The holes in EMTALA

by The Incidental Economist on August 15, 2012 · 3 comments

In 1986, the Emergency Medical Treatment and Labor Act (EMTALA) was passed in order to provide protection to people in emergent health situations. Under the law, people cannot be turned away without care if they present to an emergency room in labor or with some condition that could result in serious injury or death without immediate intervention. This protection is what allows many to believe that we have “universal coverage” in the United States, as everyone has this protection.

Of course, the measures covered by EMTALA are rather narrow. There are plenty of health services that aren’t covered by the law. Moreover, they aren’t free. The care received, even in emergent situation, can easily cause financial hardship and even bankrupt a family.

The potential pitfalls of EMTALA are significant. First of all, only people who actually go to the emergency department are covered. Moreover, the obligations of hospitals are only to screen and stabilize. Once that’s occurred, the emergency department can legally discharge patients, even if their conditions are far from cured. In other words, they can make sure the abdominal pain from your colon cancer isn’t causing a life threatening blockage, but then send you home with no follow-up cancer care at all. Quirks in rules can allow for emergency departments to divert ambulances if they have a certain diversionary status. Other loopholes exclude inpatients from the same protections as people walking into an ED off the street. A final rule in 2003 also softened the requirements for the availability of on-call specialists. Most importantly, though, EMTALA lacks sufficient mechanisms for monitoring and enforcing the provisions that it sets forth.

This is all detailed in a recent paper in Health Affairs entitled, “Case Studies At Denver Health: ‘Patient Dumping’ In The Emergency Department Despite EMTALA, The Law That Banned It”:

EMTALA is a law whose reach is limited and whose application has been relaxed as a result of revised regulations issued in 2003. The Department of Health and Human Services, which oversees the enforcement of EMTALA, maintains no ongoing transparent and public reporting system for potential violations. Furthermore, the department’s internal enforcement system, which reports on case resolutions, has been criticized by the Government Accountability Office and the department’s own inspector general as inconsistent and weak. Although EMTALA empowers both patients and hospitals that believe they have experienced violations of the law to file lawsuits on that basis, in addition to raising claims with government regulators, financial and practical hurdles limit private enforcement of EMTALA through lawsuits.

What makes the manuscript worth a read are the specific examples of patients whose care were compromised, even under the “protection” of EMTALA. In the last twenty years, Denver Health has experienced a more than four-fold growth of uncompensated care. Much of this seems to have been the result of patient dumping by other local facilities.

The stories are varied. One involves a woman with acute cholecystitis released from a different ED and told to have a procedure done later at Denver Health. Another details a woman with multiple sclerosis and epilepsy whose ambulance ignored closer private facilities to bring her to Denver Health. Another story describes a woman transferred to Denver Health with an abscess in her throat because a specialist in another facility wouldn’t see her because she was uninsured.

It’s not clear that any of these examples actually broke the law. We will likely never know, though, because it’s so difficult to crack down on these cases and investigate them. We need a better system for reporting potential violations of the EMTALA. We also need hospitals to know that reporting them isn’t a meaningless gesture. In any case, it is clear that EMTALA is not enough to serve as the safety net we assume it to be. Many people fall through the cracks.

Even better would be a system that avoids the problem in the first place. If everyone in the United States had insurance, then hospitals wouldn’t need to worry about uncompensated care at all. As long as that isn’t the case, we need to find a way at least to ensure that people at serious risk for injury from emergent conditions aren’t placed at risk, while also not burdening systems willing to provide uncompensated care from collapsing under financial hardship.

Dr. Aaron E. Carroll is an associate professor and vice chair of health policy and outcomes research in the department of pediatrics at the Indiana University School of Medicine. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll.

As part of our ongoing effort to raise awareness of health services research and increase its application in policy and practice, AcademyHealth has partnered with Austin Frakt, Ph.D., and Aaron Carroll, M.D., M.S., to contribute posts on the subjects of health care costs, delivery system transformation, and public and population health – areas AcademyHealth has identified as a priority in the current policy environment. As regular contributors, they’ll be discussing current events with an eye toward how new and existing research informs the issues.

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Isaac July 13, 2014 at 3:11 pm

Well both parties benefit financially from the political fighting that results from poorly written laws. So, they really aren’t motivated to fix this problem and is also the reason why we will never have universal anything.

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