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Posted at 11:30 AM ET, 01/27/2011

Repeal EMTALA!

By Ezra Klein

Okay, it's a bit of an awkward slogan. But reader RC is right. A universal health-care insurance program is the logical endpoint of the bill Ronald Reagan signed into law mandating (pretty much) universal emergency hospital care:

If the Republican Party is serious about decreasing government control of health care, they should start by introducing a bill that would repeal the law signed by President Ronald Reagan that mandates free health care for all who seek it. That law, the Emergency Medical Treatment and Labor Act (EMTALA), was the largest expansion of government mandated health care since Medicare. Remember George Bush stating that all Americans had access to health care? That all they had to do was present to their local emergency department? That is EMTALA. If we are going to mandate that hospitals treat and stabilize patients with emergency medical conditions, we should mandate that individuals purchase insurance to pay for that care. If we don't, then we truly have a health care system where the few pay for the many. I bet that many hospitals in DC collect less than 50% of their emergency department billings right now. The government has been mandating health care coverage for more than 25 years -- only now President Obama wants those who utilize the system to pay for it.

By Ezra Klein  | January 27, 2011; 11:30 AM ET
Categories:  Health Reform  
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Comments

*conservative heads explode*

Posted by: vvf2 | January 27, 2011 11:44 AM | Report abuse

the problem is that so called such "welfare" cost shifting is neither pervasive nor large. almost all empirical studies I know of conclude that cost shifting from the uninsured simply isn't a major driver. (in fact, medicare and medicaid lead to much much greater cost shifting. see, e.g., http://www.cfcepolicy.org/NR/rdonlyres/46C2B526-D9BF-4556-A310-37C3A7CDF53D/30/CFCE_Cost_Shift_Study.pdf). For a lit review, see http://theincidentaleconomist.com/wordpress/all-the-cost-shifting-literature/

now of course, who needs empirical evidence on a wonkish blog, especially when a post will "make conservatives heads explode."

Posted by: stantheman21 | January 27, 2011 12:00 PM | Report abuse

hmmm. So inactivity (declining to care for someone who can't pay) by corporate "persons" (hospitals) is not an unconstitutional infringement on liberty (we know that cuz St. Ronny signed the bill), but it is an intolerable infringement on liberty to be told you cannot decline to carry insurance.

Posted by: Ken36 | January 27, 2011 12:10 PM | Report abuse

This is literally the argument that the Heritage Foundation used to sell the individual mandate in Massachusetts. "As long as we mandate emergency care we should make sure people take responsibility and have insurance to pay for that care."

It doesn't matter how it's packaged (this is just Reagan's healthcare plan!), if a Democrat is proposing it conservatives hate it.

Posted by: DKOSullivan | January 27, 2011 12:25 PM | Report abuse

Stantheman21 - Thanks for the data. Always useful for moving the ball, rather than throwing balls at each other.

However, as I read the study you cite, it does NOT claim that the uninsured impose no significant costs on the health care system as a whole. Rather, it answers a slightly different question - whether those costs are passed on to the privately insured in a significant way (and concludes they are not).

In fact, the study acknowledges, if I read it right, that there ARE significant costs as a result of the uninsured. It's just that those costs are spread among a number of parties in addition to the privately insured.

Isn't it reasonable to require those who benefit from the mandatory coverage system, and are able to pay for it but currerntly do not, to contribute through, e.g., the individual mandate? In fact, isn't that the ONLY fair thing to do, unless we are willing to eliminate the idea of insurance as the way to pay for medical care?

Posted by: lynnh00 | January 27, 2011 12:48 PM | Report abuse

EMTALA does seem like the kind of law today's republicans would call an affront to liberty or something - this explains why they never do. I looked @stantheman21 's link for the lit review of cost shifting, which was a great reference. It says that cost shifting is not pervasive AND large - so it is large sometimes but it's not large all the time. But that post is mostly talking about cost shifting from Medicare and Medicaid capped payments. Out of laziness, I looked at wikipedia's summary of EMTALA - hospitals aren't able to cost shift as much anymore (because of managed care, etc.) so now they write off uncompensated care (which makes up 55% of total US emergency care) as charity. This makes emergency rooms less profitable, so many of them (over 400) have closed, even as the number of emergency visit has risen, resulting in overcrowding. So some effects of EMTALA without universal insurance seem to be reduced tax revenues (from the writeoffs), reduced profits for private hospitals, fewer emergency rooms, and more crowded conditions (if you believe wikipedia).

Posted by: tysonsahib | January 27, 2011 1:03 PM | Report abuse

Just to point out: I know this is just a way of highlighting some Republican hypocrisy, but if they actually started advocating for repeal of EMTALA along with the individual mandate that would be a disaster. EMTALA is a good thing from a liberal perspective, and we should be pleased that Reagan passed it, pleased that Bush supported it and pleased that even today's Republicans aren't even considering trying to repeal it.

