Two recent DK blogs I’ve commented on have been medically-related, and for both I was the one person who brought up EMTALA and how it affects our medical system (both positively and negatively). Because others seem not to know about it, I feel it’s a good idea to write up an article on the subject.
EMTALA is the Emergency Medical Treatment and Active Labor Act of 1986. It’s a federal law, part of the much-better known COBRA. It was enacted to protect patients from “dumping”. Prior to EMTALA, an ER hospital had no direct legal requirement to treat or evaluate patients who could not provide proof that they could pay. Some hospitals sent patients away on foot or in taxis (think Skid Row) without ever knowing if they’d die. Pregnant women could be left outside practically until their baby was crowning. EMTALA sought to control those actions, and ensure that anyone in need of emergency medical care — regardless of ability to pay — would be seen and treated!
EMTALA is fairly simple, but basically (aside from one flaw) well-written. Information on it can be found at Centers for Medicare and Medicaid Services. From their site, here are the most basic guidelines:
Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual's ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.
EMTALA also requires that patients agree to a transfer when possible, and that medical records accompany the patient. The law does provide protection to patients who need it. Better still, it has acted as a deterrent from anyone who might break it. Hospitals can be fined $50,000 for doing so, and if their acts are repeated or egregious they can lose their ability to receive funds from Medicare and Medicaid! Upon reading Kerry Eleveld’s recent "View from the left:…" here at DK, I was left asking why a Catholic ER (that receives public funds) wasn’t being held to EMTALA standards. After all, rather than treat or transport, they sent a pregnant woman home until she’d gone into labor! Even if a civil suit can’t successfully be pursued, that hospital should be investigated for breaking EMTALA guidelines.
At its heart, EMTALA is a very good, and human, piece of legislation. There’s only one problem with it, but it’s not minor. EMTALA is not only an example of an unfunded mandate, it’s the largest one ever written! The law requires providers (ERs and those who work in them) to do things that cost money, but it doesn’t provide a method of compensation. There’s no tax supporting the cost of the law. At the time EMTALA was enacted, hospital ERs and doctors took on the loss of payment when they were visited by the uninsured. Unfortunately, by telling the uninsured that they were protected from pursuit of payment if visiting an ER (rather than a critical care or doctor’s office), the law unintentionally drove more uninsured to ERs for problems not requiring emergency care. That resulted in crowded ERs, ER doctors and hospitals going unpaid more often, and even the closure of American ER hospitals.
ER doctors really have felt the sting of the law. There’s an excellent (however, out of date) article titled “The Impact of Unreimbursed Care on the Emergency Physician” from the American College of Emergency Physicians. According to that article:
In 2000, emergency physicians reported that 61% of their bad debt was related to EMTALA mandated care. For 27.7% of emergency physicians, EMTALA was the only source of bad debt.
Their fact sheet on EMTALA may be found here.
ERs covered by the law have faced serious debt — even closure. In fact, from 1991 to 2011, 30% of urban ERs closed! The areas most affected were our poorest areas, where fewer people had insurance and more debt was accrued by the ERs. Those closures had direct results in the form of deaths when people either couldn’t get to an ER or (due to crowding) be seen at one fast enough to be treated. The negative effects of not funding EMTALA are real, haven’t yet been fully corrected, and they affect any one of us who may need ER care. After all, emergency care moves quickly, and fewer ERs mean a greater distance between them and fewer doctors on call!
This is a part of why the PPACA, and health reform in general, is so very important. While it is far from a perfect law, through enacting the PPACA, a larger percentage of our population is insured, and that will directly help protect our remaining ERs. According to Gallup, as of 2014’s fourth quarter, the percentage of adults uninsured in the U.S. is 12.9%. That’s 4.2% down just since the requirement to be insured or pay a fine came into play, and the rate is lower in all recorded categories including low income. In a very short time, the PPACA has a had a very real effect on a problem many people don’t even know exists — or if they do, they don’t know why.
So, the next time you’re in a crowded ER, you can just remember EMTALA, and try to be patient with those trying to help you. They’re just as frustrated. The last twenty-five years have been a time of massive change in our health industry, and we’re only starting to head back in the right direction!