On November 7, 2007, Tom DeLay, the former exterminator who later became Speaker of the House of Representatives and even later than that an unsuccessful contestant on Dancing with the Stars, famously said, “No American is denied health care.” In the subsequent six years this claim has been repeated by many who are opposed to the Affordable Care Act. Mitt Romney voiced the same claim during his presidential campaign, and Governor Rick Perry of Texas has often said it, although he usually restricts his references to his altruistic constituents in Texas.

These men are presumably talking about the emergency rooms of hospitals, which by law are not allowed to deny emergency care to anyone seeking it. If someone has had a heart attack or has broken a leg, the doctors in the emergency rooms will, of course, treat them even if the patients lack insurance.

The most common argument in response to this claim of universal coverage is that relying on the emergency rooms is one of the reasons that health care in the United States is so expensive compared to the rest of the civilized world. It is much more costly to deal with medical issues in this way. The extra cost is just passed on to the people who have insurance.

This argument is true enough, or at least I have never heard a cogent response to it. If I had to argue against DeLay’s proposition, I would employ the cost argument, but by no means would it be my first answer. In fact, I would only mention it if I had time and an accurate idea of how much the additional expense was. After all, people who have insurance now are not too likely to be upset about how much they have to pay. People who do not have insurance may actually be glad to hear that someone else will be footing their bills. I realize that there is a third group of people who are facing financial ruin and bankruptcy because of high health care costs, but they are seldom the focus of the argument. The primary problem with the cost argument is that it is too nebulous for too many people. There are other arguments that are are much more concrete.

The first response should be that the answer is both factually incorrect and indicative of one of the primary problems with the American health care system. This is because DeLay used the phrase “health care” when what he meant was “emergency health care.” The difference is huge.

Consider three cases. The first involves someone who has a chronic condition such as hypertension that can be treated with prescription drugs. To begin with, that individual needs a diagnosis of his problem, something that no emergency room physician will be willing to do when he has gunshot or stabbing victims holding their guts in their hands in the waiting room. If the problem has been diagnosed, the patient then needs to obtain the medication, which is not cheap. The emergency room is not in that business either, and I have never heard of a pharmacy that provided free drugs. So, perhaps this individual is not “denied” care in the sense that someone tells him that he must succumb to his condition, but in many cases he/she is not likely to receive the care needed to live a healthy life. The fact that death from the condition is unlikely to occur on any given day is a distinction without a difference.

The second situation concerns the high percentage of health care that is not provided at the emergency room at all. For example, anything that has to do with the eyes or the teeth is subject to the free market. The first thing that you must establish with anyone in the dental or optical fields is how you plan to pay. If you cannot pay, you will almost certainly be denied care. It may be possible for poor people with no insurance to get some kind of care in these areas, but it is rare.

The last case is elective surgery. It may be surprising to discover that all of the following are considered “elective surgery:”

• hernia surgery (600,000 performed per year);
• cataract surgery (3,000,000 per year);
• mastectomies (60,000 per year);
• knee replacements (719,000 per year);
• hip replacements (332,000 per year);
• installation of pacemakers (200,000 per year);
• rotator cuff surgery (600,000 per year).

I doubt that anyone would argue that any of the above should be included in the broad class of “health care,” but none of them will be provided gratis by hospitals. If you want the procedure, you or your insurance company must pay.

This was recently brought home to me by my wife’s recent double knee-replacement. We have good insurance, and everything went fine. The surgery may have been elective, but the problem that impelled her to do it was severe. Her arthritis was serious enough that, even though she took as many pain relievers as she dared, she avoided stairs entirely and never walked any farther than she needed to to get to the next chair.

What if we had not had insurance? We would have needed to foot the bills ourselves. I haven’t seen them yet, but I dare say that they would have to cart me to the emergency room in an ambulance shortly after I opened that first envelope if that were the case. At least the emergency room would probably not deny me care.