“The statutory definition renders irrelevant any medical definition.”
—Judge, in the case of U.S. Dept.
of HHS vs. Dr. Burditt
In the early 1980’s, dreadful stories began to stack up about “patient dumping,” the practice of refusing treatment due to a patient’s lack of insurance or ability to pay. Some hospital emergency departments and physicians were refusing to treat patients in the throes of an emergency. Some only perfunctorily examined patients before transferring them (in medically unstable conditions) to public hospitals.
Congress responded to patient dumping in 1986 by enacting The Emergency Medical Treatment and Active Labor Act (EMTALA). While EMTALA did not address the causative issue of uncompensated care, it did guarantee universal emergency access for all. Through its financing powers under the Medicare Act, Congress required health care providers to assume fiscal responsibility for the emergency care of the indigent and the uninsured. Refusing treatment based on payment status could result in punitive fines, civil liability, or loss of participation in the Medicare and Medicaid programs.
Essentially, the law created a federal right to emergency care for anyone in the United States.
More than 30 years after its enactment, EMTALA now governs virtually every aspect of hospital-based emergency medicine, including triage, registration, the “medical screening examination” done by the hospital’s designated “qualified medical personnel” to determine if the individual has an emergency medical condition, and stabilizing treatment and transfer, which includes ED discharges. Unknown by many, EMTALA even controls the role of advanced practice providers in the emergency department or their participation in the on-call panel, as well as the duties of the nurses and obstetricians in the hospital’s labor and delivery department. Hospital owned and operated ground and air ambulances, urgent care centers, psychiatric intake centers, and freestanding emergency departments also may be subject to EMTALA to varying degrees.
But awareness of the law and an appreciation for its potential benefits spread very slowly at first. The Act was a mere four pages tucked into the “miscellaneous” section of the giant 2,200-plus page year-end omnibus bill.
The Centers for Medicare and Medicaid Services (CMS), the agency charged with drafting the EMTALA rules for hospitals and enforcing the law, took nearly 10 years to promulgate the initial regulations. Since that time, it has adjusted these regulations as well as published a number of explanatory EMTALA “Survey & Certification” memos and “Interpretive Guidelines.”
The law itself was also amended a few times over the years, most meaningfully in 1989, to require our country’s more capable hospitals to accept unstable patients in transfer from the emergency departments of less capable hospitals, if they had the capacity to stabilize the patient’s emergency condition. Previously, tertiary hospitals refused to accept ED transfers, even of dying patients, unless payment was assured in advance, branded as “reverse dumping.”