Summer 2016 Legislation Update – What Matters in the Emergency Department

This post represents an individual resident’s reflection on current events and does not primarily represent the views of IUSM EM nor does it intend to provide expert level resources or facts on the matter, though a fair assessment of readily available information was attempted in writing this post. 

Just past midnight on July 28th, 2017 an unexpected twist took place in the Senate chamber as Senator John McCain broke from Republican party lines and voted no for a “skinny repeal” on Obamacare, joining the other Republican senators Susan Collins of Maine and Lisa Murkowski of Alaska (and many Democrats) who steadfastly opposed healthcare reform in this manner. This effectively terminated the bill which would have dismantled parts of Obamacare and according to the U.S. Congressional Budget Office would have led to 16 million additional Americans becoming uninsured in 10 years and health insurance companies estimating rate increases for coverage. This was the stripped down version of a larger repeal and replace bill BRCA proposed by senators but also that met opposition and failed to pass voting earlier this month.

John McCain made it clear that he was not protecting Obamacare but that he wanted real health care reform that would not have happened in the form of the skinny bill in the following statement,

“While the amendment would have repealed some of Obamacare’s most burdensome regulations, it offered no replacement to actually reform our health care system and deliver affordable, quality health care to our citizens,” he said. “The Speaker’s statement that the House would be ‘willing’ to go to conference does not ease my concern that this shell of a bill could be taken up and passed at any time.”

“I’ve stated time and time again that one of the major failures of Obamacare was that it was rammed through Congress by Democrats on a strict-party line basis without a single Republican vote. We should not make the mistakes of the past that has led to Obamacare’s collapse, including in my home state of Arizona where premiums are skyrocketing and health care providers are fleeing the marketplace. We must now return to the correct way of legislating and send the bill back to committee, hold hearings, receive input from both sides of aisle, heed the recommendations of nation’s governors, and produce a bill that finally delivers affordable health care for the American people. We must do the hard work our citizens expect of us and deserve.”

(https://www.mccain.senate.gov/public/index.cfm/2017/7/statement-by-senator-john-mccain-on-voting-no-on-skinny-repeal)

The question is – – what next? And what does it matter to Emergency doctors?

Far from the stone edifices of Washington D.C. we are taking care of patients day in and day out in the Emergency departments of Indianapolis. Hundreds of thousands of visits by Hoosiers (and sometimes neighboring states since we are “the Crossroads of America) take place here every year. Do our patients care about this reform? Recent polls suggest two thirds of U.S. citizens have cooled to the idea of immediate reform and want Congress to get to other tasks. (https://www.reuters.com/article/us-usa-healthcare-poll-idUSKBN1AE0RY)

I am an Emergency doctor with a mind for trying to play my role in the medical team of the system at large; since I cannot address and change the course of every ailment our patients come to the Emergency Department for. Aside from ruling out any bad emergencies, I take time to think about what I can do to help them in the meantime, what they need to know, and what they should try next for solutions. It matters to me that I play this role and that my patients understand that when our visit ends today, we may just be scratching the surface and not be done yet. It also matters that they discover other places to get this appropriate care and planning aside from the Emergency Department.

There is a particular part of me that despairs when I see someone without health insurance, who will surely not be able to better their health on their own, and will have a much steeper if not impossible time of getting appointments with my colleagues in the outpatient and surgery world. They came to me because they had a problem, I showed that it was not an emergent problem that required hospitalization, surgery, or intervention at that second, however, their problem will likely persist and frustrate them, feeling like “no one helped.” Without access to the medical system most typically through insurance, things are not going to be looking better for them.

We see lots of patients. We have the honor of serving patients regardless of their ability to pay or their insurance status and I appreciate the equality of that. I chose to train at IUEM program for the number of patients and the variety of people I can help. Unfortunately, business can also mean ED overcrowding and physician burnout, and it seems that numbers of ED visits climb every year. That is the trend in many Emergency Departments, and providing insurance does not do what we might have expected, which is give people a better option to outpatient doctors to get their conditions under control so they can avoid coming to the ED. Instead we are seeing a growing number of ED visits since implementation of the ACA and more people gained access to health care. (http://www.annemergmed.com/article/S0196-0644(17)30319-0/fulltext)

What gives?

