One of the problems with the current arguments in the healthcare debate is that they do not deal with a reality that was present before a current Federal Law, a reality to which the bishops of the Roman Catholic Church (and the Pope) say we must not return to. What is that reality? Well, let Father Orthoduck point you to the Emergency Medical Treatment and Active Labor Act passed in 1986, and signed by President Ronald Reagan. Father Orthoduck trusts that no one will try to accuse “The Gipper” of being either leftist or liberal. What does that act say? Well, let me quote from an entry written about the act:
The Emergency Medical Treatment and Active Labor Act (EMTALA) is a U.S. Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). It requires hospitals and ambulance services to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. As a result of the act, patients needing emergency treatment can be discharged only under their own informed consent or when their condition requires transfer to a hospital better equipped to administer the treatment. …
The cost of emergency care required by EMTALA is not directly covered by the federal government. Because of this, the law has been criticized by some as an unfunded mandate. Similarly, it has attracted controversy for its impacts on hospitals, and in particular, for its possible contributions to an emergency medical system that is “overburdened, underfunded and highly fragmented.” More than half of all emergency room care in the U.S. now goes uncompensated. Hospitals write off such care as charity or bad debt for tax purposes. Increasing financial pressures on hospitals in the period since EMTALA’s passage have caused consolidations and closures, so the number of emergency rooms is decreasing despite increasing demand for emergency care. There is also debate about the extent to which EMTALA has led to cost-shifting and higher rates for insured or paying hospital patients, thereby contributing to the high overall rate of medical inflation in the U.S. …
EMTALA was passed to combat the practice of “patient dumping”, i.e., refusal to treat people because of inability to pay or insufficient insurance, or transferring or discharging emergency patients on the basis of high anticipated diagnosis and treatment costs. The law applies when an individual with a medical emergency “comes to the emergency department,” regardless of whether the condition is visible to others, or is simply stated by the patient with no external evidence.
As these medicare advisors point out in this article, the act may even be responsible for the closure of some hospitals and the diminishing of the number of emergency rooms available in the USA. You see, this law signed by a conservative Republican President forces private hospitals to treat all people regardless of their ability to pay. Nevertheless, in good Congressional fashion, having approved a “moral” requirement that people not be turned away from medical treatment to perhaps die, they refused to approve any outside funding for the private hospitals who were now forced to take on patients they may not have wanted. After all, it is wrong to have the government involved in healthcare. The end result was predictable. People flocked to the “free” medical care since a hospital–since then and up to now–has no realistic way of enforcing a payment scheme. More than that, given the cost of some medical procedures, there was and is no realistic way that uninsured or underinsured people could or can possible repay the treatment they had received and continue to receive. And, hospitals began to close while health insurance began to rise.
This is very important for you to realize. Instead of a tax to fund the mandate forced upon private hospitals, the Congress of that time forced an unacknowledged tax on you through your increased health insurance payments. When you look at your health insurance payments, please realize that you are funding those people without insurance or underinsured. This increase in health insurance costs came as hospitals started to close. While not officially, insurance companies realized that if someone did not subsidize the emergency rooms, the health system in the USA would collapse. And so health insurance rates rose and are rising. And you are subsidizing people who do not pay their primary care received through the emergency room.
Looking at this situation, the Catholic bishops of the USA have said that we cannot return to a situation in which people can be turned away from an emergency room for an inability to pay. They agree with the Congress of 1986 that this would be to return to an immoral situation. But, they also recognize that any moral mandate of this type needs to be funded precisely so that there can be some hope of accountability. Study after study has shown that healthcare costs could be stabilized if people were encouraged to go to a primary care physician rather than waiting until they were forced to go to the emergency room. But, people will not go to a physician if they are too poor to pay. More than that, and let’s speak frankly, there are those who could afford to pay some basic health insurance but will not since they can get free care simply by showing up at the emergency room.
