Yves here. Please welcome Dorothy McNoble, a practicing surgeon who has an interest in health care policy. Her first post focuses on the not-sufficienty-recognized way that the requirement that hospitals accept emergency room patients has stymied health care reform and how the ACA was designed in part to alleviate this “unfunded mandate” and reduce the number of patients coming to emergency rooms for primary care (whether by design or by waiting until manageable conditions became acute).

I must confess to having a personal interest in this article, since I’ve had a big dose of emergency room visits this month. I considered myself lucky in that my insurance policy covers medical care from any provider in the world and so paid for these incidents (in addition to being a hoary old indemnity plan, it also has a low deductible). But it may be more correct to see it as the hospitals that were lucky, since they were obligated to treat me regardless of my ability to pay and they will be paid.

Hoever, this article mentions an issue in passing: how Obamacare has reduced the load on emergency rooms. The MD’s wife who accompanied me to Cedars Sinai mentioned that, and while the plural of anecdote is not data, my experiences confirmed that.

In LA, I got into a room in less than 15 minutes after being admitted, despite not having anything life threatening, and was by two different doctors and discharged in 5 hours. It would have been even faster except when my eye un-numbed from the pain-killling eyedrops, it still felt like I had something in it, so I went back and had a doctor who wound up being a second doctor, give the eye a really good look to make sure there was nothing in it.

This took place on a Saturday night, which is presumably a prime time for incidents. Similarly, on a Sunday night (really Monday AM) at UCSF, which is a bad time, since an evening of people came in ahead of me, I saw a doctor in 3 hours who established I didn’t have any of the worst case scenarios for the sudden deterioration of vision in my right eye (sudden onset glaucoma or a detached retina). By 6:30 AM two opthalmologists (one I think an intern, but still…) examined me, when the ED had led me to expect I’d have to wait until the eye clinic opened at 8:00 AM. So that was a bit over 6 hours after arrival.

By contrast, the last time I had a scare (and it was only a scare) in 2009, pre Obamacare, I went to Mount Sinai in NYC on a sunny Sunday afternoon, which ought to have been a dead time, and the ER staff confirmed that it was slow. Even so, seven hours later, I had only been moved to a gurney and a doctor chatted briefly with me then. Based on what he said (hardly an exam, but “Oh you take X [snort]?” meaning my symptoms could be explained by the one prescription I was taking) I decided to leave. It was hardly good patient behavior but I thought the thing I was worried about (deep vein trombosis, when I have no family or personal history and hadn’t been on a plane) seemed pretty unlikely to begin with, so having the doctor say my symptoms were attributable to my meds was all I needed to know.

But the bigger point was that in 2009, it was clearly going to be another 6 hours minimum before I would have been seen properly, much the less tested, so I was on track to being there for 18 to 24 hours before I got an answer based on test results. So the load on emergency rooms, and the resulting increase in risks to people suffering from life-threatening conditions, like strokes or serious injury due to an accident, and discomfort to everyone else, is a hidden cost to everyone if Obamacare is rolled back.

By Dorothy J. McNoble, MD, JD, who can be reached at Badmedicine005-at-gmail.com

A 46 year old man comes to the hospital by ambulance for severe abdominal pain. He is diagnosed with a perforated ulcer and undergoes emergency surgery. He receives post-operative fluids, antibiotics, pain medication and ulcer medication. He recovers after five days and is discharged. He is unemployed, has no insurance and neither the hospitals nor the physicians receive any payment for his care.

This story of timely and appropriate emergency medical care delivered to patients unable to pay for it occurs tens of thousands of times a day in this country. Though physicians and hospital administrators might provide such services for moral or ethical reasons, it is unnecessary to rely upon the consciences of these providers since a law mandates that they provide care.

Specifically, The Emergency Medical Treatment and Active Labor Act (EMTALA), passed by Congress in 1986 unequivocally requires that hospitals provide emergency medical and surgical care and other ancillary services to patients requesting this care irrespective of their ability to pay.

