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Another perspective - June 7, 2014

The Emergency Medical Treatment and Active Labor Act was passed in 1986 and signed into law by President Ronald Reagan. It was a legislative response to a nationwide problem of patient dumping by hospitals.

Patient dumping is defined as “the denial of or limitation in the provision of medical services to a patient for economic reasons and the referral of that patient elsewhere.”

Physicians from Cook County Hospital in Chicago dealt with the problem and undertook a study of its effects on their hospital and patients. The physicians discovered that the majority of transfers from other hospitals to Cook County involved patients who were minorities and unemployed. The reason given for the transfers was lack of insurance in 87 percent of the cases with only 6 percent of patients giving written consent for their transfer. Those patients who were transferred were twice as likely to die as those treated at the transferring hospitals and 24 percent of the patients were considered to have been transferred in an unstable condition.

This study concluded that the transfers were done primarily for financial reasons and that patient dumping delayed care and jeopardized the patient’s health. The practice of patient dumping was a growing problem especially in large cities with public hospitals. In Dallas, such transfers increased from 70 per month in 1982 to more than 200 per month in 1983.

“Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay,” the Centers for Medicare and Medicaid Services explained in its summary of the law. “Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC) including active labor, regardless of an individual’s ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.”

Former Republican Presidential candidate Mitt Romney has expressed conflicting views on the EMTALA. In 2008, he used the term “free riding” to describe emergency room visits by the uninsured: “If somebody could afford insurance, they should either buy the insurance or pay their own way. They don’t have to buy insurance if they don’t want to, but pay their own way. But they shouldn’t be allowed to just show up at the hospital and say, somebody else should pay for me.” By 2012, Romney had come full circle on the subject. He was actually offering the EMTALA as an alternative to Obamacare. This is a segment of his interview on 60 Minutes with Scott Pelley:

Pelley: Does the government have a responsibility to provide health care to the 50 million Americans who don’t have it today?

Romney: Well, we do provide care for people who don’t have insurance, people - we - if someone has a heart attack, they don’t sit in their apartment and die. We pick them up in an ambulance and take them to a hospital, and give them care. And different states have different ways of providing that care.

Pelley: That’s the most expensive way to do it…In an emergency room.

Romney: “Different, again, different states have different ways of doing that. Some provide that care through clinics. Some provide the care through emergency rooms. In my state, we found a solution that worked for my state. But I wouldn’t take what we did in Massachusetts and say to Texas, “You’ve got to take the Massachusetts model.”

While the EMTALA would cover a person giving child birth or having a heart attack, Romney failed to mention the shortcomings of that law. It does not cover treatment or medication for chronic conditions like diabetes, asthma or breast cancer.

Dr. Arthur Kellerman, a health analyst with the Rand Corp. explains the limitations of the EMTALA: Patients with emergency medical conditions “will be stabilized and if necessary hospitalized. They are not entitled to primary care, they are not entitled to preventative care, they are not entitled to followup. That is more humane than letting people die in the gutter. But it is a ridiculous way to try to manage a health care system.”

States that are refusing the Medicaid expansion under Obamacare are preventing over 5 million people from receiving health coverage. Republican Gov. Nathan Deal of Georgia is denying Medicaid expansion to 500,000 of that state’s poorest citizens. As a result, hospitals that serve a disproportionate number of poor and uninsured people are having a difficult time remaining open.

Several hospitals in rural areas have already closed. Deal does have a plan to help these struggling hospitals. His proposed solution involves repealing the EMTALA. He advised that Congress should reconsider the EMTALA: “If they really want to get serious about lowering the cost of health care in the country, they would revisit another federal statute that has been there for a long time,” Deal told a University of Georgia political science alumni gathering. “It came as a result of bad facts, and we have a saying that bad facts make bad law.”

At least Deal did acknowledge that there are true emergency situations that need to be addressed. He said that lawmakers could build in protections for pregnant women and others while restricting access to emergency rooms in other ways saying: “I think we should be able in this passage of time to figure out ways to deal with those situations but not have the excessive costs associated with unnecessary visits to the emergency room.” Just how Deal expects people to accurately diagnose and identify the seriousness of their medical problems is baffling.

With Deal denying poor people the basic medical care that Medicaid expansion would provide, the only option left for them is to have their medical situation evaluated in the emergency room or at a free medical clinic if one is available. Deal’s plan would effectively block entrance to both the doctor’s office and the hospital for millions of people.

Under the Deal plan private hospitals could benefit financially by refusing to treat uninsured patients or by resuming the dumping of poor patients on public hospitals. That someone could be so cruel as to simultaneously advocate against both Medicaid expansion and the EMTALA is incomprehensible. Deal’s health plan would surely fit Rep.Alan Grayson’s description of the Republican Health Plan for America: “1. Don’t get sick; 2. And if you do get sick… 3. Die Quickly.”

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