Full text of DOI:10.1111/j.1553-2712.2001.tb01116.x

1064
EMTALA
Fields et al. • EMTALA AS SAFETY NET
The Emergency Medical Treatment and Labor Act as a
Federal Health Care Safety Net Program
W. WESLEY
REGORY L. LARKIN, MD, MSPH, CATHERINE A. MARCO, MD,
OREN A. JOHNSON, MD, CHARLOTTE EH, MD,
EITH T. GHEZZI, MD, MICHAEL APP, MD
FIELDS, MD, BRENT R. ASPLIN, MD, MPH,
G
L
Y
K
R
Abstract. Despite the greatest economic expansion appreciated or addressed by Congress or the Ameri-
in history during the 1990s, the number of uninsured can public. Cuts in payments from public and private
U.S. residents surpassed 44 million in 1998. Although payers, as well as increasing demands from a larger
this number declined for the first time in recent years uninsured population, have placed unprecedented fi-
in 1999, to 42.6 million, the current economic slow- nancial strains on safety net providers. This paper
down threatens once again to increase the ranks of reviews the financial implications of EMTALA, illus-
the uninsured. Many uninsured patients use hospital trating how the statute has evolved into a federal
emergency departments as a vital portal of entry into health care safety net program. Future actions are
an access-impoverished health care system. In 1986, proposed, including the pressing need for greater
Congress mandated access to emergency care when public safety net funding and additional actions to
it passed the Emergency Medical Treatment and La- preserve health care access for vulnerable popula-
bor Act (EMTALA). The EMTALA statute has pre- tions. Key words: Emergency Medical Treatment and
vented the unethical denial of emergency care based Labor Act; safety net; health insurance; funding. AC-
on inability to pay; however, the financial implica- ADEMIC EMERGENCY MEDICINE 2001; 8:1064–
tions of EMTALA have not yet been adequately 1069
OR several decades, the U.S. Department of (EMTALA) is a civil right extended to all U.S. res-
F
Health and Human Services has promoted idents.3 This federal law requires screening and
health care access by emphasizing the importance stabilization for all who seek emergency depart-
of having health insurance and a regular source of ment (ED) care, regardless of ability to pay, and it
continuing care.1 Yet because public and private ef- threatens both physicians and hospitals with ex-
forts to achieve universal access to health care in- plicit legal and financial penalties for noncompli-
surance and to promote affordable and convenient ance. Hospitals with EDs, emergency physicians
points of service have been unsuccessful, an un- (EPs), and the medical and surgical specialists who
funded mandate on hospital-based providers has back them up are providers of the first health care
emerged as the most important and least recog- service to be legally identified by the federal gov-
nized federal health care safety net program. As ernment as an essential public service.
enacted by Congress in 1986, enforced by the Cen-
The Institute of Medicine (IOM) recently noted
ters for Medicare and Medicaid Services (CMS), several threats to the future viability of the health
and recently upheld by the U.S. Supreme Court,2 care safety net, including inadequate funding, poor
the Emergency Medical Treatment and Labor Act integration of services, increased price competition
in the health care marketplace, and rapid growth
in Medicaid managed care.4 The IOM defined ‘‘core
safety net providers’’ as having two distinguishing
From the American College of Emergency Physicians Safety
Net Task Force (WWF); Regions Hospital and HealthPartners characteristics: 1) either by legal mandate or ex-
Research Foundation, St. Paul, MN (BRA); Guy’s & St. Tho-
mas’ NHS Trust, London, UK (GLL); St. Vincent Mercy Medi-
cal Center, Toledo, OH (CAM); Sutter Medical Center, Davis,
CA (LAJ); American College of Emergency Physicians Task
plicitly adopted mission they maintain an ‘‘open
door,’’ offering access to services for patients re-
gardless of their ability to pay; and 2) a substantial
share of their patient mix is uninsured, Medicaid,
Force on Health and the Uninsured (CY); American College of
Emergency Physicians Federal Government Affairs Committee and other vulnerable patients.
(KTG); and American College of Emergency Physicians.
Received February 26, 2001; revision received July 17, 2001;
accepted July 31, 2001.
