Bruce Bartlett held senior policy roles in the Reagan and George H.W. Bush administrations and served on the staffs of Representatives Jack Kemp and Ron Paul. He is the author of “The Benefit and the Burden: Tax Reform – Why We Need It and What It Will Take.”

Republicans have a dilemma on health policy. They are adamantly opposed to government paying for health care or a mandate requiring people to buy health insurance. At the same time, they recognize that they cannot say to the world that if a dying person shows up at an emergency room without insurance, that person will be left to die in the street. Thus they support a little-known mandate requiring hospitals to treat the uninsured, the Emergency Medical Treatment and Active Labor Act.

Today's Economist Perspectives from expert contributors.

Often referred to as Emtala, the bill passed a Republican Senate and was signed into law by Ronald Reagan on April 7, 1986. It was enacted because, previously, people had in fact been left to die in the street when hospital emergency rooms would not admit them without insurance. This problem was highlighted in a “60 Minutes” broadcast on March 17, 1985 that spurred Congressional action

Since then, Republicans have routinely cited Emtala as a key reason that the United States already has de facto national health insurance and does not need further government involvement in health care. As George W. Bush put it in a July 10, 2007, speech: “People have access to health care in America. After all, you just go to an emergency room.”



During the 2008 campaign, one of John McCain’s health advisers asserted that because of Emtala, there were, in fact, no uninsured in America. As the economist John Goodman of the National Center for Policy Analysis told The Dallas Morning News in an article published on Aug. 27, 2008: “The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care. So there you have it. Voila! Problem solved.” (This article is no longer available on the Dallas Morning News Web site, but the reaction it drew can be found in blog posts from that week.)

This year, Mitt Romney is making the same assertion – that the Affordable Care Act and its hated individual mandate for health insurance is unnecessary because Emtala effectively constitutes a sufficient safety net for those needing health care but lacking insurance.

As Mr. Romney said on “60 Minutes” on Sept. 23, 2012, “We do provide care for people who don’t have insurance, people – we – if someone has a heart attack, they don’t sit in their apartment and die. We pick them up in an ambulance, and take them to the hospital and give them care.”

Mr. Romney repeated this point in an interview with The Columbus Dispatch on Oct. 11, 2012. As the paper reported:

Romney minimized the harm for Americans left without health insurance. “We don’t have a setting across this country where if you don’t have insurance, we just say to you, ‘Tough luck, you’re going to die when you have your heart attack,’” he said as he offered more hints as to what he would put in place of “Obamacare,” which he has pledged to repeal. “No, you go to the hospital, you get treated, you get care, and it’s paid for, either by charity, the government or by the hospital. We don’t have people that become ill, who die in their apartment because they don’t have insurance.” He pointed out that federal law requires hospitals to treat those without health insurance – although hospital officials frequently say that drives up health-care costs.

In fact, the Emergency Medical Treatment and Active Labor Act isn’t even remotely a substitute for health insurance or something that obviates the purpose of health reform. It does not demand that all hospitals care for whoever walks in, only those who require urgent care to avoid serious injury or life-threatening consequences. Only hospitals that both participate in Medicare and have emergency rooms are covered by the law

Moreover, someone admitted to an emergency room under Emtala is not held until cured, only stabilized until she can be sent home or to a public hospital or other facility willing to treat the patient without charge.

Needless to say, the questions of whether an uninsured person seeking care at an emergency room is indeed in an immediate, urgent situation and whether she or he is stable enough to be discharged are highly contentious. A new report in the journal Health Affairs found that hospitals continue to engage in a practice known as “patient dumping” – turning away uninsured patients from emergency rooms despite the law.

One reason they are able to do so is because in 2003 the George W. Bush administration eased the rules regarding Emtala. The official responsible for weakening the law was Thomas A. Scully, who served as president of the Federation of American Hospitals from 1995 to 2001 and is now a lobbyist for the health care industry.

It’s worth remembering that once upon a time – in the 1990s – Republicans were in high dudgeon about “unfunded mandates.” In their 1994 “Contract With America,” they promised to fix this problem and in 1995 enacted the “Unfunded Mandates Reform Act.”

The Republican argument on mandates was perfectly valid. To save money on-budget, the federal government often mandates that businesses or state and local governments undertake some activity. But of course, the cost doesn’t disappear just because it doesn’t involve federal taxes or spending; it just comes out of someone else’s pocket.

Therefore, even if we accept the Republican contention that Emtala is sufficient to deal with the problem of the uninsured without mandating that people obtain health insurance, all that is happening is a shifting of the cost of caring for such people. To a large extent, they end up being paid by the insured through higher medical bills and insurance premiums. In New York, for example, a 9 percent surcharge on all hospital bills covers the cost of caring for indigents, though complaints abound of hospitals failing to comply with the law.

The purely partisan hatred by Republicans for the individual mandate – which used to be the foundation of their health policy – has ironically led them to embrace another mandate on hospitals. But it is a very inadequate and inefficient substitute for health insurance – something Mr. Romney used to acknowledge – and every bit as much a violation of Republican principles, which oppose unfunded mandates, as the individual mandate that they abhor.