Highland Hospital in Oakland. Many homeless people have no other recourse but to seek medical care at the emergency rooms of county hospitals.
Highland Hospital in Oakland. Many homeless people have no other recourse but to seek medical care at the emergency rooms of county hospitals.


by Kamran Abri

The possibilities for homeless individuals entering the emergency medical system in this country are extremely limited, to the point that anyone who works in the arena of medical services for the underserved is familiar with the predictable difficulties.
Time and time again, we hear stories of people on the streets needing medical services being turned away from emergency departments; being “dumped” onto county hospitals by private entities; or being forced to use hospital emergency rooms as their only source of medical care, whether for significant or routine medical needs.
What we see as a result of these trends is the overburdening of county-based emergency departments, the hemorrhaging of hospital funds, and poor care of the low-income and homeless populations that need the care the most.
This begs an important question: are emergency departments, and our laws regarding the treatment of uninsured patients in them, a problem? My belief is that the systemic and economic issues of emergency rooms are not the problem. Instead, they are just the symptoms of a medical system that is still not doing enough.
When it comes to patient treatment in an emergency room, the law of the land is the Emergency Medical Treatment and Active Labor Act, or EMTALA. Hospitals under EMTALA (i.e., any hospital with an emergency department that accepts Medicare payments) are obligated to meet three criteria.
First, any person requesting emergency care must at least be medically screened, regardless of financial or insurance status.
Second, should an emergency department decide that the individual warrants further treatment, they are required to treat that individual until the issue is resolved or the patient is stabilized.
Third, hospitals must transfer patients to a different, more capable facility should they feel they cannot meet the patient’s health needs.
To violate EMTALA means that a hospital risks losing the privilege to be reimbursed by the federal government via Medicare. These are the very criteria that make emergency rooms the only viable medical option for many homeless and uninsured persons.
Now, EMTALA and its principles by themselves seem like a logical, compassionate solution to people having sudden, isolated medical events and requiring emergency medical attention.
However, our problems arise when we combine this set of laws with a health system designed to shut the uninsured out of primary care for routine needs, forcing them to go to the emergency rooms. These individuals do not just experience a single, extreme medical event that can be resolved through emergency intervention. They have a high number of chronic medical needs as well.
The emergency room visit lands the uninsured individual with a huge bill that they likely cannot pay, thus losing the hospital money, for a condition that could have potentially been addressed months earlier before escalating into a serious medical issue.
On the surface, it may appear that the policies surrounding emergency departments and EMTALA are the issues, but the root of the problem lies within our system of insurance and coverage for the underserved.

Stories from the Suitcase Clinic
Stories from the Suitcase Clinic

But surely these issues have been addressed by Obamacare? For many, yes. They are now able to afford basic medical care through government-subsidized plans and through expanded Medicaid, with estimates of the newly covered hovering at over 16 million people. That is 16 million people who now have access to primary medical care, and who are also able to access emergency services and actually pay emergency departments for those services.
The caveat to this success story is the remaining 32 million uninsured Americans who continue to rely on the criteria laid down by EMTALA as a major outlet for medical care. While the system has changed, there are still many, many people who rely on emergency departments as their sole access point to healthcare, which simply should not be happening.
There are many potential solutions to these problems: increased social and financial counseling services at hospitals, changes to the legal language of EMTALA, making Medicare reimbursement to private hospitals contingent upon their acceptance of Medicaid plans, etc. We are also still learning about the effect of the 2010 healthcare reform on emergency departments, and many unknowns remain.
One of the biggest options in terms of solutions is universal healthcare — a model that has proven effective in many flavors in countries like Canada, Britain, Taiwan, and Sweden. This is the only way that we can truly close the gap and end our overreliance on emergency care general as a substandard substitute for comprehensive medical care, closing the gap for the homeless and low-income populations of this country.
However, whatever the solution may be, we cannot ignore this fact: we are currently forcing people to rely on a system of emergency medicine to meet medical needs that the primary care system has been designed to handle. This is a failure of our medical institutions to the uninsured and underserved, and must be addressed as a matter of principle and the achievement of health equality.
Kahntroff J, Watson R. “Refusal of Emergency Care and Patient Dumping.” AMA Journal of Ethics 11.1 (2009): 49-53.
D’Amore J. “The Epidemiology of the Homeless Population and Its Impact on an Urban Emergency Department.” Academic Emergency Medicine 8.11 (2001): 1051-055.
Salit, SA, EM Kuhn, and AJ Hartz. “Hospitalization Costs Associated with Homelessness in New York City.” New England Journal of Medicine 338.24 (1998): 1734-740.
Vila-Rodriguez, F, Et Al. “The Hotel Study: Multimorbidity in a Community Sample Living in Marginal Housing.” American Journal of Psychiatry 170.12 (2013): 1413-422.
“HEALTH INSURANCE COVERAGE AND THE AFFORDABLE CARE ACT.” ASPE.HHS.gov. US Department of Health and Human Services, 5 May 2015.