Address for correspondence and reprints: W. Wesley Fields,
MD, 24411 Health Center Drive, Suite 385, Laguna Hills, CA
92653. Fax: 949-951-6673; e-mail: fieldsw@medamerica.com
The U.S. emergency medical care system con-
tinues to operate on the basis of universal access
to care for all who seek it, and EDs play a vital
role as core safety net providers in today’s health
care system. As mandated by EMTALA, emergency

ACADEMIC EMERGENCY MEDICINE • November 2001, Volume 8, Number 11
1065
services are uniformly available to all, regardless
of age, race, gender, religion, insurance status, or
time of day. In practice, EMTALA is far more than
a legal requirement for providers to perform emer-
gency medical screening for ED outpatients. Be-
cause of the legal and ethical obligations of physi-
cians and hospitals to stabilize life- and
limb-threatening medical conditions, EMTALA in
effect guarantees definitive hospital care for cata-
strophic illness or injury to all U.S. residents. The
EMTALA statute protects 42.6 million uninsured
individuals, as well as those who are enrolled in
private or government-sponsored insurance plans.5
In this respect, it rivals all other federal health
care programs in both scope and influence. In an
era of fragmented delivery systems and growing
numbers of uninsured U.S. residents, EMTALA
has profound implications for access to medical
care. This paper reviews the financial implications
Figure 1. Estimated emergency department (ED) visits
per 100 individuals by insurance type. The overall mean
was 37.3 visits per 100 residents. Uninsured individuals
had 34.2 and privately insured people had 19.9 visits
per hundred. Medicaid beneficiaries had the highest uti-
lization rate (64.2). From National Center for Health
Statistics/Census Bureau 1998 data.
The National Center for Health Statistics
of EMTALA, illustrating how the statute has (NCHS) estimated that 100.4 million ED visits oc-
evolved into a federal health care safety net pro- curred in the United States in 1998, including
gram.
15.1% by patients who were self-pay.8 Although
NCHS staff equate the uninsured with self-pay pa-
tients in their surveys, this approach somewhat
understates the number of ED patients without in-
surance, since many states mandate that EDs not
charge patients who are medically indigent yet not
covered by Medicaid. The NCHS data suggest that
1.2 million no-charge visits occurred in 1998.
Taken together, ED visits by the uninsured were
approximately 16.3 million in 1998. Census Bu-
reau data for 1998 also estimated that 16.3% of the
U.S. population was uninsured.9 While it is com-
monly assumed that the uninsured frequent EDs
much more than other payer classes, the Census
Bureau and NCHS data do not support this notion.
For 1998, the NCHS estimated the annual ED visit
rate for all persons to be 37.3 per hundred U.S.
residents. By applying Census Bureau data on the
numbers of U.S. residents without insurance for
1998 to the number of self-pay ED visits in NCHS
data, the annual ED utilization rate can be esti-
mated to be 34.2 per hundred. If the same analysis
is applied to other payer classes for the same year,
the uninsured appear to use EDs more than per-
sons with private insurance (19.9/100), who have
better access to non-ED care, slightly less than all
U.S. residents, and barely half the rate of Medicaid
beneficiaries (64.2/100) (Fig. 1).
EMTALA AS A
H
EALTH
CARE
DELIVERY MANDATE
Although the IOM report did not explicitly list
them as core safety net providers, the nation’s
5,000 EDs have emerged as perhaps the most vis-
ible safety net facilities in the current health care
environment. The importance of EMTALA-man-
dated access to basic health care is underscored by
the fact that there are only 1,000 federally char-
tered nonprofit clinics.5 Although most safety nets
are by nature local or regional in structure, the
American Hospital Association’s (AHA’s) annual
survey demonstrates the vast size and national
scope of the EMTALA safety net.6 For the 5,229
nonfederal acute care hospitals reporting in 1994,
hospitals were sorted by the percentage of uncom-
pensated care provided.7 The top decile reported
that 15% of total operating revenue was uncom-
pensated care. This decile was more than twice as
likely to contain public or district hospitals (50%
vs 22% for all other deciles) and also included most
of the major teaching facilities in the nation, yet
only 55% of these hospitals were within metropol-
itan statistical areas. Thus, nearly half the hospi-
tals in the top decile of uncompensated care were
rural facilities, many with fewer than 50 beds. For
the other nine deciles of safety net facilities, which
provided approximately 60–70% of all uncompen-
sated care in 1994, the overall picture is different.
