The following views and opinions are based on my own understanding of this bill and our healthcare system; they are my own and do not represent the views or opinions of any organization with which I may be affiliated. Any response to these views and opinions should be solely directed at me, and not at any representative of any organization with which I might be affiliated.

I'd like to start by acknowledging that there is significant amounts of waste in Emergency Departments. However, from my experience and understanding, this is a result of corporatized medicine and of the litigiously defensive medicine that many physicians feel forced to practice. 

This waste (unnecessary tests, ridiculous prices for medical supplies and drugs, top-down policies requiring certain levels of coding for different charts in some facilities) is symptomatic of a deeper problem within our medical system, and is ABSOLUTELY NOT going to be fixed by this legislation. 

This legislation will only make the problem worse, as hospitals find some way to cut corners in order to make up for the losses from seeing Medicaid patients, some of whom would have been absolutely excellent candidates for emergency room care. 

While it may not be entirely obvious how this legislation will hurt patients, since as I understand they will not be billed for the difference in what the hospital would charge and what Medicaid will reimburse, I'll try to illustrate it as best as I can, using just one example of a diagnosis on this list of diagnoses that will be down-coded.

On this list is Type 1 diabetes mellitus, diabetic ketoacidosis without coma. 

Any medical professional will tell you that diabetic ketoacidosis is absolutely a medical emergency. Patients come in very, very sick LONG before they're truly in a coma. They're lethargic, shaking, cognitively impaired, pale, and anyone who looks at them could tell that something is terribly wrong. Not only is this condition horribly dangerous in and of itself, it also predisposes the patient to many other problems, including deadly infections. Many of these patients are children and teenagers, who for any number of reasons (couldn't afford it, they were with the non-custodial parent, or they just were out of the house) didn't have access to their insulin at the time (or even DID have their insulin, but their prescribed dosage was wrong) and present with their parents or family members because well, what would you do if that were your child, brother, cousin, or friend? You'd likely take them to the emergency room, which would be an entirely appropriate decision, because for the most part these patients need to be admitted to the ICU for an insulin drip. However, even before this patient is admitted, they require a great amount of care: meds, IVs, consults, and a lot of time spent on them from their physician, nurses, and techs. Time and resources that will cost MUCH more than the ~$15 that the hospital will be able to bill Medicaid for. 

You can see how this would be punishing the hospital for doing nothing wrong, and this is only one scenario- one single diagnosis on the list of ~800 diagnoses, probably all of which I could write a similar exposition. And where this hospital's bottom line suffers, corners and costs will be cut. This might manifest as decreased salaries for employees, employee layoffs, cheaper equipment, rationing and reuse of supplies, etc. Another notable effect: ER physicians, who are often independent contractors, will not want to practice in places with large amounts of Medicaid patients because they'll make less money and work in an even more heavily strained department than before. And rest assured, any nurses, techs, physicians, and other employees who don't leave and aren't laid off, will face much higher rates of burnout as they experience poorer working conditions, deliver lower quality care, and experience greater administrative oversight and superintendence. 

These disenfranchised workers WILL provide lower quality, slower care, and their patients WILL suffer because of it. 

And the patients who will suffer the most will be those patients who live in places where there is more Medicaid utilization, places with lower income, rural places, and places which house already vulnerable populations which already have worse healthcare outcomes. 

We DO need reform to our medical system, and there is room for improvement in terms of money-saving efforts in the emergency room, but this is not it.

Things that I believe would work better than this bill:

-Tort reform like they have in Texas, so that physicians don't have to practice so litigiously defensive, and can provide more efficient care.

-limiting the amount of money that hospitals can be charged for drugs and medical   supplies, so that a single band aid doesn't cost $7. And to further that, complete transparency about where every dollar from a hospital bill is going. 

- Ensuring that patients covered under medicaid are able to access primary and preventive care, as well as urgent cares without copay, to reduce the load on emergency departments and improve their long-term health outcomes.

-Creating a safe place way for physicians to get involved in the conversation of increasing care efficiency without the fear of administrative backlash. 

-Either incentivize or force more (all?) physicians to participate in Medicaid. This would increase Medicaid users' abilities to access appropriate healthcare, decrease wait times for appointments for primary, preventive, and specialist care, and further reduce ER usage.

-Wait and see. It's possible that as Virginia's newly expanded Medicaid program matures, patients who were accustomed to frequently visiting the ER will become more accustomed to first seeking out primary/preventive care in order to treat things that are truly non-emergent.

Thank you for taking the time to read this. Please make the right decision for our patients.