Posted by: bigmandave | January 27, 2011 1:21 PM | Report abuse

only now President Obama wants those who utilize the system to pay for it.


This Ezra is blatently wrong. Will the 16 million on Medicaid pay for it? NO. Will those getting generous subsidies pay for it? NO.


I agree with the concept of get them out of ER's and into PCP's earlier to treat problems for their own benefit (and to hopefully reduce the overall heathcare costs of the country) but don't try to make it seem like those people who are targeted to benefit most from PPACA are actually paying for their care.

Posted by: visionbrkr | January 27, 2011 1:24 PM | Report abuse

--*EMTALA does seem like the kind of law today's republicans would call an affront to liberty or something - this explains why they never do.*--

It's an affront to liberty.

The EMTALA was part of one of the many omnibus continuing resolutions which the Dem controlled Congresses packed all kinds of nonsenses into during Reagan's tenure. I couldn't find the detailed vote breakdown just now, but it looks like the bill passed about on party lines in the House (where the Dems had a large majority) with more bipartisan support in the Senate.

Reagan should have vetoed it, even if it would have been futile.

One of the great modern myths is that Reagan significantly stopped or turned back the ever growing socialist monster.

Posted by: msoja | January 27, 2011 1:33 PM | Report abuse

I apologize for my "heads exploding" comment. I actually tried to cancel the submission before it went through. (I guess that's what "preview" is for, right?) The other comments have been much more useful to the conversation.

Regardless of the degree to which emergency care for the uninsured contributes to insurance premiums, it does seem philosophically odd to see a conservative icon like Reagan putting a mandate on hospitals to provide "charity care" and for a progressive icon like Obama to be saying that people need to take responsibility for paying into the system rather than just expecting a handout at the hospital. It's representative of how out of whack the conversation has gotten recently and how what was once considered a conservative idea (the mandate, as supported by Romney, Hatch, Bennett, Grassley, Dole, etc.) has suddenly instead become seen as some sort of big government liberal boogeyman.

As has been discussed frequently on this blog and elsewhere, many of my friends on the left are vehemently opposed to the mandate because they just think it's a giveaway to insurance companies, and if the lack of a mandate causes prices to go up, so be it -- the government should just be willing to defer the higher costs. That's why when Obama flipped from his campaign stance and supported the mandate, it made many liberal heads explode. Figuratively, of course.

Posted by: vvf2 | January 27, 2011 1:34 PM | Report abuse

This post is just sleight of hand. The fact is that the uninsured using the ER would not be able to afford mandated insurance either, so it would have to be subsidized for them. So either way, the few are paying for the many.

Posted by: tomtildrum | January 27, 2011 1:34 PM | Report abuse

i certainly think cost shifting is a problem, but individual mandate in large part doesn't compensate for these externalities by forcing internalization...rather, it is a shift to externalize costs ex ante onto the young and healthy.

this shift (somewhat)undermines the pay your own way self insurance justification, especially to the extent that health can (again somewhat) be controlled..

but i do recognize the inherent issues when we decide that everyone is entitled to some level of care. i just think the exact way cost shifting plays out can be more complicated, and want to point out that government programs themselves contribute most to cost shifting. as to whether our current health proposals address these issues, well...

Posted by: stantheman21 | January 27, 2011 1:46 PM | Report abuse

tomtildrum: There's certainly some truth to that, but not entirely. That's the same misconception that Senator Obama promoted during the 2008 campaign, thinking that the only reason people don't have insurance is because they can't afford it. That's certainly a major factor, but not the only one.

27% of people with income from 100-250% of the poverty line don't have insurance, and under the new law most of those would have to pay at least a portion of their income towards health insurance (the lower end of that range could indeed be covered by Medicaid).

And from 250-400% FPL, the uninsured rate is 13%, and those folks would now have to pay for a large portion towards their health care.

http://www.kff.org/uninsured/upload/7451-06.pdf

Posted by: vvf2 | January 27, 2011 1:49 PM | Report abuse

EMTALA is a relic of the massive booming Reagan economy. It no longer has a place in Obama's world.

There's no need for full repeal. Rather, we merely need to appropriately shield ERs from lawsuits, grant the power to ER billers to garnish the EIC and other wages, and require strict identification to claim EMTALA benefits.

Posted by: krazen1211 | January 27, 2011 2:14 PM | Report abuse

"hmmm. So inactivity (declining to care for someone who can't pay) by corporate "persons" (hospitals) is not an unconstitutional infringement on liberty (we know that cuz St. Ronny signed the bill), but it is an intolerable infringement on liberty to be told you cannot decline to carry insurance."

You obviously cannot read. EMTALA only applies to participating hospitals.

PPACA, on the other hand, applies involuntarily.

Posted by: krazen1211 | January 27, 2011 2:16 PM | Report abuse

"hmmm. So inactivity (declining to care for someone who can't pay) by corporate "persons" (hospitals) is not an unconstitutional infringement on liberty (we know that cuz St. Ronny signed the bill), but it is an intolerable infringement on liberty to be told you cannot decline to carry insurance."