This law, though rarely mentioned by name during discussions of existing and proposed health care policy or law, has a profound and pervasive impact on the delivery of health care in this country. In fact, there is no area of government or privately provided health care which is not affected by the provisions of EMTALA and by the current economic sequela of this law.

In particular, many of the provisions of the Affordable Care Act were designed to remove some of the burdens imposed by the EMTALA. If the ACA is repealed, the benefits and burdens of EMTALA will emerge as more important than ever. It’s therefore important to make an explicit examination of EMTALA. Medicare, Medicaid, the Affordable Care Act and even rules governing private insurance cannot be fully understand without acknowledging the existence of this long standing health care safety net.

The Origins of EMTALA

EMTALA was passed in 1986 and requires that patients needing emergency medical care not be discharged or transferred to another hospital until the patient has received a medical screening exam. If the patient is found to have a condition requiring urgent medical or surgical care, that patient must receive the care unless he or she consents to discharge or transfer to another facility. The patient must receive this care without regard to his insurance status or his ability to pay for the care.

The law is an unfunded mandate. That is, unlike Medicaid, Medicare and the Affordable Care Act which establish taxpayer subsidy for the health care provided, EMTALA mandates the delivery of care, but contains no provision for funding the care. The law, as will be discussed below, has been interpreted very broadly and, as a result, it has a significant financial impact on health care in this country.

Uncompensated care represents up to an estimated 6% of total hospital costs. This number does not include the costs borne by the physicians and other providers as opposed to the institutional hospital costs, so the 6% is an underestimate of the cost. The hospitals in urban and rural areas with large numbers of medically indigent patients assume a much greater proportion of this cost and since the law is silent on funding and contains no provisions for reimbursement, there is no mechanism for spreading the cost among hospitals in a region in order to better distribute the loss.

In order to appreciate the breadth of the law, we’ll look at some examples illustrating the requirements of the law and how EMTALA can be invoked.

Non-Discrimination Under EMTALA

A 32 year old start-up billionaire in Silicon Valley is injured in a bicycle accident. He suffers a ruptured spleen and requires urgent splenectomy. He is hospitalized for approximately ten days and is discharged when he has fully recovered.

A 32 year drug dealer is assaulted during a drug transaction and suffers a ruptured spleen and requires urgent spelectomy. He is hospitalized at the same facility as the bicycle accident victim. He too is hospitalized for ten days and is discharged when he has fully recovered.

Both patients undergo the same operation, spend the same number of days in the ICU and on the ward and receive the same post-operative care.

This rather pedestrian example is designed to illustrate one of the fundamental mandates of EMTALA. Not only must medical care be identical for paying and non-paying patients, but any discrimination based upon socio-economic status, personal hygiene, behavioral issues (within reason), is prohibited under the law. Hospitals and providers are forbidden from proffering any suggestion that care could be withheld or in any way altered due to any of these considerations. The law itself incorporates a “what would Jesus do?” standard of care.

The Prohibition Against Involuntary Transfer Or Discharge

A 52 year old woman with chronic alcoholic pancreatitis is seen in the emergency room for an exacerbation of her condition. She is having pain and vomiting and requires hospital admission. The emergency room physician has contacted the County Hospital to request transfer since the patient is uninsured and she has had multiple admissions to several hospitals, including the County Hospital, in the past. The County Hospital accepts the admission, but the patient refuses to be transferred and insists on admission to the private hospital where she has sought care. She is admitted as she has requested.

A 44 year old uninsured, indigent man sustains a distal humeral fracture (a break in the bone of the upper arm). The emergency room physician reduces the fracture (aligns the two segments of bone into a straight line) and splints the arm. The fracture is stabilized temporarily and there is no threat to the nerves, blood supply or muscle of the arm as long as the splint is in place. The ER arranges for the patient to be seen the next day in the orthopedic clinic of the publically funded County Hospital so that definitive treatment of the fracture, including possible surgical placement of a rod in the center of the bone to stabilize it, can be undertaken.

