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Comment by drak0n1c | Hacker News Reader

Hopefully they have a plan for a better mechanism to discourage frivolous ambulance calls and ER visits. Those resources are overloaded by casual abuse resulting in higher costs and wait times for those who truly need emergency care. Without an alternate disincentive that problem will only get worse with this change.

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I think having cost be the anti-abuse disincentive is the worst of all worlds -- cost is clearly not an effective deterrent of abuse given our current state of overutilization. It IS a deterrent in the case of avoidance, or arguably worse, a punishment in the case of attendance, for those who DO need it.

I'm a volunteer EMT and my org runs free clinics staffed by doctors+nurses at major events to handle emergencies. It's truly free -- we don't bill anyone, insurance included -- but I've had people in dire medical distress avoid coming with me because they're afraid of the bill. Hell, I've had people in the midst of full blown psychosis and their single lucid thought is to yell "DON'T TAKE ME I CAN'T AFFORD AN AMBULANCE BILL" and my heart breaks.

The American healthcare system is continuously setting and raising the high water mark for how deeply in failure the system is, but bankrupting people is not the holistic solution we need, in my opinion.

People make "frivolous" visits because they are legally required to stabilize patients. This is what passes for a social safety net in the US, and we have failed in developing anything better for those not covered by Medicaid.

People often make frivolous ambulance calls if they have trouble getting to the hospital or PCP.

There are often reasons, and we would have a more reliable, more humane system if we focused on cheaper care over penalizing the poor. Providing only guaranteed emergency care is absurdly expensive.

IIRC this gap exists in states (guess which!) that opted out of Medicaid expansion. So a solution is available if states take it.

This is a nationwide problem, it's not restricted to states that opted out of expansion. Federal Law requires that ERs treat anyone who comes in, regardless of ability to pay. Until the poor are able to access other resources like urgent care clinics, this is going to continue to be a problem.

Well the poor have access to Medicaid, and if they make more than the Medicaid maximum, subsidized ACA plans. In neither of those cases should you have to go to the ER for non-emergency care.

I believe the biggest problem is the coverage gap I mentioned, where 10 states for political reasons have not opted into the higher Medicaid maximums which creates a gap between Medicaid and ACA. This is dumb as hell.

I am having trouble figuring out where exactly the other coverage gaps are or how big they are. I'm sure there are some.

I would definitely support a switch to single payer to smooth out this mess.

To be fair, someone making $25,000 a year will have almost as much trouble paying out of pocket for an MRI as someone making $15,000. But the former won't qualify for Medicaid and the heavily-discounted health insurance won't do much to help with their first $10,000 of medical debt.

Good but worthless advice to the majority living without any savings: don't get sick and don't get injured. Can anyone blame them if they avoid expensive testing? Medicaid is a great bandage, but the US needs a better system.

That’s not the only reason. A (well known, national) turkey company considered building an on-site clinic just because so many of their Somali immigrant employees were going to the ER over frivolous things.

They have insurance. Of course, that’s certainly not limited to immigrants. I think anyone who has spent any time in an ER waiting room has thought “you’re in here for that?” I’ve heard plenty of anecdotes from doctors about people with insurance or no going to the ER for colds.

As an aside, even though the Somali population is just a small fraction of the total population in the area they seem to be about half of the people in the (non-ER) clinic. I’ve always wondered what was up with that.

> Without an alternate disincentive that problem will only get worse with this change.

The ER is the only place that people can get care when they are uninsured and not wealthy. Your family doc will say no. Immediate care will say no. But the ER can't say no. People in this situation are mostly upper lower class and lower middle class who have lost their jobs or fell into an administrative crack. If you are poor, you will qualify for something to cover the cost. It's terrifying and is probably one of the best arguments for reform there is.

> Without an alternate disincentive

The problem isn’t (IMO) an insufficient disincentive — it’s lack of a credible alternative. I have perfectly fine insurance, and getting an appointment for a merely slightly urgent issue is a pain in the rear. If I’m traveling, it’s almost impossible.

COVID made this all worse. Last year, I saw a resort clinic (well staffed by assorted medical professionals) turning away anyone with any symptoms of illness and sending them straight to the ER (10 miles or so away through the snow) because they “might have COVID”.

This is yet another problem that could, hypothetically, be addressed by centralizing / single-payering the system.

With one administrator having access to all that data, it would be straightforward to see where ERs and ambulances are being over-used for non-emergencies and address that in the community with both more funding for preventative care and intervention / education initiatives to get people using preventative care.

Imagine thinking a visit to the ER was "frivolous". As if significant numbers of people would subject themselves to an ER for fun. Imagine looking at a situation in which significant numbers of people have no other access to care but ERs and think, "Those freeloaders!" What sort of twisted mirror-world ethics are these? How does one get to the point where they could type this, read it over, and hit send? You'd think the shame alone would be lethal.

> Hopefully they have a plan for a better mechanism to discourage frivolous ambulance calls and ER visits. Those resources are overloaded by casual abuse resulting in higher costs and wait times for those who truly need emergency care.

Do you have any statistics regarding this? I'm sure there are some people that use the services unnecessarily, but is it really enough that it's a significant issue?

The hilarious thing is that the emergency room mandate has long been used as an excuse for opposing universal coverage. People used to say thing like "nobody in America is dying because they can't go to the hospital," as if that was bar.

Now it apparently serves an excuse for claiming ER should cost more. Truly a universal policy, I guess.

Urgent care facilities ought to be offloading ERs in most cases. Something as trivial as needing some stitches is an ER visit instead. I think this kind of ends up trivializing ER.

That and drug seeking...

I've had to use urgent care a half dozen times over the past 20 years. In all but one case, they sent me to the ER because they didn't want to be responsible for my care outcomes. None of them were really "emergencies".

I'm lucky if there is an actual MD on premises at my in-network urgent care.

Our local urgent care closes at 7:30pm on weekdays and 4pm on weekends. That doesn’t help.

It helps for half the day.

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