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The Uninsured: Access to Medical Care Fact Sheet

Main Points

  • Emergency care is the safety net of the nation’s health care system, caring for everyone, regardless of ability to pay.i
  • Inadequate coverage of the uninsured, cutbacks in Medicare, declining payments by health plans and a medical liability crisis threaten the ability of emergency physicians to continue to provide high-quality care to everyone.
  • Emergency physicians provide the most uncompensated care for uninsured patients of all physicians.ii
  • America’s emergency departments are under severe stress, facing soaring demands. They are essential to every community and must have adequate resources.
  • Coverage does not guarantee access to medical care. Emergency visits have increased at twice the rate of the U.S. population,iii and they will continue to increase, the implementation of the Accountable Care Act (ACA). There will also still be people uninsured after the ACA is implemented.

Q. Who are America’s uninsured?

The federal government estimates approximately 49 million Americans are uninsured in the United States. 9.4 percent (7 million) of those are under the age of 18.iv

  • 30 percent of the uninsured are Hispanic
  • 20 percent are black
  • 15 percent are white
  • Less than 2 percent are over the age of 65v

Q. Did ACEP support the health care reform law (Affordable Care Act) that was enacted in 2010?

ACEP supports universal health insurance for everyone, but did not take a formal position on the ACA. ACEP advocated for provisions that would benefit emergency patients, for example, making sure that emergency care was part of any essential health benefits package and preserving the national prudent layperson standard, but opposed other provisions that would harm emergency patients, such as the Independent Payment Advisory Board.

The nation’s emergency physicians are dedicated to working to achieve the long-term benefits of true health care reform. ACEP is asking Congress and the president’s administration to recognize and fund the central role that emergency medicine plays in the health care system.

In a 2010 ACEP member poll, 61 percent of emergency physicians did not think the Affordable Care Act would effectively address the problem of uncompensated care,vi which has contributed to the closure of hundreds of emergency departments across America.

In Massachusetts, emergency visits went up after the state passed universal health care in 2006.vii Visits will continue to go up nationwide despite implementation of the ACA.

Q. What is the nation’s health care safety net?

Health care safety net providers are those that have a legal mandate and mission to offer medical care to all patients, regardless of their ability to pay, and have a substantial number of patients who are uninsured or on Medicaid.

Health care safety net providers include emergency departments, community health centers, public hospitals, charitable clinics, and in some communities, teaching and community hospitals—organizations that people turn to when faced with barriers to obtaining medical care elsewhere.

Emergency departments are the only health care entities with a legal mandate to provide health care.  The Emergency Medical Treatment and Labor Act (EMTALA).viii This law ensures that anyone who comes to an emergency department, regardless of their insurance status or ability to pay, must receive a medical screening exam and be stabilized.

Q. Are uninsured patients with nonurgent medical problems causing overcrowding?

No. Overcrowding is caused when emergency patients are admitted to the hospital but are “boarded” (for hours or days) in the emergency department, waiting for inpatient beds. This causes the backups in waiting rooms and ambulance diversion.

According to a survey of emergency physicians released in March 2003, most uninsured patients who seek emergency care are very sick.ix The uninsured also are more likely to delay medical care, live with more serious medical conditions and to die earlier than those with health insurance.

Patients with non-urgent medical conditions may wait longer for care, but once seen, they can be treated quickly and released. The Centers for Disease Control and Prevention (CDC) classified only 8 percent of hospital emergency department visits as non-urgent in 2009.x The CDC also says “the term ‘non-urgent’ does not imply unnecessary.”

Q. What are the costs of providing health care to the uninsured?

Hospitals and physicians shoulder the financial burden for the uninsured by incurring billions of dollars in bad debt or “uncompensated care” each year. Fifty-five percent of emergency care goes uncompensated, according to the Centers for Medicare & Medicaid Services.xi  Health care costs for both the full-year and part-year uninsured have been estimated to total $176 billion dollars per year - $86 billion of which will be incurred when they are uninsured.

In the past, hospitals shifted uncompensated care costs to insured patients to make up the difference. However, cost shifting no longer is a viable option because managed care and other health plans have instituted strict price controls, leaving little margin to shift costs. More than one-third of emergency physicians lose an average of $138,300 each year from EMTALA-related bad debt, according to a May 2003 American Medical Association study.xii

With projections that health care costs will double and the number of uninsured will increase, the nation is faced with how it will continue to provide care for all Americans, not just the disadvantaged. Emergency departments provide an essential community service, similar to fire departments, police departments, and public utilities. The nation cannot afford to allow the emergency care system to collapse because of a lack of funding. It is too high a price to pay in terms of public health effects and human suffering.

