![]() ![]() Although they were correct concerning the law's ambiguities, they could not have been more wrong about the impact of the law over the next decade. It is interesting to note that shortly after EMTALA was passed the same physicians who authored the study on patient dumping to Cook County Hospital commented that “monitoring, enforcement and the effectiveness of this federal law will be crippled” by its vague definitions of emergency care and stabilization ( 1). The combination of reports in the professional and lay press, the obvious impotence of the laws already on the books, and the increasing presence of the federal government in all things health-care related led to the enactment of EMTALA. The Hospital Survey and Construction Act of 1946 (commonly called the Hill-Burton Act) had established federal guidelines for emergency medical care at certain hospitals, and many state laws were also on the books mandating nondiscriminatory access to emergency care ( 1). The American College of Emergency Physicians had similar language in its bylaws ( 4). ![]() The Joint Commission on Accreditation of Hospitals stated that “individuals shall be accorded impartial access to treatment or accommodations that are available or medically indicated, regardless of race, creed, sex, nationality, or sources of payment for care” ( 3). The ironic twist to this story is that safeguards for indigent patients already existed however, most were guidelines without the force of law that were being ignored by private hospitals and doctors. In Dallas, such transfers increased from 70 per month in 1982 to more than 200 per month in 1983 ( 1). This practice was not limited to Chicago but occurred in most large cities with public hospitals. It was concluded that this practice was done primarily for financial reasons and that it delayed care and jeopardized the patient's health. Medical service patients who were transferred were twice as likely to die as those treated at the transferring hospital, and 24% of the patients were considered to have been transferred in an unstable condition. Only 6% of the patients had given written informed consent for their transfer. The reason given for the transfer by the sending institution was lack of insurance in 87% of the cases. The majority of such transfers to Cook County Hospital involved patients who were minorities and unemployed. The authors defined dumping 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” ( 1). In 19, 2 articles appeared in the literature by physicians from Cook County Hospital in Chicago detailing the extent of patient dumping to that facility ( 1, 2). The emphasis is on the impact of the statute-not just on the emergency care of patients but on the hospital and its medical staff. It includes discussions of on-call physician responsibilities under the statute, penalties, and enforcement procedures. This article summarizes the historical context of EMTALA and discusses the requirements of the statute both in the law's original language and in the subsequent interpretations by HCFA and the courts. Thus, all physicians on the hospital staff, not just emergency physicians, need to be familiar with its general requirements. Even though its initial language covered the care of emergency medical conditions, through interpretations by the Health Care Financing Administration (HCFA) (now known as the Centers for Medicare and Medicaid Services), the body that oversees EMTALA enforcement, as well as various court decisions, the statute now potentially applies to virtually all aspects of patient care in the hospital setting. Although only 4 pages in length and barely noticed at the time, EMTALA has created a storm of controversy over the ensuing 15 years, and it is now considered one of the most comprehensive laws guaranteeing nondiscriminatory access to emergency medical care and thus to the health care system. The law's initial intent was to ensure patient access to emergency medical care and to prevent the practice of patient dumping, in which uninsured patients were transferred, solely for financial reasons, from private to public hospitals without consideration of their medical condition or stability for the transfer. The Emergency Medical Treatment and Active Labor Act (EMTALA) was passed by the US Congress in 1986 as part of the Consolidated Omnibus Reconciliation Act (COBRA), much of which dealt with Medicare issues. ![]()
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