Emergency Medical Treatment and Active Labor Act

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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 hospitals that accept payments from Medicare to provide emergency health care treatment to anyone needing it regardless of citizenship, legal status, or ability to pay. There are no reimbursement provisions. Participating hospitals may not transfer or discharge patients needing emergency treatment except with the informed consent or stabilization of the patient or when their condition requires transfer to a hospital better equipped to administer the treatment.[1]

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."[3] The combined payments of Medicare and Medicaid, $602 billion in 2004,[4] or roughly 44% of all medical expenditures in the U.S., make not participating in EMTALA impractical for nearly all hospitals. EMTALA's provisions apply to all patients, not just to Medicare patients.[5][6]

The cost of emergency care required by EMTALA is not directly covered by the federal government. Because of this, the law has been criticized by some as an unfunded mandate.[7] Uncompensated care represents 6% of total hospital costs.[8]

Mandated and non-mandated care[edit]

Congress passed EMTALA to combat the practice of "patient dumping," i.e., 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 has a medical emergency "and a request is made on the individual's behalf for examination or treatment for a 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."[9] This 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.[9]

An emergency medical condition 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 must be treated until delivery is complete unless a transfer under the statute is appropriate.[9]

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.

Non-covered medical conditions[edit]

Not all medical problems are covered by EMTALA, meaning that a person cannot assume that if they are ill, they will be treated. Specifically, EMTALA does not cover non-emergency situations. The hospital is allowed to determine that there is no emergency, using their normal screening procedure, and then refuse EMTALA treatment [1].

Examples of conditions not considered emergencies by courts or hospitals[edit]

A significant portion of emergency room visits are considered not emergencies as defined by EMTALA and are therefore not covered [2]. The medical profession refers to these cases as "non-emergent".

If a patient is already in the hospital for another reason and develops an emergency condition, EMTALA similarly does not apply. [4]

Hospital obligations[edit]

Hospitals have three obligations under EMTALA:

  1. Individuals requesting emergency care, or those for whom a representative has made a request if the patient is unable, must receive a medical screening examination to determine whether an emergency medical condition (EMC) exists. The participating hospital cannot delay examination and treatment to inquire about methods of payment or insurance coverage, or a patient's citizenship or legal status. The hospital may only start the process of payment inquiry and billing once they have ensured that doing so will not interfere with or otherwise compromise patient care.
  2. The emergency room (or other better equipped units within the hospital) must treat an individual with an EMC until the condition is resolved or stabilized and the patient is able to provide self-care following discharge, or if unable, can receive needed continual care. Inpatient care provided must be at an equal level for all patients, regardless of ability to pay. Hospitals may not discharge a patient prior to stabilization if the patient's insurance is canceled or otherwise discontinues payment during course of stay.
  3. If the hospital does not have the capability to treat the condition, the hospital must make an "appropriate" transfer of the patient to another hospital with such capability. This includes a long-term care or rehabilitation facilities for patients unable to provide self-care. Hospitals with specialized capabilities must accept such transfers and may not discharge a patient until the condition is resolved and the patient is able to provide self-care or is transferred to another facility.


Since its original passage, Congress has passed several amendments to this act. Additionally, state and local laws in some places have imposed additional requirements on hospitals. These amendments include the following:


Improved health services for uninsured[edit]

The most significant effect is that, regardless of insurance status, participating hospitals cannot deny urgent medical assistance. Currently EMTALA only requires that hospitals stabilize the emergency. According to some analyses of the U.S. health care safety net, EMTALA is an incomplete and strained program.[10][11]

Cost pressures on hospitals[edit]

According to the Centers for Medicare & Medicaid Services, 55% of U.S. emergency care now goes uncompensated.[12] 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 this cost shifting amounted to $455 per individual or $1,186 per family in California each year.[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 end up writing off 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,[12] but it is unclear what percentage of this was emergency care and therefore attributable to EMTALA.

Financial pressures on hospitals in the 20 years since EMTALA's passage have caused them to consolidate and close facilities, contributing to emergency room overcrowding.[14] According to the Institute of Medicine, between 1993 and 2003, emergency room visits in the U.S. grew by 26 percent, while in the same period, the number of emergency departments declined by 425.[15] Ambulances are frequently diverted from overcrowded emergency departments to other hospitals that may be farther away. In 2003, ambulances were diverted over a half a million times, not necessarily due to patients' inability to pay.[15]

See also[edit]

Notes and references[edit]

  1. ^ a b c 42 U.S.C. § 1395dd
  2. ^ 42 U.S.C. § 1395dd (e)(2) The term "participating hospital" means a hospital that has entered into a provider agreement under section 42 U.S.C. § 1395cc of this title.
  3. ^ Emergency Medical Treatment and Active Labor Act summary, Families USA.
  4. ^ Key Medicare and Medicaid Statistics from kff.org
  5. ^ Text of act from law.cornell.edu
  6. ^ EMTALA FAQ Website / Information from Garan Lucow Miller, P.C
  7. ^ Fact Sheet: EMTALA from the American College of Emergency Physicians accessed 2007-11-01
  8. ^ American Hospital Association, Trends Affecting Hospitals and Health Systems 2011, Chapter 4, Slide 7
  9. ^ a b c American College of Emergency Physicians: EMTALA Fact Sheet, accessed 2007-10-05.
  10. ^ Catherine Hoffman and Susan Starr Sered (November 2005). "Threadbare: Holes in America's Healthcare Safety Net" (PDF). The Kaiser Commission on Medicaid and the Unisured. Retrieved 2007-10-22. "Health conditions that are not immediately life-threatening, but urgent and should be managed initially by specialists, fall through the holes in the safety net." 
  11. ^ "Report Brief. America's Health Care Safety Net: Intact but Endangered" (PDF). Institute of Medicine, National Academies of Science. 2000-01-01. Retrieved 2007-10-22. "In the absence of universal health insurance, a health care “safety net” is the default system of care for many of the 44 million low-income Americans with no or limited health insurance as well as many Medicaid beneficiaries and people who need special services. This safety net system is neither uniformly available throughout the country nor financially secure." 
  12. ^ a b The Uninsured: Access to Medical Care, American College of Emergency Physicians, accessed 2007-10-05[dead link]
  13. ^ a b (Peter Harbage and Len M. Nichols, Ph.D., "A Premium Price: The Hidden Costs All Californians Pay In Our Fragmented Health Care System," New America Foundation, 12/2006)
  14. ^ http://www.washingtonpost.com/national/health-science/medstar-washington-hospital-center-to-cut-more-than-200-jobs-due-to-financial-woes/2013/11/11/913dfbd4-4afe-11e3-9890-a1e0997fb0c0_story.html
  15. ^ a b Fact Sheet: The Future of Emergency Care: Key Findings and Recommendations, Institute of Medicine, 2006, accessed 2007-10-07.

External links[edit]