The patient returns to the original emergency room the next day, having missed his orthopedic appointment in the County Hospital. He has loosened the splint and the bone alignment has been compromised. The emergency room physician contacts the county hospital orthopedist and asks her to accept the patient in inpatient care and treat the fracture. The County orthopedist refuses the request and asserts that the fracture can be managed on an outpatient basis as long as the bone is realigned and the splint replaced. The ER physician requests the patient to allow this treatment, but the patient refuses and says that he wants to be admitted to the hospital to which he has returned and receive treatment, including surgery in this hospital. The patient is admitted to the hospital and taken to surgery where the definitive rod placement is made.

The patient is hospitalized for several days because he does not find the oral pain medicine provides adequate post-operative relief and demands intravenous pain medicine for several days. When the surgical site is healed and he is willing to use oral pain medicine, he is discharged.

These examples illustrate several of the mandates of EMTALA and highlight some of the logistic and practical problems posed by the law. Hospitals may neither discharge nor transfer patients needing medical care without the patient’s consent. In theory, the law allows transfer to facilities such as county hospitals which receive federal, state and local funds to provide care for indigent patients.

In practice, however, this transfer of care is often unsuccessful. Many patients, especially those with recurring conditions, understand their right to be treated at the hospital to which they present. Although perhaps not able to identify EMTALA by name, many patients know the “no involuntary transfer” provision in substance.

Moreover the lack of insurance sometimes results in more expensive inpatient care such as the case of the patient with the broken arm who could have been managed electively with a secure splint until such time as a county clinic appointment were to be made available. He refused to comply with maintaining a secure splint and demanded more urgent surgical treatment at the hospital of his choice.

In contrast, an insured patient who does not want to incur unreimbursed expenses, may find that he or she must accept limitations on care such as placement in a splint for several days, until an in plan orthopedist is able to see the patient. Arguably, the hospital could have insisted that the patient in this example agree to replacement of the splint and transfer to County care, but, many hospitals feel compelled to err on the side of providing full treatment rather than risk the expense and penalties of a possible EMTALA violation.

Private Hospitals’ Own Safety Net from the EMTALA Mandate – The Public Hospital System

Historically, the health care system in this country has had an extensive public hospital system. Most of these hospitals are county and city based and are funded almost exclusively by federal, state, county and even city funds. The staffs are salaried rather than dependent upon patient billings and many contain programs specifically designed to assist the medically indigent, such as expanded social services programs, drug and alcohol treatment and assistance for homeless services. Many of these hospitals are well-known and well-respected for their patient care and their research programs.

Increasingly, however, these hospitals cannot care for the large numbers of uninsured patients. This burden falls upon the private hospitals, especially those in urban areas. As alluded to the in the examples above, transfer to these hospitals is often very difficult.

For example, it is clear in the EMTALA mandate that all patients, irrespective of immigration status be provided the same treatment as would a citizen. While many county hospitals provide care for undocumented immigrants, these hospitals do rely on their mandate to care for the citizens of their respective jurisdictions to refuse transfer of undocumented immigrants.

However, the main impediment to relying upon county and public hospitals to provide care for the uninsured is, of course, financial. In my experience, County Hospitals almost never accept patient transfers from private community hospitals. Fewer than 5% of patients for whom transfer is sought are granted a transfer. This includes patients who have received care at a County Hospital and are brought by ambulance to a private hospital for a complication following discharge from the County Hospital.

It is not uncommon for private community hospitals to be saddled with care for patients who have been treated and released from County Hospitals. County Hospitals are often at capacity. As long as the patient who has been discharged from their facility has been admitted to an emergency room at another hospital, the county hospitals have no legal obligation to resume care for the patient. Neither EMTALA nor any other law requires that publically funded hospitals provide any particular level of indigent care, or even agree to accept patients for whom they have begun providing care.

