Extending the Emergency Room Rules to the Entire Health Care System

Hospitals run by government used to be the place where people who could not afford other health care were supposed to go for treatment. In 1986, EMTALA, the Emergency Medical Treatment and Active Labor Act, turned this system on its head. It required hospitals to provide the same kind of emergency treatment to everyone, whether or not an individual had made provisions for payment.

The problems created by EMTALA are severe. They illustrate a crucial problem in health care policy: can a health care system be stable if it requires that people who do not pay be treated in the same facilities and to the same standard as those who do?

After all, if free care is available to all, who will pay? And if no one will pay, how will care be made available to anyone?

The stability question is especially important in view of the fact that ObamaCare would expand EMTALA’s equal treatment provision to the entire health care system.

EMTALA has raised costs by imposing very expensive requirements on hospitals that accept Medicare patients. They must screen anyone in a 250 yard zone of a “main building” who would appear, to a reasonably prudent person, to be in need of medical care. If a patient is in active labor, or has a condition of sufficient severity such that the absence of immediate medical attention could reasonably be expected to put the health of the individual in serious jeopardy, the hospital must provide treatment or arrange for transfer to a hospital that can provide treatment. All kinds of records are required.

EMTALA has raised costs by spawning extensive litigation. Lawyers debate such fine points as whether specialists who refuse to be on-call for hospitals are in violation of the Act if they respond to emergencies for their existing patients. They debate whether a hospital is still liable under EMTALA if a person presents himself for treatment but that treatment is not authorized by the managed care plan that insures him and the plan requires preauthorization before rendering emergency treatment. They debate how thorough the screening exam has to be, and under what conditions hospitals can turn away ambulances once radio contact is made.

EMTALA has reduced the quality of care available to the entire population by bankrupting emergency rooms, particularly in areas with high populations of illegal aliens. It has made trauma care transfer more difficult as hospitals and physicians seek to protect themselves from the losses represented by non-paying patients. It has even forced hospitals to provide dialysis to illegal aliens. In August, 2009, Las Vegas University Medical Center was reportedly spending about $2 million a month providing emergency dialysis services to 80 illegal immigrants.

WhiteCoat’s Call Room, the blog section of Emergency Physicians Monthly, has a sobering summary of EMTALA’s lethal effects on US emergency medicine. Given that the federal government threatened to withdraw the University of Chicago’s Medicare funding over an EMTALA violation, WhiteCoat’s Call Room wonders, in view of the mess Medicare and EMTALA have created, what the University of Chicago hospital really would have to lose if the feds were to take away its Medicare funding over EMTALA violations.

The biggest problem? Medicare funds resident positions.

As usual, the government that makes the rules has chosen not to live under them. Military hospitals, VA hospitals, and Indian Health Service hospitals are exempt from EMTALA requirements.

Comments (5)

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  1. John R. Graham says:

    EMTALA was supposed to stop “patient dumping”. Instead, it made it worse. Judges are now micro-managing care for mentally ill homeless people in Los Angeles (http://tinyurl.com/ckpz95). A source told me that certain of these folks walk into LA ERs and demand treatment, or “I’ll call the sheriff”. After they get the drugs they demand, they leave and the TV cameras catch them walking shoeless in the streets.

    The hospitals cannot get it right in this system. Their response? Lobby for more government money. Incredible.

  2. Dennis G. Vollmer says:

    Mr. Graham is correct about EMTALA facilitating “patient dumping”: hospitals and physicians can call to transfer a patient to a
    “higher level of care”. By law, the sending physician, not the receiving one–who ostensibly has more expertise, hence the justification for the transfer–is the person who gets to label the transfer as an emergency and medically necessary. If the receiving physician balks or refuses he/she may be personally liable for thousands of dollars in fines. Hospitals refusing transfers are also at risk. As a result of EMTALA, large tertiary centers (county hospitals, university medical centers and Level I trauma centers etc.)are especially vulnerable to “cherry picked” transfers of patients from Drs. & Hospitals who allegedly cannot provide the appropriate level of care.
    EMTALA has far more unintended and negative consequences than positive results…what does that imply for the Baucus bill?

  3. Joe S. says:

    Very good post. This is a very insightful way of thinking about the health care system.

  4. Larry C. says:

    Imagine what the health care system would look like if we had not completely suppressed the price system.

  5. Ken says:

    Larry, whatever it would look like, we are going to get even farther from it with ObamaCare.