This is where the requirement that everyone get health insurance comes in. This is one of the most important parts of the healthcare bill. It ensures that enough money flows into private insurance companies so that your rates will not continue to go up as a result of the unintended side effects of the EMTAL Act. (Let Father Orthoduck point out that there is no Federal health insurance in the bill.) This is where there is a serious Republican fail. On the one hand, they use Federal monetary power to force private hospitals to take on patients who cannot pay. On the other hand, they argue that it is wrong for the Federal government to have a mechanism whereby money flows to the hospitals in order to cover patients who cannot pay. This is called hypocrisy of the worst sort. Some hospitals have the right advertising for clinical trials with PatientWise, which is of benefit to patients who cannot pay for their medical care.
Either Republicans need to repeal EMTALA or they need to approve the requirement that individuals buy health insurance from a viatical settlement companies. To do what they are doing now, which is to keep EMTALA and refuse payment to hospitals for the requirement imposed on them, is a violation of their principles. The Catholic bishops (all the way to the papal level) weighed in years ago. Republicans need to keep EMTALA and need to have some form of universal healthcare. If you are Roman Catholic or Orthodox (since our bishops have spoken as well), you need to ask yourself what makes you any different from those liberals you despise who also reject other parts of Catholic (or Orthodox) teaching. If you can freely reject Catholic and Orthodox moral teaching on healthcare (which is listed by the United States Conference of Catholic Bishops as part of their pro-life stance), why is it wrong for liberals to reject other Catholic and Orthodox pro-life teachings? If you are Catholic or Orthodox, you may not use your private interpretations of Scripture or your private economic opinions over against the Pope, the Patriarchs and our hierarchs. To do so means that you are simply a politically conservative Protestant who attends a Catholic or Orthodox parish and makes you no different from a liberal who attends one of our parishes while rejecting other parts of our moral teaching.
Very clearly explained Fr. Although not Catholic or Orthodox your conclusion is a strong one and requires me to think about where my loyalties and to whom will I submit myself to. I need that, thank you.
I find it interesting that both Nancy Pelosi and John Boehner are Roman Catholic, but only the former is publicly castigated for taking positions contrary to the Pope and Council of Bishops.
Also, the entire “you can’t make me” argument reminds me more of a two year old than anything else. There are all sorts of mandates and demands any government places on its citizens. The private insurance exchange approach is essentially a Republican model, though when it was first proposed, the private insurance companies were almost all non-profit. And, as you point, mandating that everyone receive care without mandating an individual level of accountability is highly irresponsible.
If I recall correctly (and it was a large and complex bill, so I may not) the “fine” is technically a “tax.” And the federal government certainly has the authority to “encourage” individual behavior through the tax system. It would have been harder to set up and administer, but I wouldn’t have been averse to making it a tax on every American and adding it to payroll taxes for those who have them. Then also include a 100% credit for those who maintain qualifying insurance. (If you don’t want extra withheld, adjust your withholding to balance it out.) If you make the credit refundable, you have part of your subsidies. And if, for qualifying income levels you make it payable in advance like we do with some EITC payments, you have at least part of the required subsidies throughout the year. Anyway, the whole concept is something that is clearly within the scope and power of our federal government, so the suits (and the Republican judge decisions) are simply fighting over the technicalities of wording and are, in the process, being highly irresponsible.
That is because politically conservative Roman Catholics have their eyes firmly shut to any pronouncements by the bishops with which they disagree. This is just like politically liberal Roman Catholics who do the exact same thing but with a different set of pronouncements. During the 1960’s, one heard from the Daniel Berrigans and other politically liberal Roman Catholics who were castigating the right. Now the pendulum has swung and one hears from the Buchanans and the O’Reillys castigating the left. Both sides adopt only those pronouncements that they find politically helpful and ignore those that are not. In fact, for both sides their “cause(s)” is more important than the Church, if truth be told.
I think that there may be problems in the bill itself in terms of the unfunded mandates to states for increases in Medicaid, though I have not read the bill itself.
In terms of enforcing the insurance coverage issue and the Fine/tax if one does not have insurance could develop into a nightmare itself. If we look at IRS and the tax law which is so complicated that even IRS personnel do not always understand it, I am fearful of such a debacle. There are also many people who do not pay their taxes and live off the radar–they will undoubtedly stay off the radar in health care as well.