Moreover, County Hospitals in some jurisdictions are often on “divert” meaning that they are not accepting ambulances which would be bringing patients to their facility. These ambulances are “diverted” to other hospitals in the area and, as a result, those hospitals often see a disproportionate number of uninsured, emergency patients.

Thus, for two major reasons, patient “preference” for private hospital care and the public hospitals own resources limitations, the care of the medically indigent increasingly falls upon private hospitals and upon private practice physicians who have to rely on increasing their compensated patient billings to compensate for the provision of unreimbursed care.

Co-Pays, Deductibles and Pre-Existing Conditions – The Effect of EMTALA

A 55 year old man presents to his primary care doctor for rectal bleeding. He is found to be anemic and the physician recommends a colonoscopy and refers the patient to a gastroenterologist. The colonoscopy is scheduled, but the patient cancels the procedure because the gastroenterologist demands a $4000 payment toward the expense of the procedure. The patient has a plan with a $5000 deductible.

The patient continues to bleed and three weeks after the cancelled colonoscopy, he presents to the emergency room with the bleeding and is found to have worsening anemia. At the time of admission to the ER he suffered a syncopal episode (he fainted), and his bleeding has increased. No outpatient colonoscopy has been rescheduled because the patient does not have the requisite co-pay.

The emergency room staff and the admitting staff decide to admit the patient to the hospital and schedule a colonoscopy as an inpatient. They find a non-obstructing, not actively bleeding 4cm colon cancer. The patient undergoes definitive colon resection, recovers and is discharged.

The hospital bills the patient for his portion of the care. However the patient is unable to pay the deductible or co-pay. Under the patient’s plan, no services can be reimbursed until the patient meets his deductible, so that all of the care, including the costs which exceed the deductible remain unpaid.

A 32 year old woman undergoes an uncomplicated delivery. Following the birth of her child, she resigns from her job and obtains an individual health insurance plan. The plan excludes coverage of pre-existing conditions during the first 18 months of the coverage.

The woman experiences right upper abdominal pain and is seen by her primary care doctor who orders an ultrasound and diagnosis gallstones with intermittent biliary colic (gallbladder attacks). The patient is referred to a surgeon who concurs with the diagnosis and schedules an elective laparoscopic cholecystectomy.

However, when the surgeon submits a request for authorization for the insurance, he is notified that the gallstones were present on the patient’s pre-natal ultrasound, though she was asymptomatic at the time. The authorization is denied because the gallstones are a pre-existing condition. The patient attempts to manage any subsequent gallbladder attacks with a low fat diet and intermittent use of pain medicine. However, two months before her 18 month waiting period has elapsed, she develops fever, severe abdominal pain and jaundice. She is seen in the emergency room and diagnosed with an infected gallbladder and a gallstone trapped in the duct to the liver. She undergoes an endoscopic removal of the trapped stone and a laparoscopic removal of the gallbladder. She recovers, but her insurance does not cover any of the costs of the surgery or hospitalizations.

A 27 year old man purchases an individual insurance plan after beginning free-lance consulting work for a start up. He has no medical problems and takes no medicine. Two months after purchasing the plan, he develops abdominal pain and vomiting and is found to have a bowel obstruction from an adhesion band which formed at the time of his appendectomy 24 years earlier. He undergoes a successful laparoscopic cutting of this band and freeing of the bowel and is discharged from the hospital two days after surgery with no complications. The charges for the surgical care and the hospitalization are denied by the insurance company because he did not state that he had had an appendectomy under his past history.

Each of these cases may seem to be exceptional or unusual and not representative of the usual practice of insurance companies. However, examples such as these are actually fairly commonplace.

Moreover, what these examples do demonstrate is the critical role of EMTALA in allowing insurance companies to deny payment for care with relatively few deleterious medical consequences. That is, if denial of payment for care equated with denial of care, at least as far as emergency care goes, there would be significantly more pressure on insurance companies to cover the costs of care under their plans, and not engage in convoluted mechanisms to avoid payment. In fact, hospitals and physicians sustain millions of dollars in losses every year due to insurance companies’ denial of payment for care provided. As noted above, a significant amount of this uncompensated care results from emergency room visits and other emergency medical and surgical care.

