Diaz v. North Carolina

One counter-argument to the drive for developing a universal health insurance system often goes something like this. “People get care when they go to an Emergency Room for free, so we already have a type of universal system.”

The case of Diaz v. North Carolina helps to demonstrate the limits of the Emergency Medical and Active Labor Treatment Act (EMTALA) 1986, and shows that the ‘everyone gets anything in an emergency room for free’ meme is false. Diaz was an illegal immigrant to the U.S.who was diagnosed with Cancer during an emergency room visit in October, 2000. North Carolina’s Medicaid program paid for care over a 9 month period that was deemed to be an emergency, but denied payment for other care, asserting that Medicaid does not have to pay for the care of illegal immigrants unless it is of an emergency nature, a decision affirmed by the North Carolina Supreme Court. In short, Medicaid must pay for care deemed to be an emergency per EMTALA for illegal immigrants, but does not have to pay for non-emergent care sought in an Emergency Department or elsewhere by such persons. The case really hinges on interpreting what constitutes emergency care, and says that medical providers can make such judgments and act accordingly; the case is not only about illegal immigrants and access to health care (how the case is typically discussed).

Fast forward to today, and the Hospital Corporation of America has implemented a policy in which persons seeking care that is not of an emergency nature per EMTALA are denied care (after being screened to ascertain whether it is an emergency) unless they pay $150 up front. 80,000 persons in the past year have left Emergency Departments in HCA hospitals without receiving care after being required to pay an up front fee to receive what had been judged to be ‘non emergent’ services. More on the pilot program:

HCA says it complies with federal requirements to screen and stabilize anyone with an emergency. Of more than 6 million ER visits to HCA hospitals last year, 314,000, or about 5 percent, were determined not to be emergencies, Fishbough said. About 230,000 of those patients paid and remained in the emergency room for treatment. The other 80,000 or so left. The HCA payment policy excludes children 5 and younger, pregnant women, and those 65 and older.

There are a variety of concerns about how this policy make effect access to care. My main point here, however, is simply to point out that people cannot necessarily get any care they want for free at an emergency room. And providers appear to be moving more aggressively to limit such care. If we want a coherent safety net, we will have to create one.