For perhaps as many as one in five Georgia adults, the only door open for the medical care they need is through a hospital emergency room.

Now, that door may be slamming shut as well. With overcrowded conditions and too many patients who can't pay their bills, Georgia hospitals have begun restricting access to emergency services for the uninsured.

The new ER policies are legal if not necessarily wise. Federal law requires only that hospitals conduct a medical screening on incoming ER patients — insured and uninsured — and treat those whose conditions are serious and in need of immediate care. It does not require ERs to treat uninsured patients who do not need urgent care.

Under the new policy at several large metro Atlanta hospitals, emergency room patients who are screened and found not in need of immediate medical care will be denied treatment unless they pay a deposit or co-payment on insurance. Those unable to pay are directed elsewhere to get the care they need.

And too often, there is no "elsewhere" in Georgia. The state's political leaders have never really focused on the issue of primary-care access or on programs to provide care to the one in five adults not covered by insurance.

In the last General Assembly, a statewide coalition of free clinics asked for a one-time grant of $2 million to expand services and hours, but the Legislature declined to provide the funds. Instead, the Legislature approved $40 million in tax breaks over the next five years for health insurance underwriters to offer low-cost plans with high deductibles.

As a result of such decisions, even those county health departments that do provide some basic primary-care services — blood pressure screenings, diabetes monitoring, immunizations and the like — are chronically underfunded. In some rural Georgia counties, no primary-care physician is available. As a result, many patients denied initial care will simply go untreated and be back in the hospital later needing more costly in-patient care.

Even in large urban areas such as Atlanta, with more than two dozen government-subsidized clinics and health centers in Fulton and DeKalb counties alone, patients flood Grady Memorial Hospital's ER for treatment of minor illnesses or chronic conditions. That's in part because the local clinics that might otherwise take such patients are closed on nights and weekends.

Still, ER physicians and hospital administrators where the new screening process has been adopted insist that their own financial concerns haven't been the primary motivation.

"We had to do something to relieve our capacity," said Dr. Kent Cohen, chief of the emergency department at Gwinnett Medical Center. "We're medically triaging anyway. This was the next logical step."

According to Cohen, some ER patients were becoming routine visitors seeking relief from chronic pain or to have prescriptions refilled.

"To some degree we are hoping to change a behavior practice with these patients," he said. "We created some of this overload ourselves by just treating them and billing them later."

Cheryl Christian, director of the Good News Clinics in Gainesville, a 15-year-old nonprofit charity that treats about 800 patients a month for free or on a sliding-payment scale, said her staff has worked closely with Northeast Georgia Medical Center to reduce the impact of the hospital's new ER policy.

"We've had a good relationship with the hospital for years," she said. The ER staff routinely called the clinic to make arrangements for follow-up care for some patients. Additionally, the Gainesville hospital has two "quick care" centers open nights and weekends that treat low-income and uninsured patients, she said. Her clinic is trying to secure a $30,000 grant to establish an electronic patient records system that would be shared with the hospital to better coordinate care.

Unfortunately, most Georgia communities haven't come close to what Gainesville is doing. Many primary-care physicians refuse to accept Medicaid or PeachCare patients. Some hospitals are reluctant to open urgent-care centers for fear of alienating the primary-care physicians they rely on for admissions. County health departments are limited in the services they can provide.

For all those reasons and more, hospitals must proceed cautiously in adopting new ER screening policies. In the best of all worlds, a coordinated, easily accessible network of primary-care services would be pulling patients away from hospital ERs. It shouldn't be necessary to push them out the door.

— Mike King, for the editorial board