The limits of the emergency room safety net

The Merriam-Webster dictionary defines a “safety net” as “something that provides protection against misfortune or trouble.” The emergency room is known as the “safety net” of the American health care system. But most Americans don’t understand the limits of the ER and can’t expect it alone to provide a stopgap solution to a broken health care system.

I recently wrote about the Emergency Treatment and Labor Act (EMTALA). This law requires all hospitals with emergency departments that receive federal funding to see all patients, regardless of their ability to pay. This means that every individual in need of emergency care is seen and medically stabilized, regardless of immigration status, income or insurance.

EMTALA was conceived and adopted in 1986 as a way to prevent hospitals from “dumping” poorer patients to charity hospitals that may be more mission-driven to care for patients in need. The action works in practice, but only to a certain extent. If your case does not qualify as an emergency, EMTALA does not apply and your ability to receive medical treatment becomes the luck of the draw based on your insurance.

I first witnessed this reality during my medical training as a physician in a California hospital. A Hispanic worker had his finger amputated with a table saw. It was a “clean cut” and he had properly placed the amputated finger in a plastic bag and immediately came to the ER with a bandaged stump. Since that hospital did not have a surgeon who could “replant” the finger, I spent over an hour making phone calls and waiting for callbacks, desperately trying to find a hospital and a surgeon who would take his case. to accept. When a hospital surgical resident finally responded, he asked me what insurance the patient had, and I immediately responded that if this was information he used to make a decision about accepting the patient, I would take this as a notification should report. EMTALA violation and he, his caregivers and the hospital would be financially responsible for these penalties. Needless to say, I had the patient transferred.

EMTALA therefore ‘works’ in certain situations. It prevents us from visibly abandoning patients in the emergency department. But patient abandonment still happens every day, albeit in less visible ways, especially among individuals without life- or limb-threatening emergencies that require immediate intervention.

I have seen more than a dozen patients with some variation of this story. A patient with an ankle fracture is seen, diagnosed, treated, and appropriately discharged from the emergency room because he did not require immediate surgery. But he has not found a specialist who will accept his case because he does not have “favorable” insurance. As a result, he cannot stand on that leg or bear weight on it. This has prevented him from working, resulting in his inability to pay his rent, which means he now has no place to live. He has been to multiple ERs who consulted their orthopedic surgeons, who appropriately informed him that his case has not occurred for months. It has now become the patient’s responsibility to find a surgeon who can handle his case. So he is back to square one. In certain cases, this patient has also become homeless. His fracture is infected and his medicine is stolen from his backpack. He comes back to the ER and we treat his infection. He is discharged, but without proper shelter he becomes reinfected and the cycle continues. Ultimately he needs an amputation.

This is more expensive for society than providing care to him, and the outcomes are also worse. Even without the homelessness and infections, the multiple emergency room visits alone – which could have been avoided had he undergone outpatient and elective surgery – have exacted a heavy price on him and on our society. How? Multiple emergency department visits from patients with nowhere else to go mean longer wait times for others, leading to emergency department crowding and ultimately higher mortality, which leads to deaths.

EMTALA is necessary, but it does not fill all the holes in our safety net. It leaves countless others without care for non-urgent but urgent needs. A functional safety net could address these gaps and provide the medical care needed to prevent avoidable emergencies. Until we confront these invisible forms of neglect, our so-called safety net will remain a broken patchwork, falling short of the very forms it was designed to protect.