Q. What is the SCHIP program and how has ACEP promoted it?

ACEP supports expansion of the State Children’s Health Insurance Program (SCHIP) to cover more low-income American children. SCHIP is the largest expansion of health insurance coverage to children since the enactment of Medicaid in 1965. Like Medicaid, the program is a partnership between federal and state governments. Enacted as part of the Balanced Budget Act in 1997, SCHIP was designed to expand health insurance coverage to working families that earn too much for traditional Medicaid, yet not enough to afford private health insurance.

ACEP has worked to educate emergency physicians about this program as a partner in the Covering Kids campaign. Many ACEP state chapters have partnered with local SCHIP programs to identify eligible children and promote the program by providing information and resources to uninsured families during emergency department visits.xiii

Q. How do illegal immigrants in the U.S. who are uninsured affect emergency care?

Most illegal immigrants lack health insurance and this means many are unable to pay – contributing to uncompensated care, especially in Border States, such as California, Texas and Arizona. Billions of dollars of uncompensated care has resulted in the closure of hundreds of emergency departments in America, which is reducing capacity and threatening everyone’s access to lifesaving care.

Q. How many illegal immigrants currently live in the in the United States?

The illegal immigration population in the United States was estimated at approximately 11.2 million in 2012.xiv More than half, (58 percent) are from Mexico. In 2010, nearly one-third (29 percent) of immigrants and their U.S.-born children (under 18) lacked health insurance, compared to 13.8 percent of natives and their children.xv New immigrants and their U.S.-born children account for two-thirds of the increase in the uninsured since 2000. The top states for illegal immigration are:

  • #1 California: 2.2 millionxvi
  • #2 Texas 1.04 million
  • #3 New York 489,000
  • #4 Illinois 432,000
  • #5 Florida 337,000
  • #6 Arizona 283,000

Q. Is health insurance available to illegal immigrants under the Affordable Care Act?

The estimated 11 million people currently living illegally in the United States will not be covered under the Affordable Care Act. Even if they were eligible for coverage, most could not afford it, nor could they afford to visit a private physician’s office, and they are not eligible for Medicaid. Census data reveal a strong link between immigration and the rapid growth of the medically uninsured.

Some illegal immigrants in this country who work as migrant farm workers find that Medicaid is frequently unavailable to them because of residency requirements, and it only covers emergency and obstetrical care when it can be obtained. Preventive care is completely unavailable.

Q. How does the health law’s treatment of immigrants affect hospitals and community health centers?

According to Kaiser Health News, “recognizing that more health centers would be needed to help care for the estimated 30 million newly insured, Congress included in the health law $11 billion over five years for community health centers. However Congress last year cut $600 million from health center funding. Unless Congress restores that money, the cuts will continue and over five years will trim $3 billion off the $11 billion. Federal payments to hospitals are also going to be reduced. Because they can expect to see fewer uninsured patients as a result of the health law, hospitals agreed to cuts in federal funding provided to reimburse facilities for caring for the uninsured. Called disproportionate share payments, the money is scheduled to be scaled back by about $18 billion from 2014 to 2020.”xvii

Q. Why do illegal immigrants go to emergency departments instead of doctors’ offices or public health clinics?

People who cannot afford to go to a private physician’s office and who do not have health insurance turn to emergency departments, which serve as a vital part of America’s health care safety net. Emergency departments are mandates by law to medically evaluate and provide stabilizing treatment of emergency conditions of everyone. Language and economic barriers also often limit illegal immigrants’ access to health care. In addition, fear of detection by immigration authorities may account for why as few as one-fourth of them use public health services. ACEP opposes initiatives to require physicians or health care facilities to report suspected, undocumented persons to immigration authorities. Furthermore, many illegal immigrants become migrant farm workers and their transient living arrangements jeopardize residency requirements for some community health clinics.

Q. How much does it cost U.S. taxpayers to provide health care for illegal immigrants?

Billions of dollars are estimated to be spent each year, although data are scare on both costs and use of health care. Transient living conditions, undercounting of migrant workers and desire to avoid contact with government agencies limit the nation’s ability to accurately determine the costs of their medical care.

Many hospitals are concerned that the U.S. government will cut money — about $20 billion annually — used to pay for emergency care for illegal immigrants — mostly in poor urban and rural areas. The health care law will eventually cut that money by half because of the anticipation that fewer people will lack insurance after the law is implemented.xviii

Q. What does ACEP propose as solutions?

ACEP advocates for universal health care coverage that builds on the strengths of the nation’s current health care system.

