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Act of Congress in the United States From Wikipedia, the free encyclopedia
The Emergency Medical Treatment and Active Labor Act (EMTALA)[1] is an act of the United States Congress, passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). It requires hospital emergency departments that accept payments from Medicare to provide an appropriate medical screening examination (MSE) for anyone seeking treatment for a medical condition regardless of citizenship, legal status, or ability to pay. Participating hospitals may not transfer or discharge patients needing emergency treatment except with the informed consent or stabilization of the patient or when the patient's condition requires transfer to a hospital better equipped to administer the treatment.[1]
Acronyms (colloquial) | EMTALA |
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Legislative history | |
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United States Supreme Court cases | |
Moyle v. United States, No. 23-726, 603 U.S. ___ (2024) |
EMTALA applies to "participating hospitals." The statute defines participating hospitals as those that accept payment from the Department of Health and Human Services', Centers for Medicare and Medicaid Services (CMS) under the Medicare program.[2] Because there are very few hospitals that do not accept Medicare, the law applies to nearly all hospitals. The combined payments of Medicare and Medicaid, $602 billion in 2004,[3] or roughly 44% of all medical expenditures in the United States, make not participating in EMTALA impractical for nearly all hospitals. EMTALA's provisions apply to all patients, not just to Medicare patients.[4][5]
The cost of emergency care required by EMTALA is not covered directly by the federal government, so it has been characterized as an unfunded mandate.[6] In 2009, uncompensated care represents 55% of emergency room care, and 6% of total hospital costs.[7][8]
The Hill-Burton Act of 1946, which provided federal assistance for the construction of community hospitals, established nondiscrimination requirements for institutions that received such federal assistance—including the requirement that a "reasonable volume" of free emergency care be provided for community members who could not pay—for a period for 20 years after the hospital's construction. Amendments to the act in 1975 removed the 20-year expiration date and instead required hospitals receiving Hill-Burton funding to provide free care in perpetuity. However, the provisions of the act were vague and rarely enforced.[9]
Congress passed EMTALA to eliminate the practice of "patient dumping"—that is, refusal to treat people because of inability to pay or insufficient insurance or transferring or discharging emergency patients on the basis of high anticipated diagnosis and treatment costs. The law applies when an individual seeks treatment for a medical condition "or a request is made on the individual's behalf for examination or treatment for that medical condition."[1]
The U.S. government defines an emergency department as "a specially equipped and staffed area of the hospital used a significant portion of the time for initial evaluation and treatment of outpatients for emergency medical conditions."[10] That means, for example, that outpatient clinics not equipped to handle medical emergencies are not obligated under EMTALA and can simply refer patients to a nearby emergency department for care.[10]
An emergency medical condition (EMC) is defined as "a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs." For example, a pregnant woman with an emergency condition and/or currently in labor must be treated until delivery is complete, until the woman and the fetus are stabilized, or until a qualified personnel identifies the labor as a "false labor" or Braxton Hicks contractions, unless a transfer under the statute is appropriate.[10]
Patients treated under EMTALA may not be able to pay or have insurance or other programs pay for the associated costs but are legally responsible for any costs incurred as a result of their care under civil law.
Not all medical conditions qualify for uncompensated mandated services imposed by EMTALA, which is contrary to the misperception that many individuals assume: that if they are ill, they will be treated regardless of their ability to pay.
The sole purpose of the EMTALA-mandated MSE is to require emergency departments to make a determination about whether an emergency medical condition does or does not exist, using their normal assessment and diagnostic protocols. Because the MSE is a mandated EMTALA service, health insurers are required to cover benefits for their subscribers. They are also required to cover EMTALA mandated services necessary to stabilize individuals determined to have an EMC.
EMTALA intentionally omitted requirements that hospitals provide uncompensated stabilizing treatment for individuals with medical conditions determined not to be EMCs. Therefore, such individuals are not eligible for further uncompensated examination and treatment beyond the MSE.
