Mitt Romney is the wrong choice for healthcare

It seems every day brings a new, glaring falsehood about medical care from Romney, who has bizarrely decided to run against his own healthcare plan in order to appease right wing voters. Now he's claiming Americans don't die from lack of healthcare coverage. His reasoning? The unfunded mandate and healthcare-of-last resort stopgap that is EMTALA. For those of you who don't know the function of the Emergency Medical Treatment and Active Labor Act, it's law passed in the Reagan era to stop hospitals from dumping patients who were acutely ill and needed emergency care. It prevents hospitals from refusing or delaying treatment of an emergency condition if the patient is uninsured or their ability to pay is unknown. It only obligates hospitals to provide enough care to stabilize the patient, and then the patient is discharged or transferred to another center if a higher level of care is needed. Despite the mandate that such patients be cared for, the federal government did not prescribe a method of reimbursement for such patients, making it an unfunded mandate, and as a result, some 55% of emergency room care goes uncompensated. EMTALA also doesn't protect you from hospitals attempts to recoup their losses, and those that can pay often receive a surprisingly large bill that can easily bankrupt those living on the edge of solvency. But besides being a cruel and stupid thing to say for someone who proposes to lead our country, it's also wildly false. Not only does the Institute of Medicine estimate these deaths at about 20,000 a year, but we also see it in admissions that aren't due to prolonged illness or chronic medical conditions, for example we see a 40% higher trauma mortality among uninsured patients even after accounting for age, race, sex, and severity or mechanism of injury. If you are injured in a car accident, you are 40% more likely to die just by virtue of being uninsured, because the fact is, many hospitals will treat you differently if you can't pay for your care.

As someone who has done almost all of my medical training at medical centers that are the highest level of care in the region, I've seen many of these patients and transfers. Often at such centers you hear griping that a patient's condition had been exaggerated to suggest that the patient was sicker than they actually were, in order to initiate the transfer of a patient that would be costly to treat, but perfectly within their means to care for. Sometimes you hear complaints the referring hospitals could have done a better job stabilizing a patient before transferring them, it's impossible to know the motivations of the referrers in any given instance, and I generally believe that the physicians are acting in their patient's best interests, but we can't ignore the fact that EMTALA creates a conflict of interest between physician and patient interests by creating a financial incentive for transfer. I suspect such patterns are the reason why you find such a huge disparity in medicare reimbursements and imaging and procedure costs between hospitals. In order to recover the costs of their "mission" expenditures, hospitals that care for more uninsured have to charge medicare and insurers more to reflect their "cost of doing business", whereas smaller private hospitals that manage to deflect more of these patients can offer elective services cheaper.

In the end, it's all one big stupid cost-shifting game that ignores the central problem. No matter what, we end up paying for people's medical care! There is no avoiding it. You can either pay for it prospectively, thoughtfully, and humanely by giving people care in primary care offices, or you can wait for them to get really sick, not to mention really expensive to care for, and pay for it then. But there's no avoiding the bill. The type of care advocated by Romney here is also just plain stupid. For example, what is the point of stabilizing a patient with COPD and asthma as they come in the hospital in crisis every month, rather than just paying for their medications as an outpatient? ICU admissions, intubation, medications, doctors fees and nursing are all far more expensive (not to mention hard on the patient) than a couple of inhalers a month. Or how about the uninsured patient with a mental illness that requires constant stabilization with inpatient admissions because no one will pay for their anti-psychotic medications? You see it happen like clockwork, a patient is discharged "plugged in" with a month of medications, plans for follow up etc., and then as they can't pay for medications after that time is up they start missing appointments, losing their job or their housing arrangement, then they're back in the ER in crisis. Or think about the risk involved in all those transfers, which the current system encourages referring hospitals to engage in even if the patient might not benefit, because it allows them to unload a patient that will just create uncompensated costs for the hospital?

This is leadership on healthcare? I don't think so.