Oregon lawmakers recently proposed a bill that would radically overhaul the way in which emergency room staff care for homeless patients. The state is already compliant with federal law under the Emergency Medical Treatment and Active Labor Act, whereby anyone presenting in an ER with an emergent condition must receive treatment but discharge timing is left to the care teams’ discretion. State Senate Bill 1076, however, contained provisions asking for ERs to release people identifying as homeless only during daytime hours from October to April, and set up discharge planning that included transportation, food and clothing, signing up for health insurance, and mental-health services follow-up. Though Oregon has a big homeless problem, the bill ignored harsh trade-offs for ERs that could make an already bad situation worse. The legislature has delayed the proposal, sending it to a task force for review, but it’s worth considering its provisions in detail.
Oregon suffers not only from the burden of homelessness, but from health-care staffing and bed-shortage issues. High employee turnover means frequent training of new staff, and slower workflows and discharges. Along with enforced daytime releases for the homeless and the burden of having to offer proper clothing and health-insurance enrollment, the staffing problem means less beds and attention are available for the critically ill.
The proposal ignored possible safety issues created by prolonged ER visits for homeless patients. A 2016 study showed that Oregonians have an exceptionally high rate of mental illness, particularly among the homeless; a more recent report found that Oregon shouldered the second-to-worst burden of mental illness and access to care. Patients suffering from chronic mental issues with acute physical illness—the former likely not receiving adequate treatment—can be disruptive or threatening in emergency settings. Of course, not all homeless people pose such a threat, but policies that make it tougher for beleaguered staff to discharge any potentially dangerous patient could court disaster.
Enforcing hospital stays for mentally ill homeless people can be good policy. Cognitively impaired or drug-addicted patients no longer have complete control of their decision-making. A mental-health hospital visit that transitions the patient to a stable psychiatric drug regimen may be one of the only ways to help some people return to a functional existence. Portland’s mayor, Ted Wheeler, advocated such a policy late last year.
But emergency rooms are not an effective means to sustain these longer-term efforts. Drug-rehabilitation and mental-health service facilities are more suitable. Partnerships between shelters and these services (which, to some degree, is already happening), with enforced treatment compliance, would be a step in the right direction. Instead, Oregon has done the opposite: decriminalizing drug use via Measure 110 without a process for enforcing drug rehabilitation follow-up.
The testimonies surrounding SB 1076 were revealing, if only for the disjunction between the bill’s ideological advocates and the people who would actually be affected by its passage. With few exceptions, available testimonies from ER and other medical staff staunchly opposed the bill. A rural ER physician wrote, “Oregon ERs are suffering from unprecedented ER overcrowding and boarding. Multiple hospitals have created overflow areas in spaces like cafeterias. . . . Our overburdened healthcare system simply doesn’t have the resources, room or staff to become shelter space during the winter.” Another ER physician wrote that “we are already struggling more than ever to keep up with the demands of our department. We simply do not have the capacity to do the things this bill proposes, and the health of our community will suffer as a consequence.” Administrator reports from multiple health systems, as well as Oregon’s low bed capacity per capita, reinforce these testimonies.
Yet community-action groups, health-equity advocates, and local volunteers largely backed the bill. They cited the need for better documentation of homeless persons’ medical history, improved coordination with local shelters, and avoiding deaths from wintertime cold—all reasonable concerns. Missing, though, was a recognition of current health-care constraints. A supportive Portland resident wrote that the “question at hand is not whether SB 1076 places unfair burdens on business activity, it’s whether SB 1076 will save peoples’ lives. Undeniably, the answer is yes!” In an unwittingly contradictory statement, a community-engagement officer wrote, “I hope that the committee will join me and many others in advocating for access to healthcare that is of good quality and accessible for all Oregonians. SB 1076 will seek to create policy that will better inform decisions when dealing with the unique livelihoods of patients experiencing homelessness.” Finally, a community-action executive offered the farcical assurance that “nothing in this bill . . . prevents hospitals from discharging patients as they please,” adding, “It’s also not going to be doctors and nurses doing this work. It will be care managers and case coordinators.” One wonders if this person read the bill in question or has ever been inside an ER.
If the bill’s advocates are not swayed by the testimonies of the emergency room staff that would be carrying out their wishes, they should consider, for comparison, California’s Senate Bill 1152. Enacted in 2019, it contains striking similarities to Oregon’s bill, yet no evidence exists to suggest that it has had any radical effect on homeless medical outcomes. One ER that was highly complaint with the bill found an increase in patients identifying as homeless (probably because they were asked about housing status more often), but nothing concrete beyond that. An additional evaluation found significant barriers to implementation consistent with oppositional testimony for the Oregon bill. “ED staff began to hear from patients that they were seeking care in the ED to obtain a meal or clothing,” its authors note. “Some patients reported to the providers that public transit workers told them to get off the bus at the ED if they wanted a place to sleep. . . . providers in the ED were left to fill the gaps when resources were unavailable.”
Emergency staff already ensure the stability of their patients, regardless of their ability to pay, as mandated under federal law. But this mandate has not historically applied to patients receiving food, clothing, behavioral health follow-up, vaccinations, and transportation, as Oregon’s bill would have required. Thankfully, lawmakers were receptive to the high volume of opposed testimonies and tabled the bill, pending the task force’s recommendations. Understanding why the initial proposal was so irrational remains important for future amendments.
The proposed bill included several good measures, such as enforcing updated contact information for all local shelters and making available training protocols for staff regarding homeless discharge plans. But Oregon lawmakers and community groups should understand that not every aspect of health care can be changed as they see fit.
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