A significant portion of emergency department visits are considered not to be EMCs as defined by EMTALA. The medical profession refers to such cases as "non-emergent". Regardless, the term is not recognized by law as a condition defined by the EMTALA statute. A term more relevant for compliance with EMTALA is "non-emergency medical condition". If the "non-emergent" term is used in the context of EMTALA, it must be defined as a medical condition that fails to pass the criteria for determination of being a true EMC as defined by EMTALA statute.
Admitted patients who experience a medical emergency while at a hospital are normally not covered by EMTALA but are instead protected by varying state laws and quality assurance under the deemed status of the facility.
Hospitals have three obligations under EMTALA:
Since the act's original passage, the Congress has passed several amendments to the act. Additionally, state and local laws in some places have imposed further requirements on hospitals. The amendments include the following:
The most significant effect is that regardless of insurance status, participating hospitals are prohibited from denying an MSE of individuals seeking treatment for medical conditions. Currently, EMTALA requires only that hospitals stabilize the EMC. According to some analyses of the U.S. health care social safety net, EMTALA is an incomplete and strained program.[11][12]
According to the Centers for Medicare & Medicaid Services, 55% of U.S. emergency care now goes uncompensated.[7] When medical bills go unpaid, health care providers must either shift the costs onto those who can pay or go uncompensated. In the first decade of EMTALA, such cost shifting amounted to a hidden tax levied by providers.[13] For example, it has been estimated that cost shifting has amounted to $455 per individual, or $1,186 per family, in California annually.[13]
However, because of the recent influence of managed care and other cost control initiatives by insurance companies, hospitals are less able to shift costs, and they end up writing off more and more in uncompensated care. The amount of uncompensated care delivered by nonfederal community hospitals grew from $6.1 billion in 1983 to $40.7 billion in 2004, according to a 2004 report from the Kaiser Commission on Medicaid and the Uninsured,[7] but it is unclear what percentage of the amount was emergency care and therefore attributable to EMTALA.
Financial pressures on hospitals in the 20 years since EMTALA's passage have caused hospitals to consolidate or close facilities, thereby contributing to emergency department overcrowding.[14] According to the Institute of Medicine, from 1993 to 2003, emergency department visits in the United States grew by 26 percent, while in the same period, the number of emergency departments declined by 425.[15] Ambulances frequently get diverted from overcrowded emergency departments to other hospitals that may be farther away. In 2003, ambulances got diverted more than half a million times—not necessarily due to patients' inability to pay.[15]
After Roe v. Wade (1973) was overturned in June 2022, transforming the legal landscape for abortion in the United States, the HHS issued guidance on EMTALA protections for clinicians that apply regardless of state laws.[16][17][18] According to the guidance, which does not change policy, EMTALA, as a federal law, supersedes state laws that ban abortion. So, doctors who perform emergency abortions to stabilize a patient are protected by EMTALA. Hospitals that fail to do so could face fines or be booted from Medicare. The guidance also says EMTALA does not prevent a doctor from being sued, though EMTALA may be used in defense of the doctor in state court actions.[16]
The Biden administration filed a motion in federal court to block Idaho's enforcement of that state's abortion ban in cases in which EMTALA applied. The judge ruled against the state and ordered Idaho's law suspended in emergency cases.[19] Idaho appealed the ruling, arguing that the federal government “cannot use EMTALA to override in the emergency room state laws about abortion any more than it can use it to override state law on organ transplants or marijuana use.” The Supreme Court agreed to hear Idaho's challenge to that interpretation of the law in Moyle v. United States (2024), which was argued that April.[20][21][22]
Texas sued the federal government, winning in federal court. A 5th Circuit judge preliminarily enjoined the Biden administration's EMTALA guidance in Texas.[22]
In June 2024, the Supreme Court issued a 6–3 ruling in Moyle which reinstated the lower court ruling requiring EMTALA's emergency abortion provision to be enforced in Idaho.[23][24] However, the issue remains unresolved, with the ruling only seen as delaying the Idaho state law banning emergency abortions rather than striking it down altogether.[23][24] However, the Supreme Court ruling did allow for the case to return to a lower court which was previously favorable to upholding EMTALA's emergency abortion provision.[24]
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