The Institute of Medicine in 2006 recommended that Congress provide greater reimbursements to large, safety-net hospitals that bear the burden of taking care of uninsured patients.xix

ACEP’s Task Force on Health Care and the Uninsured developed six principles to be used as a framework for expanding health care coverage to all. Some of those principles include:

  • All Americans should have health insurance that provides quality medical care, including access to emergency care.xx
  • The unique relationship between the emergency department and the uninsured should be used for implementation, enrollment, monitoring, and education.
  • Policymakers should take advantage of the research opportunities in the emergency department when it comes to the development and implementation of programs to strengthen the health care safety net and expand coverage for the uninsured.

The Center for Medicaid Services (CMS) and The Joint Commission (TJC) are beginning to address the issue of inpatients boarded in the emergency department. ACEP applauds these efforts.

The public’s desire for health care reform has shifted over time from wholesale reform to more targeted, incremental strategies. Among the options are: shoring up Medicaid, offering vouchers to buy insurance, offering tax credits to help small employers and individuals, and providing tax relief to those who buy insurance on their own.

Numerous polls show that most Americans support the idea of access to universal coverage, and the plight of the working uninsured clearly resonates with most of the public. But support starts to wither when people are asked whether they would be willing to pay more taxes to cover more people.

For more about this topic, visit www.ACEP.org.

[i] American College of Emergency Physicians, EMTALA Fact Sheet, 2012; http://newsroom.acep.org/index.php?s=20301&item=29930

[ii] American Medical Association, “Physician Marketplace Report: The Impact of EMTALA on Physician Practices,” 2003. http://www.ama-assn.org/ama1/pub/upload/mm/363/pmr2003-02.pdf

[iii] Journal of the American Medical Association, “Trends and Characteristics of US Emergency Department Visits, 1997-2007,” 2010, http://jama.jamanetwork.com/article.aspx?articleid=186383

[iv] U.S. Census Bureau, “Income, Poverty, and Health Insurance Coverage”: 2011; http://www.census.gov/prod/2011pubs/p60-239.pdf     http://www.census.gov/hhes/www/hlthins/data/incpovhlth/2011/Table7.pdf

[v] U.S. Census Bureau “People Without Health Insurance Coverage by Race and Hispanic Origin Using 2- and 3-Year Averages: 2008-2009, 2010-2011, and 2009-2011. http://www.census.gov/hhes/www/hlthins/data/incpovhlth/2011/race.xls

[vi] ACEP Member National Health Reform Legislation Survey, 2010, http://tinyurl.com/b95ktro

[vii] The Boston Globe, “Emergency room visits grow in Mass.,” Liz Kowalczyk, http://www.boston.com/news/local/massachusetts/articles/2010/07/04/emergency_room_visits_grow_in_mass/ 

[viii] ACEP EMTALA Fact Sheet, 2012, http://www.acep.org/content.aspx?id=25936

[ix] ACEP, “State of Emergency Medicine: Emergency Physician Survey,” 2003

[x] CDC Website, “National Hospital Ambulatory Medical Care Survey,” 2011, http://www.cdc.gov/nchs/data/ahcd/NHAMCS_Factsheet_ED_2009.pdf

[xi] Dept. of Health and Human Services, Centers for Medicare &Medicaid Services, 2002, http://www.gpo.gov/fdsys/pkg/FR-2002-12-31/html/02-32503.htm

[xii] American Medical Association, 2003; http://www.ama-assn.org/amednews/2003/06/02/gvsd0602.htm

[xiii] Centers for Medicaid Services, Children’s Health Insurance Program, http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Childrens-Health-Insurance-Program-CHIP/Childrens-Health-Insurance-Program-CHIP.html

[xiv] Pew Research Center, 2012 http://pewresearch.org/pubs/2250/mexican-immigration-immigrants-illegal-border-enforcement-deportations-migration-flows

[xv] Center for Immigration Studies, 2012, http://www.cis.org/2012-profile-of-americas-foreign-born-population

[xvi] U.S. Citizenship and Immigration, “Estimated number of illegal immigrants (most recent) by state, 2000, http://www.statemaster.com/graph/peo_est_num_of_ill_imm-people-estimated-number-illegal-immigrants

[xvii] Kaiser Health News, “How Will the Health Law Impact Coverage for Immigrants?,” 2012, http://www.pbs.org/newshour/rundown/2012/10/how-will-the-health-law-impact-coverage-for-immigrants.html

[xviii] The New York Times, “Hospitals Fear Cuts in Aid for Care to Illegal Immigrants,” July 26, 2012, http://www.nytimes.com/2012/07/27/nyregion/affordable-care-act-reduces-a-fund-for-the-uninsured.html?pagewanted=all&_r=0

[xix] Institute of Medicine: Report on Emergency Medicine, 2006, http://www.ed-qual.com/emergency_medicine_news/ED_News_IOM_Report_on_Emergency_Medicine.htm

[xx] “Preserving America’s Health Care Safety Net: Reflections from the National Congress on Preserving America’s Health Care Safety Net”, Sept. 2000