"Regardless of the degree to which emergency care for the uninsured contributes to insurance premiums, it does seem philosophically odd to see a conservative icon like Reagan putting a mandate on hospitals to provide "charity care" and for a progressive icon like Obama to be saying that people need to take responsibility for paying into the system rather than just expecting a handout at the hospital."

Two liberals who obviously cannot read. EMTALA only applies to participating hospitals. They are free to opt out if they choose to.

PPACA, on the other hand, applies involuntarily.

Posted by: krazen1211 | January 27, 2011 2:18 PM | Report abuse

"27% of people with income from 100-250% of the poverty line don't have insurance, and under the new law most of those would have to pay at least a portion of their income towards health insurance (the lower end of that range could indeed be covered by Medicaid)."

http://healthreform.kff.org/SubsidyCalculator.aspx

Paying 17% of your premium doesn't make you any less of a freeloader on the remaining 83%.

Projected income in 2014
150% of poverty
Unsubsidized health insurance premium in 2014 adjusted for age
(Based on an age factor relative to a 40 year-old of: 0.88)
Maximum % of income the person/family has to pay for the premium if eligible for a subsidy
Actual person/family required premium payment
(which equals 4.00% of income and covers 17% of the overall premium)
Government tax credit
(which covers 83% of the overall premium)

Posted by: krazen1211 | January 27, 2011 2:23 PM | Report abuse

"Paying 17% of your premium doesn't make you any less of a freeloader on the remaining 83%."

And that 17% will decline over time due to health care cost inflation.

Posted by: justin84 | January 27, 2011 2:35 PM | Report abuse

@justin,

not only will it decline over time it'll decline before we ever get to 2014 and subsidies.

And its also not as if ER's currently don't attempt to get people to pay by threatening legal action (ie collection activity) or requiring payment plans to what individuals can afford.

Posted by: visionbrkr | January 27, 2011 2:56 PM | Report abuse

"One of the great modern myths is that Reagan significantly stopped or turned back the ever growing socialist monster."

Paranoid. Delusional. Crank.

Posted by: pseudonymousinnc | January 27, 2011 4:44 PM | Report abuse

--*Paranoid. Delusional. Crank.*--

I like your new sig, mousi. It's you.

Posted by: msoja | January 27, 2011 9:36 PM | Report abuse

Not exactly, he wants me to buy coverage for them so they go to the emergency room whenever they want. If the copay is $150...

Anyway- Republicans will come around to being pro-individual-mandate once they can reduce the insanity of what is mandated.

Posted by: staticvars | January 27, 2011 11:55 PM | Report abuse

It's telling that manly man soggy, well into his second decade of internet crankdom, can do better than "I know what you are..."?

There's socialism coming through the walls, sog! Seal them up until you feel yourself getting faint, that's the only way to save yourself!

Posted by: pseudonymousinnc | January 28, 2011 2:41 AM | Report abuse

"Two liberals who obviously cannot read. EMTALA only applies to participating hospitals. They are free to opt out if they choose to.

PPACA, on the other hand, applies involuntarily."

Krazen 1211 -- Interesting. How many hospitals opt out, and what type? I was under the impression the hospitals face many federal financing carrots and sticks that making opt practically infeasible for any hospital providing general care. Is that wrong?

And actually, I'm not a liberal. My instincts are libertarian, fiscal conservative, and federalist (and non-interventionist internationally) -- all mainstream "conservative" views. I only sound liberal to you because there is no longer a party that represents those views very well. The GOP has become a logic-free and evidence-free monstrosity. The individual mandate was fine when conservative think tanks were sensibly pushing it as an integral component of health care reform to expand coverage. Now it is an affront to liberty.

Posted by: Ken36 | January 28, 2011 9:43 AM | Report abuse

--*There's socialism coming through the walls, sog!*--

Did you see the story yesterday about how the FTC fined a woman $50,000 for selling non-prescription contact lenses without first requesting and then verifying the buyers' prescriptions? Of course, she didn't have $50,000, so they took her car, instead. I suppose that's Capitalism, for ya.

Posted by: msoja | January 28, 2011 10:13 AM | Report abuse

It is nice to see that EMTALA is finally being discussed. Anyone who works in health care knows that this law is the root of some of the biggest problems our health care system faces. While it would be next to impossible to know the true impact of this mandate it has clearly lead to hospitals charging the insured more to cover the cost of the uninsured and it has also lead to the explosion of the Medicare and Medicaid. That is because once the uninsured is admitted to the hospital we in health care do everything we can get these patients into one of those programs. This is make sure they get the long term care they need. These patients end up staying in Medicare or Medicaid because they now have a preexisting condition which precludes them from an affordable health insurance plan. So while i support the intent of EMTALA, it is not sustainable without an individual mandate or a universal system.

Posted by: soscane | January 29, 2011 8:17 AM | Report abuse

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