When the board of incoming patients never clears, when the patient’s concerns and requests of you seem unreasonable, you quickly drop the Lady Liberty act, “Give me your tired, your poor, Your huddled masses yearning to breathe free…” yadda yadda. As an intern up until July 2017, I spent the last year seeing a large percentage of my patients in the lower acuity area of our emergency departments. This did not mean patients did not need help or medical attention, but that they did not need to be in shock rooms where they might get an emergent airway, trauma survey, or invasive medical procedures performed under minute to minute monitoring. The use of an Emergency department for some of the complaints seemed a bit dubious, even to me as an idealistic intern.

On the flipside, I know how the system works and I am being trained specifically to tell an emergency from non-emergency. How many years of study did it take for me to get to this position? The burden of placing the patient in determination of what an emergency is cannot be expected for the reason I mentioned before. U.S. citizens have on average a 7th or 8th grade reading level. Good luck interpreting medical literature with that reading level and while you are trying to decide if you are experiencing an emergency.

Before ACA implementation we knew as a nation we had a shortage of doctors, especially primary care doctors, surgeons, psychiatrists, which are the specialties I most acutely need the assistance of when taking care of patients in the Emergency department. (https://www.aamc.org/data/workforce/reports/439206/physicianshortageandprojections.html). We generally do not have an optimum number of providers to patients in all fields including emergency medicine. That takes more policy change and training shifts than what the ACA can provide. However, repeal also does not even begin to tackle this problem and instead offers to take away Medicaid and what small payments outpatient offices can get for seeing these patients.

Indiana’s Insurance Program HIP 2.0

I am relieved for the near future that this round of health care reform will not proceed without more deliberation and hopefully bipartisan and policy expert input. Lots of questions must be resolved. I understand that part of the opposition to leaving the ACA intact involves the increasing insurance premiums and decreased choice available on state exchanges. Indiana, which has a Medicaid waiver to run its own Medicaid expansion program called HIP 2.0 was discussed as a possible example of nationwide Medicaid reform at the 2017 ACEP Leadership and Advocacy conference in D.C.  Despite being touted as a success, this program is not without its issues, outside policy researchers found that the monthly payments or “skin in the game” notion that patients must contribute to stay active in the program confused and often locked them out of care for a time period.

“One-third of eligible individuals who apply are not enrolled because they haven’t made a premium payment… Around 30,000 people… had been found eligible in the past 60 days but hadn’t enrolled at all. HIP 2.0’s premiums are deterring significant numbers of eligible low-income people from enrolling… For many people, the cost wasn’t the biggest obstacle. Rather, 84 percent of people who were bumped from HIP Plus to HIP Basic for nonpayment said they had been confused about the payment process and the program in general.” (https://www.theatlantic.com/business/archive/2016/12/medicaid-and-mike-pence/511262/?utm_source=atlgp)

Another obstacle facing our own state, and many others, is that costs of insurance premiums are increasing and less insurance companies are participating in the exchange which negates competitive pricing options. In 2018 in Indiana only two insurers will continue to participate in Obamacare exchanges, whether this changes now that legislation to gut Obamacare has failed thus far, we will see. (https://www.ibj.com/articles/64327-only-two-insurers-to-offer-obamacare-plans-in-indiana-next-year?v=preview) Insurance markets and incentives go way beyond my level of understanding and I hope that as a state we have the right people at the table to turn back this trend for Hoosiers and propose ways to improve this moving forward.

Future for EM and American Health Care

I stand in favor of providing access and working to make the system more preventative than reactionary when providing Americans with health care. I welcome debate, education, and well-thought out ideas about how to make this system better as an Emergency resident and physician providing medical care to my fellow people. In summary and in agreement with the following, I include the most recent statement about health care reform from President of American College of Emergency Physicians, Becky Parker, MD, FACEP:

“We have expressed concerns throughout this process regarding the devastating impact some of the repeal proposals under consideration could have had.  Looking ahead, we now urge lawmakers on both sides of the aisle to work together to address the serious problems that still exist involving the health insurance market. These solutions must include appropriate protections for the tens of millions of emergency medical patients that go to emergency departments each year.

Guaranteed coverage for emergency medical care must continue to be protected by federal law. Patients should be able to seek and receive emergency care when and where it is needed, without fear that their insurance company will not cover it.  In addition, when patients have insurance plans with unreasonably high deductibles, they often delay medical care until the problem becomes a life-threatening emergency.

Policymakers, lawmakers, business leaders, physicians and health care experts must work together to help improve a health care system that benefits every American.” (http://newsroom.acep.org/2017-07-28-ACEP-Statement-on-Future-Health-Care-Legislation)

 

Reflection by Jennica Siddle, MD MPH, 2nd year Emergency Medicine Resident 

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