The Emergency Medical Treatment and Active Labor Act: Past, Present and Future
An interview with Sara Rosenbaum, JD, the Hirsh Professor in the School of Public Health and Health Services at the George Washington University, in Washington, DC, and a Robert Wood Johnson Foundation (RWJF) Investigator Awards in Health Policy Research recipient. She is the author of “The Enduring Role of the Emergency Medical Treatment and Active Labor Act,” published in the December 2013 issue of Health Affairs, which focused on the future of emergency medicine. The interview is part of a series of posts featuring RWJF Scholars who authored articles in the issue.
Human Capital Blog: Your article discusses the past, present, and future of the Emergency Medical Treatment and Active Labor Act (EMTALA), adopted in 1986. Could you tell us a little about what moved Congress and the President to create the law, and what its purpose was?
Sara Rosenbaum: The law had several roots. To begin, it was the outgrowth of a good deal of law that came before it, embracing the notion that hospitals should provide emergency care, even without the expectation of payment. So that idea wasn’t unique to EMTALA, but by the early 1970s the expectation that hospitals would provide the community benefit of emergency services had revved up, partly because states had adopted that expectation under their own common law and statutes. So EMTALA was the culmination of a lot of legal precedent. But what prompted passage of the law in 1986 was two things: First, a substantial number of news stories about patient-dumping, particularly in California; and second, on the heels of Medicare payment reform a few years earlier, there was a lot of concern that hospitals would start discharging Medicare patients in an unstable state – sicker and quicker, as the saying went.
HCB: What are the law’s key components?
Rosenbaum: The one everybody knows best is the screening component: If somebody comes to an emergency department and requests an examination, hospitals must examine the patient to determine if there's an emergency medical condition. And if they find one, they must provide stabilization treatment. Or, if the patient has an emergency condition that the hospital is unable to stabilize, it can seek the cooperation of another hospital with more specialized capabilities, and transfer the patient. And then that second hospital has a separate obligation; it can’t just say “no.”
HCB: What’s your sense of how the law operates in the daily life of a hospital?
Rosenbaum: If you talk to emergency department staff, they'll tell you that it adds complexity to their lives. They're under an obligation to see a patient, but many who come to the emergency room don't have an emergency. They have to screen the patient, and then many patients are told they’ve got a problem, but not an emergency. So a lot of cases evaporate after the screen. But there are certainly emergencies that trigger the full response of the hospital.
HCB: Your article in Health Affairs makes clear that we still have legal wrangling about the extent of EMTALA’s reach. Could you tell us a bit about that?
Rosenbaum: From the time the law was first enacted, it has been one of the most litigated health laws out there. There have been hundreds of cases. They’ve focused on all aspects of the law, but particularly on the extent of the screening and stabilization obligation: What exactly does EMTALA mean when it says that a hospital has to use the resources of the emergency department? What are the obligations of specialists on call? Do they need to be readily available?
The courts have been all over the place in their reading of the law. But taken together, the body of case law has somewhat narrowed the EMTALA obligation. The best example of that is that a lot of courts now say EMTALA ends at the point of admission. So, once a patient is admitted through the emergency department, or if the patient came in through a scheduled admission, the EMTALA obligation to attempt stabilization or transfer is circumscribed. Also, courts have made clear that EMTALA is not a basis for a malpractice case. It’s supposed to address the denial of treatment, not the quality of treatment.
HCB: More broadly, what do you think EMTALA’s impact has been on the way health care professionals and the public at large think about emergency care?
Rosenbaum: I think emergency medicine has become that much more important to the country as a result of the law. It's now an accepted fact in society, even if some hospitals might not like it, that if a patient comes to an emergency department with an emergency condition, the patient will get care.