Seventy-seven percent were private community fa-
cilities (the vast majority had nonprofit status),
80% did not have resident physicians to provide
In 1997, the American College of Emergency
Physicians prospectively studied the ED staffing of
942 hospitals randomly selected from the 1995 da-
tabase of the AHA.10 The study concluded that
3,889 full-time equivalents (FTEs) were required
to provide treatment for the 18.7 million patients
seen in the 942 sampled EDs during 1997. Using
professional services to the uninsured, and 82% these data to estimate workforce needs, approxi-
were outside of the nation’s 100 largest cities. mately 3,400 EPs were employed full-time to treat

1066
EMTALA
Fields et al. • EMTALA AS SAFETY NET
T
ABLE 1. Emergency Physician and Outpatient Facility
ably, NCHS data on all hospital discharges in 1998
suggest that self-pay patients were responsible for
only 1,469,000 admissions to acute care facilities.
Thus it appears that nearly 93% of all U.S. hos-
pitalizations by the uninsured can be directly
linked to an ED visit (Fig. 2).
Costs for Self-pay and No-charge Patients in 1998*
Emergency physician costs
Total ED visits by self-pay/no-charge
patients
16.3 million
Estimated emergency physician
RVU per visit
$63.92
Although the direct facility costs of EMTALA-
related hospitalizations are difficult to measure, an
estimate can be made from a 1987 analysis by the
Agency for Healthcare Research and Quality
(AHRQ). In this study the uninsured incurred
$5,679 in costs per hospitalization (108% of the av-
erage cost for insured patients).13,14 Thus, without
cost adjustments for the period between 1987 and
1995—a period when costs were rising rapidly in
many markets—the 1.47 million admissions (in-
Estimated physician RVU costs
$1,041,896,000
Facility costs
Total self-pay/no-charge ED patients
discharged
Estimated hospital costs per visit
Uninsured hospital outpatient ED
costs
15.2 million
$145.50
$2,211,600,000
*Estimates of emergency physician and outpatient facility
costs for the 16.3 million self-pay emergency department (ED)
patients seen in 1998. Inpatient costs arising from admission
or transfer to another facility following ED stabilization are cluding transfers) of self-pay patients from the
not included. These estimates use a relative value unit (RVU)
analysis to adjust emergency physician and facility charges by
the Medicare cost-to-charge ratio.
NCHS survey cost hospitals at least $8.35 billion
in 1998.
The Congressional Budget Office’s (CBO’s) pro-
jections regarding uncompensated hospital and
the 16.3 million uninsured ED patients seen in physician costs support the role of the ED as the
1998, or 14% of the entire emergency medicine central portal of access for America’s uninsured
(EM) workforce.
and underinsured. The CBO estimated that in
Public data suggest that the total direct ex- 1991 the uninsured received $15.2 billion in un-
pense for EP services to the uninsured is approxi- compensated hospital care, and predicted that by
mately $1 billion annually.11,12 In 1996, Williams 1995, the total cost of total uncompensated care
reported a relative value unit (RVU) analysis of EP would grow to $27.6 billion, with $11.0 billion pro-
charges adjusted by Medicare cost-to-charge ratios. vided by physicians.13,15 These losses are not lim-
The all-patient mean physician staffing cost in this ited to care for the uninsured, since Medicaid re-
study was $63.92. When extrapolated to the 16.3 imbursement does not approach provider costs in
million uninsured patients seen in 1998, estimated most states, and managed care organizations
physician staffing costs were just over $1 billion. (MCOs) are increasingly likely to contribute to un-
Using the same methodology, Williams estimated compensated care. Similarly, it is difficult to esti-
that mean facility costs for patients discharged mate the office costs of follow-up services provided
from the ED were $145.50. In 1998, 14.1 million by on-call and backup specialists, which may go far
self-pay patients in the NCHS survey were dis- beyond those provided in the ED and hospital.
