August 24th, 2019 BY HealthNetwork
It’s 3 a.m., you’re doubled up with stomach pain and your only option is to head to the ER for care. You don’t have health insurance, but everyone knows a hospital has to treat you even if you don’t have any coverage. It’s the law, right?
Well, yes and no. Regardless of your health insurance status, hospitals that accept Medicare payments – i.e., most hospitals in the U.S. – must provide life-saving care to anyone who walks in the door. But there are limits. Big ones. And if you’re uninsured, your local ER doesn’t have to go above and beyond to treat your condition as long as you’re stable when you’re discharged. There’s a federal law mandating certain types of emergency care. It’s called EMTALA. Let’s unpack what that stands for and what it means for you as a patient, especially if you’re uninsured.
What Is EMTALA?
The Emergency Medical Treatment and Active Labor Act (EMTALA) was passed by Congress in 1986 and requires all hospital emergency departments that participate in Medicare to provide medical screenings for any patient seeking treatment, regardless of ability to pay or legal status. Since virtually all hospitals receive Medicare funds, this mandate extends to nearly all emergency departments in the country. EMTALA was passed as a way to combat “patient dumping,” the refusal to treat uninsured or Medicaid patients or their transfer to public hospitals without first providing a medical screening to ensure they were stable enough to discharge.
EMTALA’s provisions require emergency departments to conduct a medical screening exam to determine if the patient is actually experiencing a medical emergency condition. This is defined as a medical episode in which there is imminent life-threatening, limb-threatening or organ-threatening symptoms. If there is a medical emergency condition present, the facility is required to stabilize the patient before discharging or transferring him to another facility.
The hospital is also required to provide care at the same level as it would to paying patients and cannot prioritize care for paying patients over treatments for non-paying patients. If a hospital is unable to provide the specialized treatment necessary to stabilize the medical emergency, they may transfer the patient to a facility that does. Facilities with specialized capabilities are required to accept such inter-facility transfers.
In summary? If you’re suffering from life- or limb- or organ-threatening symptoms (heart attack, extreme stomach pain, the worst headache of your life, a stroke, etc.), then most ERs in the U.S. are required to stabilize you before discharging you or transferring you to a hospital that can stabilize you. They can’t give preferential treatment to patients with insurance or those who can pay above people who can’t.
EMTALA places hefty penalties on noncompliant facilities. Not only can a hospital or physician’s Medicare provider agreement be terminated, but both doctors and hospitals can also be charged up to $50,000 per violation. Patients are also allowed to sue offending hospitals in civil courts for personal injury, and receiving facilities can sue for financial losses if they erroneously receive a patient due to an EMTALA violation.
What Is and Isn’t Covered Under EMTALA
While EMTALA provides a safety net to ensure that everyone can receive life-saving treatment when they need it, it is not equivalent to health coverage by any means. This law has some severe limitations and was never intended to replace or even supplement any kind of insurance. You might assume that the law guarantees that you’ll receive treatment for any medical condition if you simply go to an emergency room, but this is not the case at all.
Only emergency medical care is mandated under EMTALA. This means that hospitals and physicians are only obligated to treat uninsured patients if they are experiencing a severe medical emergency that can lead to death, loss of limb or organ failure.
For pregnant patients experiencing contractions or other pregnancy complications, EMTALA does require healthcare providers to treat patients until the baby is safely delivered or the symptoms are determined to be non-emergent. However, no further care beyond life-saving treatment and stabilization is required.
Hospitals have no obligation under EMTALA to provide non-emergency treatments to patients, so people without health insurance who show up to an ER experiencing non-emergency symptoms can and often will be turned away after receiving a medical screening exam if they can’t pay for further services. This includes medical situations like minor cuts or injuries, minor illnesses like a cold or the flu, or even a sprained ankle.
EMTALA also doesn’t mandate any level of medical care beyond stabilization of the immediate emergency situation, so patients who are unable to pay for further medical care will be discharged from the hospital as soon as their immediate threat to life is addressed. This often means no follow-up or preventive care will be given, even if follow-up care could help you avoid future trips to the ER.
Who Pays for Care Under EMTALA?
Another common misconception is that EMTALA’s provisions allow for low-income patients to receive free medical care from their local emergency room. While the intent of this law is to ensure that no one is refused emergency care when they need it most, it does nothing to mitigate the cost of that care. Patients are still fully responsible for the cost of care provided under EMTALA under civil law, and healthcare providers still bill patients and forward unpaid bills to collection agencies in order to receive payment for those services.
According to a study by the Centers for Medicare and Medicaid Services, up to 55 percent of emergency services in the U.S. go unpaid. As this federal mandate receives no government funding to mitigate the cost of unpaid treatment, hospitals and emergency physicians are often left assuming the cost of uncompensated care themselves.
In 2012, U.S. hospitals provided nearly $46 billion in uncompensated care, and the cost of uncompensated care has more than doubled in the last decade. These costs are typically passed on to paying patients in one way or another. If you have insurance, you’re most likely covering the cost of uncompensated care for people without insurance who don’t or can’t pay for ER services.
As our nation continues the complex conversation on how to best manage healthcare in America, it’s important for everyone to understand exactly what EMTALA is and isn’t. It’s a safety net for uninsured people to get emergency care when they need it, but it’s not a substitute for good health insurance (or any health insurance), and it doesn’t guarantee free medical care regardless of your income status. Both patients and policymakers need to understand the limitations of the current laws so effective, patient-centered regulations can be crafted that will benefit everyone involved, without leaving those who need it most unprotected.