EMTALA

There are many reasons patients come to an ER. Severed arteries, acute myocardial infarction, poisoning, crushed limbs/head/ego...all of these can be effectively treated in an ER or other trauma center.

But another reason that many people come to the ER is because they know they will be treated, that despite their ability to pay (or lack thereof), they will receive some sort of attention to their concerns and possible even a remedy.

Why is this?

The Emergency Treatment and Active Labor Act (EMTALA) is a federal law that requires public hospitals which accept Medicare and Medicaid payments from the government to offer a medical screening exam and necessary stabilizing treatment to anyone who presents with a medical complaint. If a hospital refuses, it is subject to substantial fines and revocation of its status as a medicare/medicaid provider (i.e., recipient of government funding).

EMTALA, like so many other government regulations (or lack thereof) in the health care industry, is a good law with some negative side-effects.

The purpose of EMTALA is to prevent hospitals from considering profitability before doing what is best for the patient. "Dumping" seriously ill or injured patients or patients who can't pay or pay much was a common practice among hospitals who believed that high-grading (choosing the best, in this case, the best paying patients) was the easiest way to improve the bottom line.

Of course, for some patients this meant disaster. Being turned away from the closest trauma center often meant wasting precious time for patients who were bleeding, having heart attacks, dying of toxicity, or suffering massive, violent injuries. And for women in active labor, having to find a hospital that would accept them often put themselves as well as their unborn babies at risk. Some people died; some hospitals profited.

So EMTALA made it (sort of) illegal to dump. Sort of, because if a hospital chose to forego government payments it could discriminate at will. For-profit, private hospitals, could choose the best of the best, the most insured of the insured, and the government couldn't do anything about it.

But no good law goes unpunished.

EMTALA has also had some unintended side-effects, the most notorious of which has been setting in concrete the two-tiered system of primary care. Patients with insurance, whether private insurance or Medicare (an entitlement program, not income-tested like Medicaid) can usually see their primary care physician for minor or inconvenient maladies or injuries. This keeps costs down, because expensive ER visits (see, "Let Sleeping Old Men...Sleep") can be minimized.

But many physicians do not accept Medicaid, the government insurance program for the poor. Overhead costs at physicians' offices are too high and government reimbursement through this program is paltry. And there is no federal law that says doctors must accept all patients.

So the poor come to us for their care, much of which is minimal. Again, it is not uncommon to pay at least $300 for just walking through the ER doors, utilizing the services of a department and a personnel staff that are equipped and trained to save lives if necessary. With nearly 35 million Americans lacking health insurance or adequate health coverage, and about a third of the population living below the poverty level, the cost to publicly-funded hospitals and Medicaid is enormous.

And who pays this cost? Anyone who pays taxes. And anyone who pays for their own health insurance.

Who benefits? The usual suspects. Doctors who can pick and choose patients. Private hospitals (read: hospitals for the rich) that don't have to abide by EMTALA. And private insurance companies that are not forced to insure poor people.

Everyone deserves health care. In our society, however, it is apparent that some are served better than others.