Cuts to Medicaid and to insurance subsidies will push ERs past the brink

Back in 2007, President George W. Bush was being challenged on his opposition to the Children's Health Insurance Program - which provides health coverage for children in families too poor to afford private insurance, yet too "wealthy" to qualify for Medicaid. His response was honest, if characteristically clumsy: "People have access to health care in America. After all, you just go to an emergency room."

In a way, he wasn't wrong. By law, ERs must evaluate and stabilize every patient who walks through the door, regardless of complaint or ability to pay. But by saying the quiet part out loud, Bush laid bare an uncomfortable truth: Emergency departments are not just for emergencies, and never have been.

I've been an ER doctor at an inner-city trauma center for 35 years. And while I've seen plenty of gunshot wounds, drug overdoses and heart attacks, true emergencies - the kind that animate medical dramas on television - are a comparatively small part of what I do. It's the "worried well," the "sick and stoic" and everyone in between who keep us busy. They're all resigned to using the ER as a stand-in for unavailable primary care.

ER docs like me hear it every day: "My doc is booked up and can't see me for three months." "The nurse line told me to come because the office is closed." "It's probably nothing, but I'm worried." "I don't have insurance, a doctor or my medicine."

When there is no place else to go, everything is an emergency. Offering high-quality, sophisticated care, day or night, without a reservation, ERs have long served as spackle for a gap-riddled health care system. But emergency care of any kind is costly, resource intensive and increasingly being swamped by unmet needs for primary care: issues best handled elsewhere that end up in the ER for lack of better options.

ERs now operate in a sort of siege mentality - hold the line at all costs - because, by design, they are the last line of defense. I write these lines fresh off three successive ER shifts in which I thought, at several moments, we were just a patient or two away from a "breach": the moment when demand outstrips capacity and the rationing of care begins. These are not rare events. In communities across the country, ERs and their staff are straining under a burden of too many patients, too few beds and a stubborn dearth of viable solutions to stem the tide.

And things are about to get worse.

The budget standoff in Washington, which has already triggered a government shutdown, centers on whether to renew federal insurance subsidies that are scheduled to expire on Dec. 31. If Congress fails to preserve the subsidies, premiums in the Affordable Care Act marketplace are expected to surge beyond the reach of millions of patients who currently depend on the program- especially people who work for small businesses and people in red states that have declined to expand Medicaid.

Just a year later, a second shock is set to arrive. The Big Beautiful Bill Act - the third-largest tax cut in U.S. history, passed by Congress last summer - will be "paid for" in part through draconian cuts in Medicaid, SNAP food assistance and noncitizen services. By design, these cuts do not take effect until after next year's midterm elections. But when they do, the consequences will be severe: an estimated 11 million people will lose Medicaid coverage, while those who remain will face stricter eligibility hurdles. Disabled patients could see Medicaid-funded home care eliminated, forcing many into hospitals because of a lack of long-term care options. Meanwhile, 14 million unauthorized residents will lose access to all services, and another 8 million legal noncitizens may face the same fate.

Which is to say, the "just go" ER will soon be the shadow insurance for more than 33 million people living in America about to lose their health coverage, two-thirds of whom are either citizens or legal residents. The consequences of these cuts can't be overstated. That's 33 million patients who will forgo trips to the doctor, health screening for cancer and infectious disease, vaccinations, medication refills for chronic diseases like diabetes, hypertension and asthma.

In 2014, with the initial rollout of Obamacare, I was giddy with optimism. Many of my patients would, for the first time, be able to make an appointment to visit a primary doctor, in an office, rather than spending hours waiting to see me. In the end, it didn't achieve all it promised, but it did a lot. Since its inception, more than 50 million individuals have been covered by Affordable Care Act policies. The proposed cuts are more than a simple course reversal. They wipe out a decade of progress in providing health care to working people and our nation's poor, at a time when Plan B - the ER - is ill prepared to deal with an onslaught.

Unlike ERs, doctors' offices and clinics are under no obligation to "evaluate and stabilize" patients regardless of ability to pay. And they won't, save for the occasional self-pay. But these patients aren't going away. They are day laborers, house cleaners, workers at restaurants, hotels and home care agencies. They work in construction, agriculture and small businesses. They are the working poor, many one illness away from losing their jobs or their homes.

Inevitably, they will end up in the emergency room - sicker, with advanced, expensive conditions beyond the reach of easy fixes. They'll have stopped taking their blood pressure medications, leading to strokes, heart attacks and kidney failure. Diabetics will see their glucose soar out of control. Untreated asthma and emphysema will render patients breathless and on death's door. Flu and COVID will flourish. Measles, mumps, rubella, H-flu and meningitis outbreaks will become the new normal.

And care for affected individuals will fall to a health care system already operating on life support. Costs will be passed on to other customers, raising premiums and co-pays. Hospitals, many in rural areas, will look to cut services or close entirely, further expanding health care deserts.

Leaving aside the human suffering, the financial logic is delusional: Disease in 33 million residents will not vanish. It can either be managed inexpensively in doctors' offices and clinics - or at orders of magnitude greater expense in ERs and hospitals. It becomes an elaborate game of cost shifting away from the federal government and onto state and local governments and hospitals.

Don't think that you will be unaffected just because you have insurance, a doctor and an unassailable citizenship status. For one thing, you'll be paying for the care that is no longer provided through federally subsidized insurance. And for another, "fortress" America has a poor record of insulating itself from the vagaries of disease: Think COVID, the opiate crisis, gun violence, etc. This is not a problem of haves versus have-nots. It will affect all of us. Costs will rise. Access will shrink. Your 911 call may be placed on hold. Ambulances will take longer to arrive. ER waiting rooms, already resembling bus stations, will be fortified with chairs and cots. Why? Because the hospital wards are full, rendering the ER a holding area for admitted patients, most of whom will end up completing their treatment on a gurney, never seeing a hospital ward. Illness is an innate part of the human experience - one that, in civil society, we share with others in a sort of universal pact. The unmet health care needs of one affect us all. To believe otherwise is to divert one's gaze, naively, hoping others will manage the problem, keeping it from your doorstep - in defiance of the medicine and simple math.

Eric Snoey is an attending emergency medicine physician in Oakland.