The Uninsured: Access to Medical Care Fact Sheet
Emergency care is the safety net of the nation’s health care system, caring for everyone, regardless of ability to pay. [i]
Emergency physicians provide the most uncompensated care for uninsured and underinsured 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.
Having health insurance does not mean you have access to medical care.
Q. Who are America’s uninsured?
The federal government estimates that the number of uninsured in the United States has declined by about 15 million since 2013[iii]. In the first three months of 2015, 29 million people were uninsured. That was seven million fewer than in 2014. While the uninsured are expected to drop to about 23 million by 2023 as a result of the ACA, according to the Centers for Medicare & Medicaid Services, many American will still not be able to afford their healthcare needs. [iv]
24.3 percent of the uninsured are Hispanic[v]
15.9 percent are black
9.8 percent are white
9.8 percent of children younger than 19 in poverty
7 percent of children under 19 who are not in poverty
Q. What type of insurance do people have?
64.2 percent are covered by private insurance (mostly employee-based health insurance)[vi]
17.3 percent covered by Medicaid
15.6 percent covered by Medicare
Q. What provisions in the Affordable Care Act protect emergency patients?
ACEP supports provisions in the ACA that 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 2015 ACEP member poll, three-quarters of emergency physicians reported that emergency visits were going up despite the implementation of the ACA.[vii] This represented a significant increase from 2014[viii] when less than half of emergency physicians reported increases. More than one-quarter (28 percent) report significant increases in all emergency patients since the requirement to have health insurance took effect. In addition, more than half (56 percent) say the number of Medicaid patients is increasing.
ACEP has said publicly during the push for health care reform that ER visits would continue to increase because of a severe primary care physician shortage and an aging population citing the example in Massachusetts where emergency visits went up after the state passed universal health care in 2006. [ix]
Q. Are uninsured patients with non-urgent 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. Boarding of patients who need mental health care is particularly serious as some availability of appropriate inpatient beds has been decreasing nationally.
According to a survey of emergency physicians released in March 2003, most uninsured patients who seek emergency care are very sick.[x] 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 4 percent of hospital emergency department visits as non-urgent in 2011. [xi]
Q. What is the nation’s health care safety net?
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.
Health care safety net providers are those that have a legal mandate or 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.
Emergency departments are the only health care entities with a legal mandate to provide health care ¾ the Emergency Medical Treatment and Labor Act (EMTALA).[xii] 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. 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. Hospitals provided over $50 billion in uncompensated care in 2013. [xiii]
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.[xiv]
With projections that health care costs will double 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. Has Medicaid expansion improved hospital compensation for medical care?
Medicaid patients are having Analysis of hospital financial reporting and member surveys from hospital associations indicates that, through 2014, payor mix is shifting in ways that will likely reduce hospital uncompensated care costs, according to the Dept. of Health and Human Services (HHS). Moreover, a projection model developed by ASPE suggests that the large observed declines in the uninsured and increases in Medicaid coverage have led to substantial declines in hospital uncompensated care in 2014.
Medicaid expansion states account for $5 billion of the estimated $7.4 billion reduction in uncompensated care costs attributed to ACA coverage expansions. [xv]
Q. What is the SCHIP program — does ACEP support 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.[xvi]
Q. How do undocumented immigrants in the U.S. who are uninsured affect emergency care?
Most undocumented immigrants are unable to obtain 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. Is health insurance available to undocumented immigrants under the Affordable Care Act?
By 2016, an estimated 5.1 million undocumented immigrants in the United States will be uninsured, according to some reports.[xvii] 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 documented legal 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.”[xviii]
Q. Why do undocumented immigrants go to emergency departments instead of doctors’ offices or public health clinics?
People who cannot afford physicians’ fees and who do not have health insurance are often turned away from private offices and urgent care clinics. With no other options, they turn to emergency departments, which serve as a vital part of America’s health care safety net. Emergency departments are mandated by law to medically evaluate and provide stabilizing treatment of emergency conditions for everyone. Language and economic barriers also often limit undocumented immigrants’ access to health care. Furthermore, many undocumented immigrants become migrant farm workers and their transient living arrangements jeopardize residency requirements for some community health clinics. In addition, fear of detection by immigration authorities may account for why as few as one-fourth of them use other health services. ACEP opposes initiatives to require physicians or health care facilities to report suspected, undocumented persons to immigration authorities.
Q. How much does it cost U.S. taxpayers to provide health care for undocumented immigrants?
Billions of dollars are spent each year caring for undocumented immigrants, 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 undocumented 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.[xix]
For more information, visit newsroom.acep.org or www.acep.org
[i] American College of Emergency Physicians, EMTALA Fact Sheet, 2012; http://www.acep.org/uploadedFiles/ACEP/News_Room/NewsMediaResources/Media_Fact_Sheets/EMTALA%20Fact%20Sheet%202012-FINAL.pdf
[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] The New York Times, “Number of uninsured has declined by 15 million since 2013, administration says, http://www.nytimes.com/2015/08/12/us/number-of-uninsured-has-declined-by-15-million-since-2013-administration-says.html?_r=1
[v] U.S. Census, “Health Insurance Coverage in the U.S.”, 2013, https://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-250.pdf
[vi] U.S. Census, “Health Insurance Coverage in the U.S.”, 2013, https://www.census.gov/content/dam/Census/library/publications/2014/demo/p60-250.pdf
[vii] ACEP Member Poll “ER Visits Continue to Rise Since Implementation of Affordable Care Act, 2015, http://newsroom.acep.org/2015-05-04-ER-Visits-Continue-to-Rise-Since-Implementation-of-Affordable-Care-Act
[viii] ACEP member poll, ER Visits Up Since Implementation of Affordable Care Act, 2014, http://newsroom.acep.org/2014-05-21-ER-Visits-Up-Since-Implementation-of-Affordable-Care-Act
[ix] 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/
[x] ACEP, “State of Emergency Medicine: Emergency Physician Survey,” 2003
[xi] CDC Website, “National Hospital Ambulatory Medical Care Survey,” Released March 2014, http://www.cdc.gov/nchs/data/ahcd/NHAMCS_2011_ed_factsheet.pdf
[xiii] HHS.gov., “Insurance Expansion, Hospital Uncompensated Care, and the Affordable Care Act, March 2015, http://aspe.hhs.gov/health/reports/2015/medicaidexpansion/ib_uncompensatedcare.pdf
[xiv] American Medical Association, 2003; http://www.ama-assn.org/amednews/2003/06/02/gvsd0602.htm
[xv] HHS.gov., “Insurance Expansion, Hospital Uncompensated Care, and the Affordable Care Act, March 2015, http://aspe.hhs.gov/health/reports/2015/medicaidexpansion/ib_uncompensatedcare.pdf
[xvi] 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
[xvii] International Business Times “Immigration, Health Care Reform 2015: States Move To Help Undocumented Immigrants Without Medical Insurance, 2015, http://www.ibtimes.com/immigration-health-care-reform-2015-states-move-help-undocumented-immigrants-without-1820458
[xviii] 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
[xix] 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