That being said, I do believe that everyone should have availability to health care. Problems arise when people do not understand the issues of preventive care, do not know when something is a true emergency or can be managed at home with rest and OTC medications and the frequent use of emergency rooms for minor illnesses that often can be left to be seen on a non-emergency basis. Our local hospital has established an urgent care clinic in conjunction with the ER. There is a nurse to triage at the front desk. This means that the critical care element of the ER is not mobilized for every runny nose that shows up.
For any mandated health care plan to work, there must be a strong educational component. People need to be educated as to which insurance will best meet their needs, finances and ability to access it. I am a reasonably educated woman, and the information my health insurance gives me every year as to what is covered, what copays apply to what, what deductable is what, what meds are covered and at what prices takes focused intensity to puzzle out and I have had this same insurance for years, so I only have to puzzle out the changes. For someone who has never dealt with insurance, it could be a disaster and folks could be scammed by those who are all to willing to take advantage.
Many people who have been uncovered have already had access to clinics, state programs and other very reasonable health care and health insurance options but have been ignorant of their availability and how to access them thereby insuring that ERs have been the primary care of choice for many–simply because they did not know where else to go. The plethora of health insurance options what will surely arise will further confuse the issue.
I am not sure what the answer is–maybe there is no good answer–I do know that folks must have available health care and they must have adequate education to choose and access it.
Alix
One good beginning answer would be to amend EMTALA. Notice that the law is activated by the person coming for treatment. If they say they are sick, then they must be treated as sick even if the triage nurse or other qualified person can see that they do not need emergency level care, or perhaps even urgent care, and may not be hospital-level sick at all. That is, based on the self-examination of a non-medical person, a hospital must then proceed as though the illness was triaged by a medical person.
Letting hospitals triage a person out of the emergency care, to be sent to a more reasonable clinic setting would save hundreds of thousands of dollars and significantly lessen hospital emergency room budgets.
But, my biggest problem is that Congress forced the first part of universal health care on hospitals back in 1986 while leaving them hanging high and dry by not paying for those who are unable to pay. This was, and continues to be, an example of how to do things in the worst possible way. For Republicans to complain about the current healthcare bill after what they began the first part of universal healthcare in 1986 is to continue to destroy healthcare without a solution.
Hi Fr. Orthoduck,
Back when I was in college, I had a doctor at a local hospital explain the law to me. Basically, you’re right in that a patient presenting with a claimed emergency at a hospital with an emergency department must be assessed, and if an emergency is present, treated regardless of the ability to pay. Technically, if after the assessment, it is decided that no emergency exists, then the patient can be turned away. In practice though, if the treatment isn’t something that would take a lot of resources, it’s cheaper to treat the patient anyway. So the doctors do treat the people. Sure, the ER is very inefficient for treating anything other than true emergencies, but it’s where people go when they feel they don’t have other choices.
Ultimately, the health-care debate I feel comes down to the philosophical question of whether and to what extent we collectively owe a duty to pay for the health-care of us collectively. There are those who believe the answer is no; they are the ones most vigorously objecting to “socialism.” I believe the answer is yes, subject to the condition that the care one has a right to is a no-frills basic level of necessary care. “Medical necessity” is unfortunately full of gray areas, with endless debates between patients, doctors, and insurance companies.
Health-insurance reform, although sorely needed, does not address the underlying issue of astronomical overall costs. A lady I know broke her arm and had surgery. The treatment cost around $20,000! Now, whether she pays, or her insurance pays, or the hospital pays, the fact is that somebody did pay for it. Tackling the overall costs is something that sorely needs to happen, and it’s something that both parties are currently shying away from. The costs per capita are more than twice as high as the runner up in the world (Japan), and yet we don’t have the world’s healthiest people, not by a long shot. Paperwork takes up like 30% of them. Could standardizing forms and insurance policies, followed by open price lists, be the first step toward more reasonable prices?
