The economics and politics of emergency health care for the poor: the patient dumping dilemma.

"When you're well, you lose the sense of how really hard it is to be sick."(1) All I can say is this: it looks as if we are all we have. Given what we know about ourselves and each other, this is an extraordinarily unappetizing prospect; looking around the world, it appears that if all men are brothers, the ruling model is Cain and Abel. Neither reason, nor love, nor even terror, seems to have worked to make us "good," and worse than that, there is no reason why anything should.(2) I. INTRODUCTION Claudia Thomas was nineteen years old and eight months pregnant.(3) She was unemployed and had a two-year-old son, Eric, at home. Her husband, Steven, worked periodically, but none of his jobs offered health benefits for him, let alone Claudia and the kids. For this reason, Claudia had not seen a doctor during the entire length of her pregnancy. One morning Claudia began having cramps and nausea that seemed worse than usual. By noon she knew that something was wrong. She called her mother to ask her to watch Eric while she went to the clinic, but her mother was not available. She decided to wait until evening when Steven came home. By the time Steven arrived her contractions were painful, even though she was a month away from her due date. Claudia was bleeding and went to the emergency room of a nearby private hospital. Before she could see a doctor, she was asked to fill out several forms and answer questions about her insurance coverage and about her medical treatment during the pregnancy. Once it became obvious to the admitting nurse that Claudia did not have health insurance, another nurse was called in. She told Claudia that she would be "better off" at the county hospital, which was some 15 miles distant. Claudia demanded to see a doctor, saying that something was wrong and she was worried about the baby. Finally, she was led back and told to wait for the doctor. After 15 minutes, Claudia saw a doctor who told her that she would not be admitted because she had not dilated sufficiently. However, he decided to run some tests to make sure the baby was all right. Although the tests suggested that the baby was experiencing some distress, the doctor assured Claudia that there was plenty of time before the baby would be born, and that the best place, for a case like hers, was County Hospital. Despite Claudia's protests, the doctor refused to admit her. Reluctantly, she departed for County Hospital by taxi. On the way to the hospital she delivered a premature baby girl in the taxi. The infant died shortly thereafter of cardiac and respiratory complications. The doctor who treated her at County Hospital believes that if she had been admitted to the private hospital and received the proper care the baby would have survived. Claudia believes that she would have been admitted to the private institution had she had medical insurance or other proof of ability to pay. As the numbers of uninsured mount(4) because of job dislocations, exhaustion of benefits, and unaffordably high premiums, the incidence of "dumping" by private hospitals is, predictably, on the rise. Dumping occurs when a hospital, in violation of federal or state law, transfers an emergency patient to another (usually public) hospital or simply refuses any treatment based on the patient's inability to pay.(5) In addition to the completely uninsured, favorite dumping targets include Medicare and Medicaid patients, AIDS patients, and cancer patients whose therapy may cost more than the maximum reimbursement under private insurance. Dumping is merely a part of what is commonly referred to as the "health care crisis" which, in turn, is really a crisis involving two related, but distinct, issues: access and cost. There are two common themes to the complaints about health care voiced by consumers, insurers, providers, and politicians. These are (1) its high (and growing) cost and (2) the fact that millions have no access to good, consistent care because they are uninsured. …