Emergency Medical Treatment and Active Labor Act

The Emergency Medical Treatment and Active Labor Act (42 U.S.C. § 1395dd, EMTALA) is a United States Act of Congress passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act. It requires hospitals and ambulance services to provide care to anyone needing emergency treatment regardless of citizenship, legal status or ability to pay. There are no reimbursement provisions. As a result of the act, patients needing emergency treatment can be discharged only under their own informed consent or when their condition requires transfer to a hospital better equipped to administer the treatment.

EMTALA applies to "participating hospitals", i.e., those that accept payment from the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) under the Medicare program. However, in practical terms, EMTALA applies to virtually all hospitals in the U.S., with the exception of the Shriners Hospitals for Children, Indian Health Services, and military VA hospitals. The combined payments of Medicare and Medicaid, $602 billion in 2004,^[1] or roughly 44% of all medical expenditures in the U.S., make not participating in EMTALA impractical for nearly all hospitals. EMTALA's provisions apply to all patients, and not just to Medicare patients.^[2][3]

The cost of emergency care required by EMTALA is not directly covered by the federal government. Because of this, the law has been criticized by some as an unfunded mandate.^[4] Similarly, it has attracted controversy for its impacts on hospitals, and in particular, for its possible contributions to an emergency medical system that is "overburdened, underfunded and highly fragmented".^[5] More than half of all emergency room care in the U.S. now goes uncompensated. Hospitals write off such care as charity or bad debt for tax purposes. Increasing financial pressures on hospitals in the period since EMTALA's passage have caused consolidations and closures, so the number of emergency rooms is decreasing despite increasing demand for emergency care.^[6] There is also debate about the extent to which EMTALA has led to cost-shifting and higher rates for insured or paying hospital patients, thereby contributing to the high overall rate of medical inflation in the U.S.

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Mandated care

EMTALA was passed to combat the practice of "patient dumping", i.e., refusal to treat people because of inability to pay or insufficient insurance, or transferring or discharging emergency patients on the basis of high anticipated diagnosis and treatment costs. The law applies when an individual with a medical emergency "comes to the emergency department." The U.S. government defines an emergency department as "a specially equipped and staffed area of the hospital used a significant portion of the time for initial evaluation and treatment of outpatients for emergency medical conditions." This means, for example, that outpatient clinics not equipped to handle medical emergencies are not obligated under EMTALA and can simply refer patients to a nearby emergency department for care.^[7]

An emergency medical condition is defined as "a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs." For example, a pregnant woman with an emergency condition must be treated until delivery is complete, unless a transfer under the statute is appropriate.^[7]

Hospitals have three obligations under EMTALA:

1. Individuals requesting emergency care must receive a medical screening examination to determine whether an emergency medical condition (EMC) exists. Examination and treatment cannot be delayed to inquire about methods of payment or insurance coverage.

2. The emergency room must treat an individual with an EMC until the condition is resolved or stabilized. If the hospital does not have the capability to treat the condition, the hospital must make an "appropriate" transfer of the patient to another hospital with such capability.

3. Hospitals with specialized capabilities must accept such transfers.

EMTALA impacts

Improved health services for uninsured

The most significant effect is that, regardless of insurance status, everyone in need of urgent medical assistance is now legally guaranteed to receive it. Currently EMTALA only requires that hospitals stabilize the emergency. According to some analyses of the U.S. health care safety net, EMTALA is an incomplete and strained program.^[8][9]

Cost pressures on hospitals

According to the Centers for Medicare & Medicaid Services, 55% of U.S. emergency care now goes uncompensated.^[10] When medical bills go unpaid, health care providers must either shift the costs onto those who can pay — mainly those with health insurance or government programs — or go uncompensated. In the first decade of EMTALA, such cost-shifting amounted to a hidden tax levied by providers.^[11] For example, it has been estimated that this cost shifting amounted to $455 per individual or $1,186 per family in California each year.^[11]

However, because of the recent influence of managed care and other cost control initiatives by insurance companies, hospitals are less able to shift costs, and end up writing off more in uncompensated care. The amount of uncompensated care delivered by nonfederal community hospitals grew from $6.1 billion in 1983 to $40.7 billion in 2004, according to a 2004 report from the Kaiser Commission on Medicaid and the Uninsured,^[10] but it is unclear what percentage of this was emergency care and therefore attributable to EMTALA.

Financial pressures on hospitals in the 20 years since EMTALA's passage have caused them to consolidate and close facilities, contributing to emergency room overcrowding. According to the Institute of Medicine, between 1993 and 2003, emergency room visits in the U.S. grew by 26 percent, while in the same period, the number of emergency departments declined by 425.^[6] Ambulances are frequently diverted from overcrowded emergency departments to other hospitals that may be farther away. In 2003, ambulances were diverted over a half a million times.^[6]

Illegal immigrants

According to the Census Bureau, some 10.2 million of the nation's 47 million uninsured people are non-citizens.^[12] Access by illegal immigrants to U.S. health care through EMTALA remains a source of controversy. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 contains a provision for $250 million per year for fiscal years 2005-2008 in payments to eligible providers for emergency health services provided to undocumented aliens and other specified aliens.

According to a 2007 analysis by the Kaiser Commission on Medicaid and the Uninsured, uninsured low-income non-citizens were the least likely to use emergency rooms, with only about one in ten reporting a visit in the past year.^[13] Illegal immigrants most often rely on clinics and health centers, many of which are funded by charities as well as hospitals seeking to unburden their emergency rooms.^[13]

See also

Health care in the United States

Notes and references