Emergency Medical Treatment and Active Labor Act (EMTALA)

In 1986 Congress passed the Emergency Medical Treatment and Active Labor Act. Its purpose was to ensure that patients seeking treatment at hospital emergency rooms received appropriate care regardless of their ability to pay. The law applies to any hospital that has an emergency department and accepts reimbursement for Medicare patients. Patient care includes screenings to evaluate the patient's condition and, if it is life-threatening, appropriate treatment to stabilize the patient. In the case of a woman in labor, the law requires appropriate treatment until the baby is born.

If a patient needs treatment beyond what the hospital can provide, an appropriate transfer must be arranged; however, patients may not be transferred without their consent or the consent of the receiving hospital. In addition, the law prohibits discrimination against patients for reasons of race, creed, color, or national origin. Hospitals that do not comply are subject to fines.

Overview

EMTALA was passed to close gaps in previous laws intended to protect patients, beginning with the 1946 Hospital Survey and Construction Act, better known as the Hill-Burton Act. Hill-Burton was the first federal law requiring hospitals to provide emergency care and stabilization to patients. Hill-Burton did not define what constituted an emergency and hospitals that did not comply were not fined.

Before EMTALA, a practice called patient dumping had developed: instead of treating a non-paying patient, the staff discharged or transferred the patient to another hospital. In Chicago, 87 percent of transferred patients in the early 1980s had been moved because they had no insurance, even though nearly a quarter of them were not medically stable at the time. Congress enacted EMTALA in response to the need for emergency medical service regardless of insurance status or income. Even so, some hospitals continued patient dumping as recently as 2012.

Implementation

Each Medicare-certified hospital is required to ensure that its physicians, staff, and administration follow the practices mandated by EMTALA. The hospitals are required to provide examinations and care when necessary and to post signs informing individuals in the emergency department (ED) of their right to emergency care. Each ED is required to keep records of patients treated and logs of patients transferred, denied treatment, or treated and discharged. When patients are transferred to another facility, the hospital is required to keep records of its treatment, reason for the transfer, and the consent of the receiving hospital.

Over the years, the Centers for Medicare and Medicaid Services (CMS), which enforces EMTALA, interpreted the law in ways that expanded its coverage. It required hospitals to apply EMTALA standards when an inpatient developed a condition requiring emergency treatment. Facilities affected by the rule include hospital clinics, obstetrics wards, outpatient surgery facilities, and psychiatric hospitals.

Between 1995 and 2001 CMS cited about 200 hospitals for violations. Because the statute had only one permitted action—to end the hospital's agreement for providing Medicare—termination action began soon after a violation was verified. Hospitals were quick to correct deficiencies, however, and in the end only two permanently lost their Medicare agreements during that time. Hospitals, emergency departments, and ED physicians may be fined for violations. Malpractice insurance does not cover the penalties, so physicians are responsible for their fines.

In 2010 regulations released for the Affordable Care Act (ACA), also known as Obamacare, required health care companies to cover emergency medical care, including out-of-plan visits, without prior authorization. ACA used language similar to that in EMTALA but did not replace the older statute.

Controversies

The main controversy surrounding EMTALA is that it was presented and enforced, but care was not funded by the government. That made hospitals and physicians responsible for the emergency services they provided but for which they could not collect payment.

Uninsured people have increasingly depended upon hospitals to care for them when they are ill or injured, even in nonemergency situations. Wait times have increased and hospitals are burdened with further expenses. Some expenses are passed on to other patients through higher hospital fees and increases in insurance rates; some are subsidized by local governments and communities; others are absorbed by the institutions. Some 1,200 hospitals closed their EDs and some hospitals closed.

Defenders of the law argue that the trend toward increasing rates of ED use can be found as early as 1955, long before EMTALA was passed. Hospital and ED closures can be attributed to other factors, including a move toward efficiency that began in the 1960s. Further, evidence indicates that more than 65 percent of the increase in ED use is due to people who have insurance or Medicare coverage, but cannot find time for medical appointments during regular hours or need care on short notice.

Legacy and Current Status

The passage of EMTALA introduced a trend toward public health care in the United States. As uninsured people began to depend on EDs for health care, and health care expenditures rose, people became aware of EMTALA's cost to the public. With the passage of the ACA, many more people gained health coverage in 2014. By the end of its first year, more than seven million people had signed up for coverage through the insurance exchanges.

Bibliography

"Emergency Medical Treatment & Labor Act (EMTALA)." Centers for Medicare & Medicaid Services, CMS.gov, www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html. Accessed 27 Jan. 2015.

Harrison, Allen. "Emergency Medical Treatment and Active Labor Act (EMTALA)." Encyclopedia of Health Services Research. Edited by Ross M. Mullner, vol. 1, SAGE Publications, 2009, pp. 347–50.

Levey, Noam N. "Estimates lowered of how many people will sign up for Obamacare in 2015." Los Angeles Times, 10 Nov. 2014, www.latimes.com/nation/la-na-obamacare-enrollment-projections-20141110-story.html. Accessed 27 Jan. 2015.

Monico, Edward. "Is EMTALA That Bad?" Virtual Mentor, American Medical Association, 2010, virtualmentor.ama-assn.org/2010/06/hlaw1-1006.html. Accessed 27 Jan. 2015.

"Results in Brief." Report to Congressional Committees: EMTALA Implementation and Enforcement Issues, United States General Accounting Office, June 2001, tutorial5.net/e/emtala-implementation-and-enforcement-issues-w20979.html. Accessed 27 Jan.2015.

Rosenbaum, Sara. "GW Analysis Examines the Emergency Medical Treatment and Active Labor Act." GW Public Health, George Washington University, publichealth.gwu.edu/content/gw-analysis-examines-emergency-medical-treatment-and-active-labor-act. Accessed 27 Jan. 2015.

Rosenbaum, Sara, Lara Cartwright-Smith, Joel Hirsch, and Philip S. Mehler. "Case Studies at Denver Health: 'Patient Dumping' in the Emergency Department despite EMTALA, the Law that Banned It." National Center for Biotechnology Information, US National Library of Medicine, 2012, www.ncbi.nlm.nih.gov/pubmed/22869653. Accessed 27 Jan. 2015.

Zibulewsky, Joseph. "The Emergency Medical Treatment and Active Labor Act (EMTALA): What It Is and What It Means for Physicians." Baylor University Medical Center Proceedings, Baylor University Medical Center, 2001, www.ncbi.nlm.nih.gov/pmc/articles/PMC1305897/. Accessed 27 Jan. 2015.