There have been some interesting experiments by some private hospitals chains to deal with costs. One of the major identified problems is that we (in this country) bill piecemeal. Changing to billing by procedure is one of the steps in the experiment. That is, a normal hip replacement would cost a set amount. That price covers everything and everyone.
They are also working in the area of who is responsible for an untoward event. It used to be that, until Medicare recently changed its reimbursements, if you got a hospital infection, you still paid! Now, Medicare will not reimburse a hospital if the infection is acquired there and will not allow the hospital to bill the patient. In the same way, the private hospital is saying that an untoward event will not be the responsibility of the patient unless there is clear evidence that it is the result of something previously wrong with the patient. So, if the patient bleeds more than expected, tough. That is, unless the patient hid a pre-existing tendency towards bleeding, of course.
Third, they are going away from the idea of the physician being an independent contractor. This allows them to standardize treatment and testing since the physician is now employed. On the other hand, the physician gains in that he is covered by a group malpractice insurance and is not forced to cover the costs of malpractice, office insurance, and other expenses of that type. The physician can still always opt to have a private practice as well, but generally they have found out that newer physicians are overwhelmingly happy to be employed and to not be responsible for every detail. All physicians receive a wage comparable to physicians in private practice, so what is there to lose?
But, they are different from an HMO setup. A patient is assured that they will see the same set of physicians through their entire treatment at the hospital. Even if an emergency happens in the middle of the night at the hospital, it will be a physician from that group who will see them, not simply some physician who happens to be on call at the hospital. They can choose any physician they wish within that hospital group as their personal physician, and he will be that. In this way they are trying to ameliorate the problems with early HMO’s. In fact, they are not HMO’s and they offer no insurance coverage or membership fee. They are private hospitals who accept the normal set of insurance options from a patient.
As a result, these small hospital chains are finding out that they can lower costs, keep salaries high, and have improved patient satisfaction levels. Interestingly enough, they are seeing improved staff satisfaction levels because physicians are no longer independent “gods” who come in and sometimes savage the staff in the certainty that no one will call them seriously to account. These physicians are seriously accountable for behavior towards fellow staff and it shows in staff satisfaction levels.
So, there are some interesting experiments going on in some small section of private practice. However, though apparently successful, they cannot deal with the bigger problem of the uninsured and underinsured. But, they can point the way toward lowering some major costs.
1. It is somewhat misleading to say that “Republicans” made the EMTLA come into being. Reagan did sign it, yes, but should all the acts of the 99th Congress (253:182 D:R in the House, 53:47 R:D in the Senate) be chalked up to “Republicans”? COBRA (of which EMTLA was a part) was a massive compromise spending bill. Still further, Reagan’s credentials as an actual conservative (despite his hagiography) are rather mixed.
2. It is something of a leap from the statements of various Orthodox bishops that we ought to care for our neighbors to that we ought to care for them by using the threat of state violence to extract money from our other neighbors and ourselves in order to care for our neighbors. If it were obvious that the traditional Christian faith requires state-sponsored universal health care (or even health insurance!), there would really be nothing to debate. There would also be a strong pattern of exactly this when looking at the record of Christian statesmen, especially saints.
You are partially correct in your first point, so I changed the word “Republican” in one sentence. However, one cannot shift responsibility for laws purely to the Congress. In our system, the President must approve a law, and given the makeup of that Congress, had President Reagan vetoed the bill that contained EMTALA and COBRA, it would have stopped those laws and forced a new compromise. But, if it is Congress that is “responsible” by itself, then why was the Affordable Care Act renamed “Obamacare” by its detractors? Because as both Presidents Truman and Reagan said, the buck stops with the Executive.
According to the Constitution, spending bills originate in the House and are approved (and/or amended) by the Senate and become effective upon the President’s signature, or fail upon his veto. Veto overrides are rare. Since the current House is Republican, it is the Republican responsibility to fund EMTALA. In fact, right now the Republicans in the House are threatening to force their desire upon the Senate and the Presidency by the simple expedient of not funding federal agencies with which they philosophically disagree. So, Republicans, pony up! Pay for EMTALA, you have the power now!
