by Madeleine Cosman, PhD, Esq

President Reagan signed the Emergency Medical Treatment and Active Labor Act (EMTALA) into law in 1985 along with the Consolidated Omnibus Budget Reconciliation Act (COBRA). It requires doctors in hospital emergency rooms to treat every person who comes in through the door without requesting whether the patient is insured, how, or by whom until after the patient is either:
stabilized for transfer
stabilized for discharge

Even if the emergency facility is overcrowded, understaffed, medically or surgically unprepared, or otherwise inadequate, the physician is forbidden to transfer to another medical facility any patient who for whatever reason is not accepted for full treatment and admission.

A pregnant woman coming to a hospital in labor cannot be sent away for any reason until after she has given birth.

Reach and grasp of the legislation expanded mightily to include "emergency conditions" which means whatever a prosecutor deems it, and which include within the hospital's requirement to screen and treat for free anyone who comes within 250 yards of a hospital's main buildings.  Some courts have interpreted the 250 yards to begin at the hospital restaurant, apartment house, private medical offices, off campus clinics, diagnostic centers, or primary care centers.  Remarkably, the 250-yard radii of the circle of mandatory inclusion include ambulances not even owned by the hospitals.

The hospital also must maintain a back-up on-call system of specialists such as neurosurgeons, cardiovascular surgeons, orthopedic surgeons, OB-GYN and pediatric subspecialists representing every specialty the hospital represents itself as providing to its community.

Failure to adhere to EMTALA stringencies results in a fine per infraction of $25,000 to $50,000, prosecution, decertification actions, and expulsions from Medicare and Medicaid.  Enforcement is brisk and punishing.

In essence, a physician is liable for criminal prosecution, as is the medical facility, if for any reason whatsoever the physician or ancillary medical personnel refuse to treat a patient requesting care.  Though involuntary servitude is Constitutionally prohibited by the 13th Amendment, any American physician licensed to practice must treat if a patient requests or requires care.

Originally intended to prevent patient "dumping," EMTALA greatly agitates emergency physicians and specialists "on call" because new demanding patients under the law crowd out scheduled patients, and practitioners are required by law to work without pay since government does not fund the strict mandate.  Managed care plans pay nothing unless the patient's ultimate diagnosis, not the reasons for coming to the emergency room, fits their criteria.  Even Medicare's "prudent layperson's" understanding of an emergency does not always produce recompense. Serious chronic diseases and accidental trauma cases threaten devastating costs to hospitals over extended time. Once arriving, the patient must stay even if reaching "stability" takes months or years.

Congress's General Accounting Office released in June 2001, Emergency Care: EMTALA Implementation and Enforcement Issues reviews "provider uncertainties about EMTALA responsibilities."  Thirty-three medical specialty societies petitioned The Centers for Medicare and Medicaid Services (CMS) in 2000 to not issue new regulations expanding the already onerous burdens of physicians and hospitals under EMTALA.