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According to the World Health Organization, health expenditure per capita in Japan was $2,244 in 2006, compared to $5,711 in the United States, and health expenditure as a percentage of GDP was 7.9% in Japan compared to 15.2% in the U.S¹. Healthcare in the U.S. is legendary for its high cost. These high costs have lead to frequent increases in the price of health insurance, making it unaffordable for many people. The Census Bureau reported that in 2006, 47 million Americans had no health insurance². What happens if someone in the U.S. who does not have health insurance needs emergency medical care? Let's look at a hypothetical example.

John is a 26 year-old man who works for a very small company. His company, like nearly half of all companies with less than ten employees, does not offer health insurance³. He does not qualify for Medicare (the government healthcare program for the elderly) because he is young, and he does not qualify for Medicaid (the government program for low-income and disabled people) because he earns $30,000 per year (in 2006, the federal poverty level was $20,000 for a family of four).

One day, John was riding his motorcycle to work. An oncoming car making a left-hand turn did not see him, and crashed into him. John was wearing a helmet, but was thrown from his motorcycle and knocked unconscious. Someone who saw the accident called 911, and an ambulance arrived quickly and took him to the nearest hospital emergency room. Due to the Emergency Medical Treatment and Active Labor Act (EMTALA), a law passed by the U.S. Congress in 1986, any patient that goes to a hospital emergency room requesting examination or treatment must be provided with an appropriate medical screening examination to determine if he is suffering from an emergency medical condition. If the patient is suffering from an emergency medical condition (a condition of sufficient severity that the absence of medical attention would result in placing the health of the injured in serious jeopardy), the hospital is obligated to treat him until he is stable or transfer him to another hospital in conformance with the law's directives. John was obviously in an emergency medical condition, and the law states that neither examination nor treatment may be delayed due to inability to pay. The law does not prohibit the hospital from asking whether the patient has health insurance or the ability to pay, but treatment cannot be delayed if the patient is in an emergency medical condition. This law was passed to prevent hospitals from rejecting patients, refusing to treat them, or transferring them to "charity hospitals" or "county hospitals" based on their ability to pay.

After John's condition stabilized, the hospital was no longer legally required to continue treating him. However, the hospital did not discharge him until appropriate, and a payment plan to cover some of the treatment costs was negotiated based on John's ability to pay. The remaining costs of treatment had to be absorbed by the hospital.

Discussion questions

1. Please summarize the article. What is the main point of the article?
2. Why has the cost of health insurance increased?
3. Explain the Japanese health insurance system.
4. Why doesn't John qualify for Medicaid or Medicare?
5. What is the EMTALA?
6. Why was the EMTALA passed?
7. Is there a similar law in Japan?
8. What is the meaning of the last sentence, "The remaining costs of treatment had to be absorbed by the hospital"?

1. World Health Organization, World Health Report, 2006.
2. Number of Uninsured Hits New High, Census Shows. Transcript of The News Hour Health, interview by Susan Dentzer. PBS. 28 August 2007. (accessed 23 April 2008)
3. The Uninsured in America. PBS. 6 April 2001. (accessed 23 April 2008)