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The wreck of the good ship, EMTALA

EMTALA, the Emergency Medical Treatment and Active Labor Act, was passed in 1986.  For those who aren’t familiar with yet another acronym, EMTALA is a federal law that was enacted to keep poor, uninsured patients from being ‘dumped’ on indigent-care hospitals, or any other facility, for financial reasons.  Although it was a good idea, it soon grew fangs, tentacles, claws, rose up to several hundred stories in height and developed a surly attitude and bad breath.  It is, in fact, one of the largest unfunded mandates the US legislative branch has ever gifted on its subjects.
For those of us who practice emergency medicine, and by now any medicine in a hospital that accepts Medicare payments, no one can be turned away for financial reasons.  On the surface, this seems fair.  Certainly, the potential exists for gross harm and injustice if we refuse to care for the most needy in our populations because we aren’t getting paid.  ‘Your child is having non-stop seizures, eh?  Well, pony up $400 we’ll see what we can do!’  It makes sense to have a provision of protection.

However, because this law basically forbids hospitals and physicians from saying ‘no,’ (without a complex, time consuming, legally perilous screening exam that is rarely worth the effort), we see all those who come through the door.  And because the ‘cat is out of the bag’ and has been for a while, many of our patients know this.  So, we have these conversations.

Doctor:   ‘I see you have a toothache.  Have you seen your dentist?’

Patient:  ‘No, I owe him money.’


Doctor:  ‘You know, you’ve been here every week for the last six months for chest pain, and you’ve had every test we can do.  It isn’t anything dangerous, yet you keep asking for pain medication, you refuse to follow up with anyone, and now owe our group $7000.’

Patient:  ‘Right, interesting.  So, today it goes around my back, to my ear, down my arm and into my testicle.  What do you think it is?’

It isn’t that we don’t take people seriously, because we do.  It isn’t that we don’t want to help, because we do.  But medicine being our business, money is often part of the transaction after the smoke has cleared.

Equally problematic, surgeons, neurologists, cardiologists, otolaryngologists and just about every other ‘ist’ is burdened with the same issue.  The people they see in the ER,  admit to the floor, or take to surgery or the cardiac cath lab will frequently be unable to pay anything, but then still be able to sue for millions of dollars.  It’s hard for specialists to run practices when large numbers of patients pay nothing for their care.  I understand their issues here.  I don’t blame them a bit for being angry.

And of course, hospitals are providing care that isn’t reimbursed to patients who can’t, or intend never to pay them.  Nurses and other staff are cut.  Rooms aren’t available, needed additions aren’t built, new technologies are hard to afford, other specialists can’t be recruited, and before you can blink a hospital is closing or reducing it’s capacity.  And to top it off, we can’t even get the Smucker’s peanut butter cups we all used to scarf from the patient supply cabinet while seeing sick people!  Woe is me!
Across America, small and medium sized emergency departments and hospitals are closing.  Trauma centers and teaching hospitals are struggling and overwhelmed.  And specialists are simply leaving hospital care in order to avoid being on call, and the attendant EMTALA responsibilities that call entails.  They’re working in surgery/outpatient centers. They’re leaving the setting where they are compelled to give care away, and where they are constantly overwhelmed by more and more demand, less and less payment.

Our own group sees increased volume every time we increase staffing.  The numbers, the lack of control, the degree of genuine illness, and the degree of ridiculous visits for life crises, narcotic abuse, work excuses or just ‘because I was here with my friend anyway,’ keep rising.  Can we say no?  Not much, not often.

You see, the federal government thought EMTALA seemed like a nice, friendly, warm-hearted way to help America’s indigent populations.  It also thought it seemed like a cheap way to do it, since EMTALA didn’t come with any money for providers or hospitals to do this epic work of securing the ‘health-care safety net.’  Like so many government programs it consists of untold numbers of legislators and government functionaries patting themselves on the back for helping the poor by having someone else pay for it and do the work; that is, America’s hospitals and physicians.

But here’s the final irony.  EMTALA has created the very conditions it sought to avoid.  Now, with specialists unavailable, hospitals full, transfers always difficult and no lack of genuinely sick and dying patients, there’s often 1) no one to care for them and 2) no place to put or send them.  EMTALA, the federal mandate to save the poor from sickness has begun to crumble at its foundations, and leave untold numbers of patients, poor and paying, without care.

This isn’t meant to be a tirade about payment, though non-medical readers may see it that way.  What I’m getting at is that our system, our government mandated system, is a failure.

