Fifteen days of blogging for health care reform: Unfunded mandates

“You know about EMTALA, right?”

Oh yes, EMTALA: The Emergency Medical Treatment and Active Labor Act. This is the law that mandates that anyone who is hurt or in labor can show up to almost any ED and has the right to be seen by a provider, no matter if they can pay or not (not that this stops private hospitals from owning ambulance companies and directing their fleet to triage their cargo to various hospital, including or not including their own, based on their gestalt assessment of the patient's ability to pay). It always seemed to me - as it probably seems to most - that emergency departments, merely by their nature, have some kind of cosmic obligation to treat emergencies. But this is not the case. There is actually an American law that states that all emergency departments - at least all those who receive any reimbursement from the Medicare/Medicaid axis - must triage, stabilize, and at least transfer to an appropriate facility (if not treat in house) anyone who presents ill, injured, or in labor. Without this law, you can bet that certain emergency departments would not accept certain patients…of that you can be certain.

EMTALA, it turns out, is a mixed blessing for the uninsured and underinsured folks of America. On one hand, it provides the final and definitive safety net for those without any other means of access to health care. You can be undocumented, on the lam from a felony charge, hopped up on meth, without a cent to your name (and believe me, this constellation of demographic niceties is not a rare story at the university ED), and if you walk into any almost emergency department in America, they have to address your chest pain, your diabetes, your stab wound, your disease du jour. EMTALA is what stands between care and disaster for a large number of American citizens and others living and working inside our borders.

EMTALA is also - in my opinion - one of the primary stumbling blocks between America and concrete health care reform. However noble in intent, it is entirely possible that without EMTALA, pressure would have mounted so high on the health care system from so many quarters by now (from so many people dying, being turned away from the ER doors with no insurance) that something would have had to give. The stitching on real safety nets might have begun. No one can say for sure, of course - Americans are breath-taking in our ability to bury heads in sands when tough but feasible answers are available to nasty problems - but EMTALA has become both a curse and godsend to every uninsured person in the country. If worst comes to worst, the ER always has to take you. It makes us all sleep a little better at night. And because we all sleep a little better at night, we don't bother to get up the next morning and do something concrete to solve the problem of lack of health care access.

Would I revoke EMTALA now? No, of course not - the ferrets are already loose in the chicken house, it would do far more harm than good. But if I could go back two decades to the year that EMTALA was passed - to a time when the health care crisis was just peaking around the corner and not brewing in forty million-plus American homes - I might have thought twice and hard about whether it was such a good idea. By providing half a safety net full of holes, we have put off the weaving of a strong social fabric to take care of the nation‘s health.