EMTALA as a Substitute For Social Services

A 48 year old homeless man is brought by ambulance to the emergency room with a large abscess on his leg. He is admitted to the hospital, taken to surgery and provided with post-operative treatment including intravenous antibiotics and wound care. After four days he is ready for discharge on oral antibiotics and outpatient visiting nurse wound care. However, as he is homeless and uninsured, he is kept in the hospital for another ten days because he requires daily wound care. Visiting nurse services are unavailable to uninsured patients.

A 58 year old woman is brought to the emergency room with the acute onset of right hemiplegia (inability to move her right side). A CT scan demonstrates an acute stroke. She is admitted and given appropriate acute therapy. After several days, she recovers some function of her right side and can walk with a walker, but cannot manage complete self care. That is, she cannot shower, bathe or prepare food without assistance. She is a good candidate for transfer to an acute rehabilitation hospital and she is gradually having improved function. However, she is uninsured and none of the rehabilitation facilities will accept her. She remains in the acute care hospital for another five weeks until her recovery plateaus and she can be discharged back to her apartment.

A 45 year old man is brought to the emergency room in a coma. Screening laboratory studies demonstrate that he is in a diabetic coma, though he had not previously been known to be a diabetic. He is given insulin and IV fluids and quickly recovers. After several days he is on a stable insulin regimen with good control of his blood sugar. He is discharged after receiving thorough diabetic management instruction and given a prescription for insulin and for glucose monitoring equipment. He has no insurance and is therefore referred to the county medical center internal medicine department and has a scheduled appointment in that clinic one week after discharge.

Four days after discharge, he is brought back to the emergency room again in a diabetic coma. He has a cardiac arrest and is unable to be resuscitated. The unfilled insulin and glucose monitoring prescriptions are found in his pocket.

As can be seen from the first two examples, complex modern medical care includes more than just acute hospitalization. Wound care and rehabilitation services are just two of the many ancillary services a hospital must be able to provide itself or, as is increasingly the case, contract with less expensive specialized provider services.

EMTALA makes clear that all care must be carried to completion, which itself includes any care which would be provided to insured or paying patients. Hospitals typically have contracts with these ancillary service providers, but these providers are not subject to the EMTALA mandate and therefore have no obligation to accept uninsured patients in transfer. Inpatient acute hospitalization is, in many cases, the most expensive and least efficient alternative, yet for the uninsured patients it is the only alternative.

In the first case, uninsured patients are general ineligible for visiting nurse and other home-based therapies. However EMTALA has clear guidelines which state that a patient cannot be discharged until he or she can provide for all needs including mobility, wound care, medication, feeding and all other personal and medical care needs. Homelessness presents a special set of problems and there are thousands of patients kept in hospitals for extended periods of time until social services departments can secure discharge housing, even when there are no specific medical needs. This inpatient care can be expensive and inefficient. In the case of the woman with the stroke, an acute rehabilitation facility would have several hours a day devoted to physical and occupational therapy and might result in a more accelerated recovery. The inpatient acute hospital has a limited ability to provide this type of service.

The final example, the case involving the man in a diabetic coma, illustrates the sometimes blurred boundary defining the mandate of EMTALA. The law does not require follow up, outpatient treatment or provision of discharge medications for patients who are otherwise stable for discharge following treatment of an acute problem. However, EMTALA does require that the hospital assist patients in obtaining follow up in county or other public hospital facilities. In the case described above, there may be questions about the adequacy of the discharging hospital’s provision of follow up care.

It could be argued that if the patient seemed incapable of buying medicine or following a new and complex medical regimen, then the patient was not eligible for discharge given the EMTALA mandate to insure that he or she be able to provide self- care after discharge.

