President Bush was recently quoted as saying that “people have access to health care in America. After all, you just go to an emergency room.” Is this a realistic response?

Asch: To me, the bigger problem with this response isn’t that President Bush said it, but that lots of people believe it. Everyone understands that when Scrooge asks, “Are there no prisons? Are there no workhouses?” he is missing the point about what constitutes adequate care for the poor. But if lots of people think emergency rooms have solved our uninsurance problem, then they need to spend some time with Tiny Tim.

Grande: The only health care Americans are guaranteed access to is emergency rooms. EMTALA is the only law that gives Americans a right to some health care—but only for assessment and stabilization. To consider this a minimum standard for decent health care in the richest nation in the world is ridiculous. It neglects the importance of primary care and prevention and the proper management of chronic illnesses that improve the chances of living a healthy life.

Pauly: Depends on whether he meant “some health care” or “the right amount and type of health care.” He is right under the first meaning; federal law requires ER patients to be treated and stabilized. He is wrong on the second, but the administration is aware that using the ER as a port of entry into the system is not the best way to do things. Seems like you are trying to follow Moore in finding “gotcha” statements.

Rosoff: I agree with David Grande on this. Even assuming hospitals’ “dumping” of sick people in violation of EMTALA—as depicted so poignantly in Sicko—is an aberration, adequate health care is way more than just episodic emergency treatment when one is in an extreme state. In most cases it costs more to deal with an illness when it has progressed to an “emergency room” state, and the outcome of the treatment is likely to be worse. To the extent that we use emergency rooms as de facto primary care centers for the uninsured who are not in extremis, that is an extremely costly way to take care of lesser ills.

 

What are the worst ideas by the presidential candidates, and the most cowardly evasions?

Asch: The concept of choice has been co-opted and is now just code for market-based approaches. Choice in selecting an insurance plan is mostly about structuring financial risk. Choice in more clinical health-care decisions might seem like a more important issue, but its value is substantially over-rated. Sure, we may differ in our preferences for bedside manner, or for more aggressive medical and surgical approaches. But most of us share the same overall goals: to live longer and with less disability.

In fact, the prevailing approach to improving health-care quality has concentrated on the standardization of care, not the proliferation of options. Choice isn’t what’s missing in health care. It’s disingenuous at best to suggest that preserving choice needs to be an important priority compared to reducing waste, improving quality, and achieving universal coverage.

Pauly: Any proposal to do something about the uninsured is better than what we have. Progress on this matter has been stymied because advocates will only support their best plan and therefore block other reasonably good plans—because this is the irrational way politics works.

Probably the worst idea is to propose employer mandates, because the cost of those mandates will surely fall almost entirely on (future) worker wages, not capitalist profits. Yet many employers, confusedly thinking it is their money that goes to pay worker health-insurance premiums, succeed in stopping any serious attempt to reduce the number of uninsured adults.

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