The Emergency Treatment and Labor Act (EMTALA) prevents us from visibly abandoning patients in the … [+]
The Merriam-Webster dictionary defines a “safety net” as “something that provides security against misfortune or difficulty.” The emergency room is well-known as the “safety net” of the U.S. healthcare system. But most Americans don’t understand the limits of the ER and how it alone cannot be expected to provide the stopgap for a broken healthcare system.
Recently I wrote about the Emergency Treatment and Labor Act (EMTALA). This act requires all hospitals with emergency departments that receive federal funding to see all patients regardless of their ability to pay. That means that any individual needing emergency care will get seen and medically stabilized, regardless of immigration status, income, or insurance.
EMTALA was devised and passed in 1986 as a way to prevent hospitals from “dumping” poorer patients onto charity hospitals that might be more mission-driven to take care of patients in need. The act works in practice, but only up to a point. If your case doesn’t qualify as an emergency, EMTALA doesn’t apply and your ability to receive medical treatment becomes the luck of the draw based on your insurance.
I first witnessed this reality during my medical training as a resident doctor at a California hospital. A Spanish-speaking laborer had amputated his finger with a table saw. It was a “clean cut” and he had properly placed the amputated digit into a plastic baggie and immediately came to the ER with a bandaged stump. Since that hospital did not have a surgeon who could “re-plant” the finger, I spent more than an hour placing phone calls and waiting for callbacks, trying desperately to find a hospital and surgeon who would accept his case. When a surgical resident of one hospital finally answered, he asked me what insurance the patient had, and I immediately retorted that if this was information that he was using to make a decision about accepting the patient, then I would need to report this as an EMTALA violation and he, his attending, and the hospital would be financially responsible for these penalties. Needless to say, I got the patient transferred.
So EMTALA “works” in certain situations. It prevents us from visibly abandoning patients in the emergency department. But the abandonment of patients is still happening every day, just in less visible ways, especially for individuals without life- or limb-threatening emergencies that require immediate intervention.
I have seen more than a dozen patients with some variation of this story. A patient with an ankle fracture is seen, diagnosed, treated, and appropriately discharged from an ER since he didn’t need immediate surgery. But he hasn’t found a specialist who will accept his case because he doesn’t have “favorable” insurance. As a result, he is unable to stand or bear weight on that leg. Because of that, he hasn’t been able to work, which leads to an inability to pay his rent, so he’s now without shelter. He’s been to multiple ERs who have consulted their orthopedic surgeons, who have appropriately told him that his case is not emergent since it’s been months. It has now become the patient’s responsibility to find a surgeon to take his case. So he’s back to square one. In certain cases, this patient has now become homeless as well. His fracture is infected and his medications are stolen from his backpack. He comes back to the ER and we treat his infection. He gets discharged but without proper shelter, it gets infected again and the cycle continues. Eventually, he needs an amputation.
This is more expensive to society than providing him care in the first place, and the outcomes are also worse. Even without the homelessness and infections, the multiple ER visits alone—which were preventable had he received outpatient and elective surgery—have exacted a cost on him and on our society. How? Multiple ER visits from patients who have nowhere else to go mean longer wait times for others, leading to ER crowding and ultimately, increased mortality—meaning deaths.
EMTALA is necessary, but it doesn’t fill all the holes in our safety net. It leaves countless others without care for non-emergent yet urgent needs. A functional safety net would address these gaps and provide the medical care necessary to avoid preventable emergencies. Until we confront these invisible forms of neglect, our so-called safety net will remain a broken patchwork, failing those it was meant to protect.