But, I must take you to task for one phrase, “by using the threat of state violence.” We are a democratic republic. Our representatives are freely elected. Taxes are legitimate and are frequently used by Old Testament Israel. In the New Testament, Our Lord Jesus refused to get drawn into the type of debate that qualifies taxes as unfair, even though they were imposed by an invading empire. Taxes approved by legitimately elected representatives are not “violence” in either moral philosophy or political science. The people can always change their congresspeople, and they have certainly done so twice in a row, once in 2008 and once in 2010.
The use of connotative terms such as “violence” with respect to the legitimate acts of a democratically elected government is very dangerous ground, ground that the Tea Party keeps trodding over and over and is a dangerous playtoy.
Finally, I notice that you carefully do not mention the pronouncements of the Roman Catholic Church, which I did in the post. Our Orthodox bishops do not tend to make the type of pronouncements that the RCC’s do here in this country because we are quite a minority. Nevertheless, there are some statements even in this country. For instance, from the Greek Archdiocese website http://www.goarch.org/ourfaith/ourfaith8076
“It follows quite logically that thecare of one’s own health and societal concern for public health are moral imperatives (Androutsos, pp. 191-195, 250). … The issue of the allocation of scarce medical resources demands a general principle of distribution. Neither the ability to pay nor an aristocratic criterion of greater human value or worth is acceptable. Eastern Christianity has always distinguished between the essential value of human life and social worth. In spite of the enormous difficulties involved, the ethical imperative from the Orthodox perspective calls for the widest possible distribution of health care and life-protecting facilities and resources, rather than a concentration of such resources for the select few.”
And, using our via negativa, I will point out that the bulk of Orthodox believers live in countries with universal healthcare without protestations from the Orthodox Church. Even now, after the fall of the wall and the revival of Orthodoxy in many of the old countries, there is no call from the Church to repeal or revise universal healthcare. From several countries, this shows quite an acceptance of it by the Church. It is a taken for granted part of life.
I read something out of the Obama adminstration that does suggest that there are leanings toward a criterion of greater human value or worth for those who are younger. This, along with his fierce pro-choice stance, and his cozying up to the corporate world …. what can I say? Love believes all things, hopes all things …. that the current trend toward stinginess to the disadvantaged will pass away like a bad dream. Why do I mostly hear about cuts to services to poor people (heating oil, Medicaid) in the newspapers, and not cuts to government payouts to factory farms and other kinds of corporate welfare? I’m ready to wake up from this dream.
*Not implying that you support the following:
Taking the theoretical repeal of EMTALA to it’s logical moral conclusion, America must then cut off foreign aid as well, especially if it cannot aid it’s own citizens (the unspoken needed reforms of entitlements for future fiscal viability). And this is actually happening, foreign aid is on the chopping block for budget cuts, while defense spending continues to grow. A world without this aid is an exponentially darker world…
It’s an ideological battle yet again. Every step of the way of this health care debate, the information has become fuzzy, To consider the individual mandate (historically supported by the likes of Orrin Hatch and Mitt Romney and others….) unconstitutional or an abdication of freedom is to deny reality. Rationing, “free lunches,” all of it is happening with health care, and to refuse to acknowledge that just digs a deeper hole. As Donald Berwick, recent recession-appointed director for the Centers for Medicare and Medicaid, once said:
“The decision is not whether or not we will ration care—the decision is whether we will ration with our eyes open….And right now, we are doing it blindly.” And former AMA president, Dr. Nancy Nielsen, also adds to this “shadow” rationing idea: “If you don’t think there’s rationing in this country, you haven’t looked at what happens when you don’t have money or insurance.”
I say this (sorry for being so verbose) to say I think I agree with you. To say we are being forced to pay for the uninsured via socialist reform without acknowledging that we actually already pay for the uninsured is not simply missing the forest for the trees, it’s blatant, old-fashioned blindness..
Thank you, and well said.