I did my pediatric residency at St. Vincent’s. As this doctor says, this is reality.
40% of the patients at the hospital I practice at are uninsured. Those 40% cannot afford the $100 cost of a clinic visit. Here’s the way this thing normally works: 1) Patient comes to the ER for something simple. Let’s use an ulcerated lesion on the forearm as an example. EMTALA (Emergency Medical Treatment and Active Labor Act) states that we are required to stabilize the patient if they are in distress. The patient is not in distress, so they are given an appointment for a dermatologist and discharged. they receive a bill for $500-$1500 (which they do not pay). 2) Patient present to dermatology clinic and is not seen because they are unable to pay the $100 clinic copayment required for those without insurance. 3) Patient does not receive further treatment. Future ER visits result in the same outcome as #1. 4) At this point, one of two things can happen. The lesion can resolve and the hospital absorbs the cost of any ER visits, since the patient is unable to pay and Medicare/Medicaid will not reimburse them for these patients. However, often the unfortunate result is that the easily treatable issue results in the patient presenting with advanced disease at a later time. In this case, let’s say the ulcerated lesion is melanoma. The patient how presents with metastatic disease to the small bowel, resulting in obstruction and causing the patient to present with unstoppable nausea and vomiting. 5) The patient is now admitted for small bowel obstruction (which is an emergency). We take the patient to the OR and find diffuse metastatic disease. We place a gastrostomy tube and a colostomy, since without them the vomiting will just return. These procedures cost approximately $5000 (which will not be paid). The patient will also require admission to the hospital for about a week ($10,000 – unpaid), with tube feeding, intensive nursing care, and colostomy care. 6) Now that the patient is stabilized with terminal cancer, they are sent home with instructions for colostomy and gastrostomy tube care. They must pay out of pocket, since they are uninsured. We try to provide them with as many “samples” as we can. 7) Eventually, the patient will require additional admissions at additional unpaid costs, leading to the final admission. This will result either in hospice placement (extra). However, since end-of-life discussion may or may not be done (death panels!) the patients family may decide to press ahead with all available measures, leading to extremely intensive and expensive measures like IV feeding or further surgery/chemo, which are experimental. 90% of healthcare costs are spent in the final 6 months of life. 8) The patient dies, bills unpaid. The hospital absorbs the cost. Multiply this by whatever you like, and the end result is a massive budget deficit by the hospital and eventually bankruptcy. St Vincent’s hospital used to serve the lower west side of Manhattan, home to a large number of uninsured patients. The hospital will likely cease to exist very soon. This is longer than I intended, but I guess my point is that the idea that these people receive adequate care via ER visits is absurd. I used melanoma in this example, but you can pretty much substitute any disabling condition which is treatable early on if detected (colon cancer and HIV spring to mind).