President Bush once said something along the lines of, “We do have universal health care in this country — just go to the emergency room.”

EMTALA.  The law requiring emergency rooms to treat everyone’s emergent conditions, a well meaning act that has had disastrous consequences for hospitals’ bottom lines.  A disgustingly flawed law on many levels.

How do you prove it is not an emergency condition?  You work it up.  You rack up the tests in the ER, you even admit the patient and rack up the costs again.

How do you really rule out an emergency condition?  You wait, you watch, you wait, you maybe run some tests again, you wait some more.  Which means that someone is occupying a valuable bed in your ER.  Leading to ED overcrowding.

How do you prevent lawsuits?  You treat everyone.  Even if it is that homeless man who comes every other day via ambulance just for his sandwich and a bed for a few hours with no immediately treatable medical condition.

What about the drunk driver or the guy who was stabbed?  Their insurance is not going to cover their care.  You treat them anyway, because that’s the right thing to do, but in states without no-fault mechanisms and when the patient can’t pay, the hospital loses.

Leading to uncompensated care.  Hospitals have to provide the care to everyone, regardless of if they can pay or not. EMTALA is a federal law, which has become an unfunded mandate.  Not all who are treated at the ER will qualify for emergency Medicaid or have their care paid for in some way by somebody.  So the hospital eats the costs and the physicians provide free care.  The federal government does pay for some of these patients’ care but not all, and then hospitals feel the pressure of the financial strain.

Like Atlanta’s public Grady Hospital.  A safety-net hospital that many uninsured and undocumented rely upon.  A safety-net that became a little less comprehensive now that it had to close it’s outpatient dialysis center, which treats those with end-stage renal disease.  ESRD dialysis is usually covered by Medicare (one of the few costs covered for people of all ages, not only those over 65).  But illegal immigrants aren’t eligible for Medicare or any of the new federal funding under the new health care law.

The agreement would not address the broader concern of how to care for illegal immigrants in the region who have developed renal disease since the Grady clinic’s closing, or those who will do so in the future. At the moment, their only option may be to wait until they are in distress and then visit hospital emergency rooms, which are required by law to provide dialysis to patients who are deemed in serious jeopardy.

Of course, waiting until you are in distress instead of receiving regular dialysis wreaks havoc on your body.  It takes much more time and much more aggressive treatment — inpatient, which is much more expensive — to deal with the state of your health after missed dialysis sessions.

The problem isn’t with the intent of EMTALA — we shouldn’t deny life-saving care based on someone’s ability to pay or their immigration status.  The problem is in EMTALA’s funding … and the fact that it is not funded.  The government is telling hospitals to fend for themselves on this one.  And more and more hospitals are finding themselves unable to stay afloat, further threatening the safety net of community care.

Suchita Shah is a medical student who blogs at University and State.

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