business of health care reform so much easier to put off by voicing such platitudes that we won’t let people die in the streets.
You may have heard other versions of Trump’s not-to-worry health care position before. President George W. Bush, in justification of his veto of expansion of the Children’s Health Insurance Program for low-income families that Democrats tried to foist upon him in 2007, famously declared that it wasn’t needed because Americans already have access to health care, regardless of their ability to pay. They need only go to a hospital emergency room, Bush said.
True, that. But also truly inadequate. Then and now.
Indeed, the law that requires most American hospital ERs to take in people without ability to pay stems from evidence compiled by the medical residency staff at Chicago’s Cook County Hospital in the 1980s. County physicians documented that competing private hospitals were routinely turning away indigent patients — including pregnant women about to deliver — and sending them instead to County. When they published their findings in a prestigious medical journal, public hospital physicians around the country reported the same thing was happening in their communities.
The resulting 1986 law, known as EMTALA (Emergency Medical Treatment and Active Labor Act), forbids the practice that became known as “patient dumping.” It’s a good law and it has no doubt stopped some of the worst abuses. But the reality is that it only applies to patients deemed to be presenting with an “emergency medical condition.” If they aren’t considered in danger of death, the hospital can legally turn them away.
Still, most American hospitals are pretty good about treating indigent patients who show up in a emergency room with a chronic conditions like diabetes, hypertension, even cancer. They write off millions of dollars of ER charges every year. But their responsibility ends once the patient is out the door — with or without a prescription or a follow-up appointment with a physician to manage the condition that sent him or her there in the first place.
This helps explain why life expectancy among Americans remains below 80 years and lags badly behind Japan, Italy, France, Canada, the United Kingdom, and 43 other nations. And why, as well, that we spend on average nearly $8,000 per year per person on health care while France spends, on average, half of that
Life expectancy by race within our own country raises even more troubling questions. Consider that there is an astounding 25-year difference between the life expectancy of Asian-American women and African-American men living in the United States. The former can expect to live, on average, 86.7 years, while the latter live just 61.7.
This is where public hospitals must shoulder the burden of a health care system that has no real program to assist the millions of Americans who remain uninsured. Yet the mission of the nation’s largest public hospitals over the years has expanded to go beyond the emergency room and attempt — often without the public financing they need — to provide primary care services to the poor and uninsured to keep them well and out of the hospital.
Public hospitals in urban areas, like Grady Memorial in Atlanta and others with large African-American populations suffering from hypertension, offer some of the best stroke and stroke recovery care in the nation. But they often go beyond just being there for stroke victims. They have vigorous outpatient and in-the-community programs aimed at preventing and controlling hypertension in populations at-risk for stroke. Cook County Hospital has a highly coordinated program with Chicago’s federally-funded primary health care clinics to manage the chronic conditions of the city’s large Medicaid enrollees so that they can stay well. By doing so they not only keep the patients healthier, they help control Medicaid’s costs.
But public hospitals often fight these public health battles without the help they need from local, state and federal officials who look for marketplace miracles to minimize public spending on health care instead of examining how to do it better. The ACA has gone a long way toward extending health insurance to millions of Americans who couldn’t afford it before the law was enacted. But there are still about 30 million without it — many of them in states where political opposition to the law’s Medicaid expansion trumps (forgive the pun) the wisdom of receiving billions in federal financing. This desperately needed money that is being sent back to the federal treasury would go a long way toward insuring more low-income workers and their families, not to mention help public hospitals keep them healthy.
No matter who moves into the White House in January 2017, we still have a lot of work to do when it comes to health care reform. Perhaps the first place to start is to challenge the role of the states in setting Medicaid enrollment and reimbursement policies. There is a reason that Texas, Florida and Georgia have the most uninsured residents in the country after Obamacare was fully implemented. By refusing to expand Medicaid those states and about 15 others have purposely left millions of working poor people behind in the arrogant confidence that public hospitals won’t let people die in the streets.
Because of a dysfunctional health care system many of these Americans will die instead inside a hospital. Isn’t it time to find a way to take care of them before they need to go there?
The author, a former editor, writer and columnist at The Courier-Journal in Louisville, Ky. and The Atlanta Journal-Constituton, blogs about health policy issues.