charged from the ED. Total facility costs for these Since NCHS survey data suggest that 45.6% of all
patients were therefore just over $2 billion (Table ED patients were referred to another physician or
1).
clinic (nearly four times the number of ED patients
The stabilization requirement under EMTALA admitted to the hospital), it is not unreasonable to
also applies to inpatients with new or unresolved assume that the full professional costs of outpa-
emergency medical conditions, extending the full tient care for the 14.1 million self-pay ED patients
costs of the EMTALA mandate far beyond the costs not requiring hospitalization are substantial, and
of ED care. The NCHS data for ED visits in 1998 might approach those of patients admitted to the
reported 1,048,000 hospitalizations by self-pay pa- hospital. In any case, EMTALA-related services to
tients at the facilities where they initially pre- self-pay and no-charge patients appear to account
sented, as well as 315,000 transfers to other facil- for half of all uncompensated hospital costs in
ities. Given the EMTALA prohibitions against 1998.
transfers for financial reasons alone, it is reason-
Regardless of their ability to pay, ED patients
able to assume that self-pay patients are only already lack timely access to services provided by
transferred to a higher level of hospital care, or to specialists who back up EPs. Because of growing
public hospitals with obligations to care for the disenchantment among specialists with the num-
medically indigent within local safety nets. Taken ber of uninsured, Medicaid, and non-contracted
together, without including 89,000 admissions and MCO patients for whom they receive little or no
19,000 transfers of no-charge patients, NCHS data reimbursement for ED services, 60% of California
suggest that 1,360,000 hospitalizations for self-pay hospital administrators and physician executives
patients directly resulted from ED visits. Remark- recently reported ‘‘serious’’ problems with ED

ACADEMIC EMERGENCY MEDICINE • November 2001, Volume 8, Number 11
1067
backup in their facilities.16 Emergency department
crowding, which recently has been widely reported
in the mass media, may continue to occur more
frequently.17 This can be traced to narrow or neg-
ative operating margins of hospitals, a shortage of
acute care nurses, and ED closure rates 27%
higher than those for hospitals themselves.18 These
disturbing trends underscore the need for explicit
safety net financing to cover the cost of care pro-
vided under EMTALA and prevent further disrup-
tions in health care access for vulnerable popula-
tions.
Beyond the commitment of hospitals and phy-
sicians participating in the safety net, EMTALA
has become the federal instrument that affords un-
insured patients the same hospital care for life-
threatening illnesses and injuries that would be
Figure 2. More than 93% of the 1.47 million hospitalized
self-pay patients in 1998 were admitted via the emer-
gency department (ED). These data reflect the essential
role EDs play in maintaining access to inpatient care for
the uninsured. NCHS = National Center for Health Sta-
tistics. From: National Center for Health Statistics/ED
hospital survey data from 1998.
expected if they were insured. This right was at tient information, enhancing communication, and
the core of a recent Supreme Court decision, which creating local networks of safety net providers may
held that a hospital’s obligation to patients admit- improve continuity of care for vulnerable popula-
ted via the ED extends until they are stable for tions. Emergency departments are also part of the
discharge home. Unfortunately, the AHRQ analy- solution in the public health paradigm and can be
sis suggests that the costs of acute hospital care used locally as a prospective surveillance, health
may be higher for uninsured patients, likely be- risk appraisal, and immunization network. Local
cause of delays in seeking care due to inadequate stakeholders may support these services if a clear
access. The full costs of ED outpatient and hospital community benefit can be demonstrated. Not-for-
inpatient care rendered to the uninsured by safety profit hospitals may wish to consider the merits of
net facilities and physicians in 1998 can be crudely allowing community-based safety net providers ac-
estimated to be $15–20 billion. This estimate is cess to higher technologies and special services for
worthy of statistical validation, given the scale and their patients before acute hospitalizations are re-
importance of EMTALA in the continuing health quired, as MCOs have already done for insured
care policy debates.
populations.
