Some key points to add to on scarcity.

EMTALA rules emergency rooms. It’s a law that requires all ERs to see everyone, with or without insurance, and determine they are medically stable or make them so. But what does that look like on practical terms.

1. People are impatient. They don’t want to wait 3, 6, or even 1 month to see a regular doctor or a specialist. So they try the ER (or urgent care) instead. While the latter can work great for an antibiotic, some stitches, or a quick breathing treatment post asthmatic attack, it will almost never fix any long term issues. Chronic back pain? Never. Diabetic maintenance? No. Chronic mental health? Psych med refill on am established prescription that’s on record with the pharmacy, sure, but no therapy. No plan. Both immediate care services will refer back to the waiting line of PCP or specialist for that “I’ve had this thing for 6 mos and I’d like it fixed…” issue.

2. People familiar with ER wait times will sit on serious issues like strokes and heart attacks, hoping it’s nothing. It’s really sad and frustrating to see someone hobble in with a flaccid right arm after the treatment window for busting up the clot that caused the stroke has passed. Potentially reversible (partially or otherwise) arm and facial droop damage or however it presents is now permanent because a section of brain has gone too long without oxygen and can no longer potentially be saved. All due to wait times (a stroke typically isn’t going to wait) discouraging people from coming in.

3. People who can’t afford to pay for the ER don’t. I’m not saying they get help from some magnanimous something or other, I’m saying they ignore the bills and don’t pay. ER has to see everyone long enough to determine medical stability or to make it so and then admit or transfer. (Though the law also forbids “patient dumping” so the transfer has to be the patients choice, no matter how overcrowded that particular hospital is). The visit is billed out, but not necessarily paid. Each doctor is billed out separately. Each doctor, nurse, tech, respiratory therapist, psychiatrist, laboratory tech, transport personnel, imaging tech, supply runner, housekeeper, security guard, pharmacist, pharmacy tech, and registration person is still getting paid by the institution regardless. And that’s just the 24hr 7days a week people side of everyone potentially orbiting a single patient in a single ER visit. There’s still equipment, medication, management, bankers hours institutional jobs, C-suite, and high tech items getting paid for, and paid, regardless. Those costs will get collected from someone, ALWAYS.

4. People with ambulance coverage try to use it as a taxi service and to bypass ER wait times. The latter doesn’t work. ER nurses will trot out to the ambulance bay and triage those the same as everyone else and then escort them to the waiting room to wait with everyone else, often presenting one reason ERs have so many security personnel on payroll as it happens. This behavior set wastes the time of paramedics and EMTs. This piece actually is a point of waste for Medicaid. As such, this tiny area might show a savings, but overall it’s highly unlikely to even remotely justify these cuts. (This phenomenon is simply the “asshole factor” in systems involving people, wherein there’s always an asshole looking for an angle to play. But they are typically the exception, the outlier, not the rule, not the average.)

5. People will get sicker, mentally and physically, just as we saw with COVID. This backlash of heavier, sicker, more mentally unhinged patients post COVID has not eased off btw. Engage conversation with and nurses or techs/CNAs you know who work hospitals. It’s pretty grim stuff. So, anticipate Medicaid cuts making the system worse, by both taxing the resources and creating higher costs. This may push even more nurses, and to some extent doctors, into moving on, thus discouraging young people from pursuing healthcare as a career, which isn’t good for the long game. All of this potentially stretches and snaps mental health, for both patients and the entire spectrum of caregivers (they’re people too, with limits).

Just an add on thought. At what point will health insurances start considering people “totaled” in the same way vehicle insurances consider vehicles totaled?