If poor people, overweight people, and smokers can’t afford health care, including preventive care, what will they do when they have a medical crisis?

They will have no choice; they will show up at the most expensive source of medical care, the local emergency room. (I had an unrelenting nosebleed one weekend and found myself with a bill for $959 for an hour at the local ER. But, I had insurance.)

Throughout the recent high-intensity fights about the Affordable Care Act and the American Health Care Act, deficits and mandates, Congress seems to be overlooking the most important mandate, the 900-pound gorilla that is seemingly invisible, the EMTALA. That’s right, the 1986 Reagan-era Emergency Medical Treatment and Active Labor Act.

This law requires most hospitals to treat patients needing emergency care regardless of the patient’s ability to pay, citizenship or even legal status. It applies to every hospital which takes Medicare funds, which means just about every hospital. Thus the big signs in the waiting room: “We can’t turn you away.”

If Congress cuts Medicaid funding and subsidies for health insurance, the uninsured patients will go to the emergency room. The expensive care provided at these public hospitals will be paid for: how? By the hospitals, which will try to cover these expensive costs by raising fees and charges to other patients? Or they will go bankrupt? I guess there is no way, after all, to avoid passing the costs of treating the sick to the healthy and solvent.

Doesn’t everyone know this? Duh, maybe not, I mean, according to President Trump, no one knew how complicated health care is. Yes, we do. One reason for health insurance is to cover hospital costs. Another is to encourage preventive care. Another is to prevent people from filing bankruptcy when they cannot pay doctors and hospitals. These are simple concepts.

Insurers try to operate on a profitable basis. Sick people threaten the solvency of insurers, particularly when they try to get insurance only when they become sick. We share the costs by paying into the system when we are not sick.

Human nature is that young healthy people do not want to pay insurance premiums. Middle-aged and older people have accumulated risk factors that require health care. If everyone does not play, someone will bear the cost. Patient bankruptcies are bad economics. Hospital failures are bad economics. These are the reasons to try to force people to participate in the insurance pool.

House Speaker Paul Ryan says freedom shall prevail. People don’t have to buy insurance. We will let them decide.

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So, poor people and healthy people won’t buy insurance. Sick people will try to buy insurance, and fail due to cost. The system will fail. But, maybe the secret agenda is that massive deaths of untreated sick people will reduce the burden on the Social Security trust fund. Cynical indeed. China has a state-owned tobacco industry which weans out the pensioners.

Obamacare is not perfect. The mix of sticks and carrots breeds resentment. But everyone needs to be in the pool. The Senate recognizes this. The president says everyone must be covered. But Ryan says no, it’s free choice.

Tax credits mean little to poor people; they don’t pay taxes anyway. If we give them money they won’t spend it on health insurance. That’s why Medicaid works, maybe somewhat inefficiently, but better than the costs of EMTALA.

U.S. Sen. Angus King, an Independent from Maine, says choice is a nice ideal, but if you need a stent, you don’t really have much opportunity for meaningful negotiation. You get the stent.

Except if you don’t have insurance, what do you do? Skip it and eventually end up in the ER with a coronary event? Run up a big bill and file bankruptcy?

King: “I may have a choice whether or not to buy a Maserati, but if I can’t afford one, what is the meaning of the term ‘choice’?” For poor people who cannot afford a car, we have subsidized public transportation. For poor people who cannot afford health insurance, there are benefits to the larger public to provide subsidized health care.

If you don’t like mandates, folks, better repeal EMTALA while you are in repeal mode.

U.S. Sen. John Barrasso is a physician. U.S. Sen. Mike Enzi is an accountant. They surely understand these simple concepts. How do they reconcile the federal mandate of EMTALA with repealing the mandates in the ACA?

It’s one part easy and one part hard. Keeping Medicaid or expanding it is the easy part. Creating successful incentives to force healthy people to buy insurance is the hard part. Or we can gaily just promote “choice,” thereby to “choose” our health care system, hospitals, sick people and older people into bankruptcy.

RT Cox is a Gillette lawyer and formerly served on WyoFile’s board of directors. He has written columns for The Sage Grouse off and on for many years. He resigned his columnist post in 2012 in a dispute over editorial content but returned later, unable to resist taking up his pen. This is another in his series of occasional columns.

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  1. So very accurate!

    “So, poor people and healthy people won’t buy insurance. Sick people will try to buy insurance, and fail due to cost. The system will fail. But, maybe the secret agenda is that massive deaths of untreated sick people will reduce the burden on the Social Security trust fund. Cynical indeed. China has a state-owned tobacco industry which weans out the pensioners”

    With the system we have costs cannot be controlled, only shifted to the weakest player, which is the patient. If we really wanted to control costs the US would have some kind of universal health care. Canada, Great Britain, and Germany all have different models that work.