State policy can demonstrably be influenced
when policymakers, hospital and professional as-
sociations, and patient advocacy organizations
hear the collective voice of EM. These groups can
collaborate to generate data that define the scope
and cost of EMTALA-related care, and also identify
the most efficient mechanisms to allocate re-
sources. National associations in EM must coordi-
nate state-level efforts and serve as clearinghouses
for effective solutions and strategies.
Policymakers at CMS and elsewhere in the fed-
eral government should consider whether the cur-
rent mandate on individual hospitals under
EMTALA could not more effectively be defined as
an obligation of communities and health care sys-
tems. This approach would take into account the
extensive consolidation of both hospitals and phy-
sician groups that has occurred since EMTALA
was enacted. Further, it would encourage compet-
ing provider organizations within local markets to
consider how to cooperatively share the burdens
created by EMTALA. Local emergency medical ser-
vices agencies are already given discretion regard-
ing transfer and destination policies under
D
IRECTIONS FOR THE
FUTURE
For better or worse, EMTALA has become more
important today than when it was first enacted.
The statute ensures that hospital EDs have been
one of the few sources of stability in an otherwise
fraying health care safety net. We applaud the eth-
ical basis for EMTALA, yet question whether its
mandates can be maintained given the resource
limitations in the health care system following an
era of market-driven reform. We must continue to
advocate for incremental expansions in health in-
surance coverage. There are many mechanisms for
expanding coverage, and a detailed discussion of
these is beyond the scope of this paper; however,
the EMTALA funding gap will never be filled if the
number of uninsured Americans continues to grow.
But barriers to the expansion of insurance cover-
age, however frustrating, should not eclipse crea-
tive strategies for funding EMTALA-mandated
care at the local, state, and federal levels.
At the local level, EPs must network more ef-
fectively with other core providers in the commu-
nity to help mend the safety net’s fabric in ways EMTALA. Broadening participation of local and re-
heretofore unimagined. For example, sharing pa- gional governments and community leaders in de-

1068
EMTALA
Fields et al. • EMTALA AS SAFETY NET
cisions about safety net services and resource al- safety net, and act quickly to support the essential
location would appear to support EMTALA’s orig- services that EMTALA guarantees for all.
inal intent of protecting vulnerable populations.
With the decline in Hill-Burton funds, the clo-
Federal policymakers should also consider using sure of public and private hospital EDs, MCO gate-
disproportionate share (DSH) payments to support keeping, and the growing strata of uninsured, ED
EMTALA-mandated services. Currently, DSH pay- access is at a 20-year low.20 The need for ED access,
ments are added to Medicare and Medicaid pay- however, has never been greater: interpersonal vi-
ments for facilities that serve a high proportion of olence, illegal immigration, drug and alcohol ad-
uninsured and Medicaid patients. It may be pos- diction, mental illness, the rise in asthma-related
sible to reform the DSH payment system to include mortality, and other acute illnesses all demand
funding for care provided under EMTALA.
ready access to safety net providers.21,22 If America
continues to take the EMTALA-based system for
granted, increasing numbers of patients will fall
through the ever-widening holes in the health care
safety net. The old economics, which treats health
care as a commodity, must give way to a new order,
which affirms that safety net care in general, and
emergency care in particular, constitutes an essen-
tial public service worthy of protection.
CONCLUSIONS
It is increasingly difficult for hospital-based safety
net providers to deliver on the EMTALA promise
of universal access to ED services in the absence
of direct funding for the mandate. Given that the
U.S. health care delivery system is increasingly
predicated on market-driven pricing of services to
separately pooled populations in MCOs, the task
grows more impossible by the day. Ultimately,
Americans must decide as a democratic society
how to resolve the crisis of inadequate access to
health care and health insurance. Access to emer-
gency services will be increasingly in jeopardy for
all U.S. residents, regardless of their insurance
status, if we fail to reconcile the inherent conflict
between government mandates on a shrinking pool
of hospital-based safety net providers and a health
care marketplace still driven by profit. Although
EMTALA-related costs do not appear among their
principal drivers, overall increases in medical costs
and managed care market share have combined to
produce a funding vacuum that the safety net can-
not hope to fill.
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