EMTALA and the Affordable Care Act

The Affordable Care Act was designed to reduce reliance upon expensive emergency room care and, by extension on the unfunded EMTALA mandate. A review of the four major provisions of the Act demonstrates how this goal could be accomplished.

First, the dramatically increased funding for Medicaid, along with the expansion of Medicaid eligibility, was intended to provide the previously uninsured medically indigent with elective and preventative care and, when emergency care was necessary, provide physicians and hospitals giving this care, some reimbursement.

The California experience is illustrative of how the ACA could achieve this goal of reducing reliance on emergency care. The California Medicaid program (Medi-Cal) was poised to take advantage of the Medicaid expansion provision of the ACA. California received nearly a third of the available increased Medicaid funding from the federal government during the first two years of the Act.

The State expanded significantly the eligibility for Medi-Cal coverage among its citizens. Prior to the ACA, Californians could only qualify for Medi-Cal if they had certain chronic health conditions or had custodial care of a minor. After the ACA Medicaid expansion, Medi-Cal coverage became available to millions of Californians who were medically indigent simply due to being unemployed, underemployed or otherwise meeting the income criteria. Thus elective and preventative care, previously unavailable to low income Californians, could now be provided. (It must be noted that due to the very limited participation in the Medi-Cal program by California physicians, this guarantee has not been fully realized.)

Moreover, physicians and hospitals providing emergency care to these patients could now receive some reimbursement.

Second, the employer and individual mandates, though very controversial, were designed to require individuals to obtain, and employers to provide, insurance for those not previously covered. Again, this would increase the number of patients now able to obtain less expensive, elective care. The federal subsidy for obtaining commercial insurance was intended to increase compliance with the mandate. Those individuals complying with the mandate, and employees of employers forced to comply with this mandate, would have insurance policies which allowed them to access previously unavailable elective care.

Finally, the more popular ACA provision which abolished the pre-existing conditions exclusion from insurance coverage for would mean that people with “chronic”conditions such as diabetes, arthritis, cancer diagnoses and even obesity could have continuity in their care.

Historically, patients lose, change and reacquire insurance coverage routinely, and, as a result often suffer from the robustly enforced pre-existing condition exclusions of their insurance policies. Under the ACA, these patients could expect some continuity of care, preservation of their provider network and even coverage for their medications. Moreover, this patient population often seeks and receives emergency care, and under the ACA, the providers and hospitals could be paid for this frequently-needed emergency care.

The success of the ACA in insuring this increase in elective and preventative care and the decreased reliance upon emergency care, and thus on the unfunded mandate of EMTALA, may never be known. There is very little stable data at this point, and “repeal and replace” could occur in short order. The proposed provisions of the replacement law, at least as far as they can be ascertained, will likely result in increased reliance upon emergency, unfunded care. One proposal is to return all responsibility for Medicaid to the states and reduce the current federal subsidy by $100 billion dollars. In this scenario, the rolls of the medically indigent would swell.

The unpopular individual and employer mandates may be repealed. If so, individuals and employers, feeling burdened by the requirement to pay for health insurance, will drop coverage. Health care emergencies will inevitably arise among those choosing to drop coverage, yet EMTALA will be there to insure emergency care even when there is no insurance coverage.

Finally, Dr. Price has proposed re-instating the right of insurance companies to exclude coverage of pre-existing conditions for 18 months. Patients with chronic and recurrent acute medical conditions will in all likelihood again be required to seek emergency care which, in many cases will not be paid for.

The Role Of Emtala In Avoiding The Complex Problem Of True Health Care Reform

In 1986, at the time of the passage of EMTALA, the health care landscape was in many ways different from that which we face today. For example, there were several dozen insurance companies, including many regional plans, and health insurance was an exclusively non-profit industry. Today there are only four major, for-profit insurance plans, and there are plans to merge some of those plans.

