The myth of EMTALA

In 2007, President George W. Bush repeated one of the most frustrating misconceptions in American healthcare. “[P]eople have access to health care in America. After all, you just go to an emergency room.” This statement reflects a deeply flawed but pervasive notion that limited access to care through an emergency room is equivalent to meaningful access to healthcare.

In his statement, President Bush was referring to EMTALA (Emergency Medical Treatment and Labor Act), passed by the U.S. Congress in 1985 and signed by Ronald Reagan in 1986. The law mandates that all patients seeking care in an Emergency Department (ED) receive evaluation by a competent clinical professional; if an emergent medical condition is discovered, the patient must receive stabilizing treatment. The law was passed after extensive reports of “patient dumping” and “wallet biopsies,” where individuals were denied emergency care or transferred while medically unstable, because of their inability to pay. Dr. Ron Anderson, medical director of the ED at Parkland Memorial Hospital in Dallas during the early 1980s, recalled “I would see patients transferred with knives still in their backs, or women giving birth at the door of the hospital, simply because they were uninsured."

Of course there are myriad subtitles to the law, and debate about the legal interpretation persists. However, limitations are clear. A patient diagnosed with cancer may be medically stable, with little risk of imminent death. Without treatment, the cancer will inevitably kill the patient, but not immediately. Thus, under EMTALA, the patient has has no right to curative chemotherapy or surgery. While a moral imperative exists to care for indigent patients—hospitals provided over $35 billion in charity care in 2015—there is no legal obligation to do so. Patients have a right to medical care only once disease has progressed to a critical juncture, when the disease is undoubtedly more difficult and costly to treat.

Although the law requires EDs to provide only an evaluation and stabilizing care, many EDs exceed this threshold, providing non-urgent care to patients regardless of ability to pay, serving as the ultimate safety net of the American healthcare system. In a typical ED, 1 in 5 patients are uninsured or have no clear means of paying for care. While this is commendable, there are many reasons why EDs are poorly suited to serving as the safety net providers. Emergency departments are prepared diagnose and treat the most critically ill patients, providing access to a bevy of specialists and diagnostic modalities around the clock, resulting in high overhead costs. Providing care for a non-emergent condition (such as a rash or sinus infection) in the ED is many times more costly than providing that same care in a clinic. Furthermore, the ED has limited capacity for follow-up care and thus is poorly equipped treat chronic conditions.

As frustrating as the status quo may be, independent experiments shed light on what a more functional system might look like. Situated in Richmond, the Virginia Commonwealth University Medical Center is the largest safety net provider in the state of Virginia. Several years ago an analysis showed that, among uninsured patients, 60 percent of ED visits were for conditions that could be easily treated in a primary care setting. Since many uninsured patients lacked the means to pay their ED bills after receiving their care, VCU was absorbing the the cost this care—which was all the more expensive since patients were seeking care in the ED instead of a clinic. This situation was resulting in longer wait times for all patients, uncoordinated care for the uninsured patients, and huge financial losses for VCU. There had to be a better way.

In 2000, VCU created the Virginia Coordinated Care (VCC) program for uninsured indigent care patients. While not insurance, enrollment in VCC gives individuals who qualify for indigent care (free charity care) access to a primary care provider, assistance paying for medications, and limited access to specialty care. VCU pays for this outpatient care because, as a safety net hospital, they were already providing a great deal of free charity care to their indigent patients—non-urgent care in the ED, urgent care in the ED and inpatient hospitalizations. In fact, many patients were recruited into the program after presenting to the ED with a non-urgent complaint or after a serious exacerbation of a manageable chronic condition. The results, published in the journal Health Affairs, have been stunning. Proactively providing these patients access to a primary care doctor and necessary medications actually saved money for VCU in the long run. Hospitalizations and ED visits dropped, and over three years of enrollment, per patient expenditures decreased by 46 percent.

As a medical student, there is nothing more outrageous than seeing a patient admitted to the hospital in the end stages of an easily, and often inexpensively, treated disease. The moral ramifications of such unnecessary suffering, death and disease are profound. Our current system strikes me as tragically inefficient and uneconomical, but more importantly, horrifically unnecessary. Even if you’re not concerned by the ethical implications of our current paradigm, you should be outraged that we are failing to take measures to reduce healthcare expenditures, leading to lower healthcare costs for all.

In 2012, Mitt Romney, in an interview with the Columbus Dispatch, stated, “[w]e don't have people that become ill, who die in their apartment because they don't have insurance." Evidence has shown that this is patently untrue. After a traumatic injury, controlling for confounding factors, uninsured patients are 2.8 times more likely to die than privately insured patients and have 80 percent lower odds of receiving care in a rehabilitation facility. Compared to insured patients, uninsured stroke patients experience greater neurologic impairment and are over 50 percent more likely to die. Access to care through EMTALA is not sufficient to prevent these deaths. Some self-righteous people hold up EMTALA because they are convinced that the wealthiest nation on earth does not allow citizens to die because of denied medical care. This confidence is misplaced.