You might make the argument that nationalized health-care can fix this with money, but as we see in so many problems, money doesn’t do much.  Money in the school system still leaves us with staggering drop-out rates and high-school illiteracy.  Money, in the hands of an irresistible, un-yielding, entitlement crazy, grandiosity-leaning government system will probably result in an even greater disaster than EMTALA.

My suggestion?  Get the government out of it all.  If you do, the poor will likely get better care, since we’ll be able to screen out and turn away those who abuse their privilege.  And doctors, that pesky, generally unimportant part of the medical equation, will actually return to hospitals and be available; out of a sense of duty, professionalism, entrepreneurial spirit and genuine compassion without federal compulsion.

It’s unlikely to happen, but a doctor can dream.  ‘And then I saw a scarecrow and some flying monkeys and a witch, and a hospital where I was in charge and could always do what I thought was right, oh Auntie Em, it was wonderful!’



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2008-05-08 23:02:35 Reply

Continue to elect the same buggers to Congress…that way none of your dreams will be realized. Take responsibility by electing people that won’t “give” away our country.



2008-05-09 01:07:53 Reply

EMTALA and JCAHO are the two biggest obstacles to effective, efficient and compassionate care for all. All in the name of fairness and excellence.



2008-05-09 19:48:00 Reply

All true. Recently the dept of homeland security counted ER beds available in big cities on a certain date, at a certain time and found few available. The idea was how many would be available in a terrorist attack. Who do you think were probably taking up half of these beds?


2008-05-10 00:19:58 Reply

No one listens to doctors anymore. Neither will Congress.

I just read your article in Medical Economics. Congratulations. It was nice.

Tammy, MD

2008-05-11 00:08:37 Reply

Once again, Dr. Leap, you are a voice of reason in what seems like an ocean of nonsense! I practice in small town ED (census 46K visits/year) and have watched my list of specialists on call dwindle (No ENT, GI, Urology, Neurology, or Opthomology.. don’t even think about neurosurg, plastics, trauma surgery) I’ll be honest…it has gotten downright frightening! This winter was a nightmare since most of the “big city” hospital beds were filled to the brim. My ortho guys cringe to take any call, because they get pulled out of an office of paying patients to see patients who will never pay them but not hesitate to sue them if the doctor’s socks didn’t match that day.

Thank you for reassuring me that I am not alone in this battle! I just hope that my patients (and my medical license!) can survive the ordeal.

Mike Zemack

2008-05-13 01:51:29 Reply

The “silent protest” by doctors and specialists walking away from hospital practice is certainly appropriate and moral. And I agree fully that we should “Get the government out of it all.” But it doesn’t have to be just a dream.

The real power in the health care arena is the doctor, and he should use it. Fleeing the hospitals for surgery/outpatient centers or some other means of practice is only a short-term fix. The politicians will eventually go after them wherever they go.

The best, and likely the only, way to turn the tide toward a full-fledged government-run health care dictatorship is for the doctors to stand up en masse for their rights. Doctors are “that pesky, generally unimportant part of the medical equation” only so long as they allow this to be the case. An uncompromising and principled stand against the state would stop socialized medicine dead in its tracks.

That is my dream.


2008-05-13 20:55:11 Reply

Is this a new position for you Dr. Leap?

I’ve long held the position that EMTALA makes things worse, but I seem to be under the impression that EM physicians did not share the feeling. I don’t think we’ll have any action on this law until organized Emergency Medicine takes the position that the law should be repealed.


2008-05-17 09:00:30 Reply

dear dr leap.
long, long time fan. now that i have a semi-successful blog i find myself linking you quite frequently and you are linked for this one my friend. at the time you were writing this piece i was writing two others which you can peruse if you choose. when are we going to link arms as physicians and hold our breath until we change this idiocy? the sermo letter is namby pamby and i’ll have a suggested letter up soon. please keep it up, my wife and i love your stuff.




2008-05-31 04:28:21 Reply

Long, long ago, I took a friend to a local community hospital/medicaid clinic to seek treatment for his headache. It turned out he had a mild sinus infection, easily treated. But we had to wait approximately eight hours in a small, cramped waiting room before he got to speak with a doctor.

Nationalized health care would be this, but worse. Instead of waiting eight hours, the hours would turn into days and weeks, maybe even months. This has been the experience of many of my Canadian friends who live under a nationalized health care system. “You need cataract surgery and a hip replacement. Your first opportunity for the surgery will be in four months. You won’t mind laying in bed, blind, for the next four months, will you?”

With good insurance, I’m spoiled with the ability to schedule an appointment, walk into my doctor’s office, and be in and out in just a couple of hours. I cannot imagine that the American public would willing accept the longer waits (and significantly higher taxes) that nationalized health care would necessitate.

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