Second, historically hospitals were generally single, free-standing, not-for-profit institutions, often funded by religious or other charitable endowments. There were almost no consolidated health care systems, a model which now dominates both the for-profit and not for profit hospital markets.

Though only 18% of hospital systems in this country are for profit institutions, the drive for profitability dominates both the for-profit and not-for-profit- hospital markets. The forces dominating health care at this time are the quest for lucrative “service lines,” such as elective spine and orthopedic care, the drive to increase market share among the well-insured patients,(advertising by hospitals did not exist in 1986 and it is now nearly as ubiquitous as drug company advertising), and the attempt to avoid providing costly, unprofitable care. For example, between 1993 and 2002, the number of emergency room visits in the U.S. grew by 26%, while in the same period, the number of emergency rooms declined by 425.

This changed landscape, namely the conversion of most aspects of health care to a highly profit-driven enterprise, makes the enforcement of EMTALA even more important as a health care safety net. Hospitals and doctors now make a concerted effort to avoid providing free or even reimbursed, but not-profitable care, such as Medicaid. While hospitals cannot exclude Medicaid patients, many physicians refuse to care for these patients electively.

In my own county, my informal survey of the 34 general surgeons in the county, found that only four accepted Medicaid patients. Although I have never found a formal study of the problem, it is my experience that when Medicaid patients present to the ER for an urgent problem, such as recurrent gallbladder attacks, they are more likely than patients with commercial insurance to be sent out with pain medicine rather than receive the definitive surgical care. It is unlikely that in the current financial climate of health care, hospitals would be as willing to care for indigent or even “underinsured” patients if there were not a federal mandate to do so.

As shown above, the EMTALA mandate has evolved to require a fairly expansive definition of emergency care, and, it is therefore remains a very costly proposition, especially for inner city and poor rural hospitals. It is impossible to know what would happen if the EMTALA mandate disappeared tomorrow, but I can predict with confidence that there would be a significant decrease in the amount of unreimbursed care provided by hospitals.

Finally, as the debate on health care reform continues, one should consider whether EMTALA may actually be responsible for allowing politicians and lawmakers to skirt responsibility for coming up with reasonable legislation to fund health care, especially care for the medically indigent.

As long as EMTALA is in place, patients will continue to receive all emergency care and even a great deal of arguably non-emergency care. Patients with strokes, diverticulitis, broken bones and even fingernail infections will be seen and treated irrespective of financial status and without regard to the existence or absence of any program for funding that care. This uncoupling of guaranteed care from payment for that care shields lawmakers from the consequences which would follow if hospitals and providers could turn away uninsured and indigent patients.

EMTALA is, in fact, a “forme frust” of single payer healthcare for the indigent. That is EMTALA requires a broad and deep level of care be provided for all patients, but has no mechanism for private or public funding of that service.

Instead, in our bastardized single player plan, the costs of the care are borne exclusively by the doctors and hospitals providing the care with no attempt to provide a sensible risk spreading plan for the multi-billion dollar EMTALA program.

President Trump and Secretary Price have stated their commitment to reduce this type of cost-shifting in health care. For example, they support the elimination of individual and employer mandates would end the program whereby healthy individuals are required to buy insurance to subsidize the sicker patients.

If the current Administration is serious about elimination unfair cost shifting, it seems that elimination of EMTALA, which is one of the most unfair cost-shifting systems in health care, should also be eliminated. If it is unfair to require healthy patients to purchase insurance to fund the sicker patients, then surely it is unfair to require individual physicians and hospitals to bear the burden of care for the medically indigent.

However, if EMTALA were to be eliminated, and hospitals and physicians responded by eschewing any responsibility for providing uncompensated care, politicians would arguably be faced with the prospect of dealing with a citizenry awash in illness, disease and suffering. I think that lawmakers recognize that EMTALA stands between them and health care chaos, and, in spite of platitudes about a fair distribution of the costs of health care they, will never have the courage to repeal this unfair law and replace it with an honest, universally accessible system of health care.