The Emergency Medical Treatment & Labor Act (EMTALA) was enacted by Congress in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (42USC§1395dd). Often referred to as the patient “anti-dumping” law, it was originally designed to prevent hospitals from transferring uninsured or Medicaid patients to public hospitals without, at a minimum, providing a medical screening examination and treatment to assure that such transfers could be done safely.
The concern for patient safety at that time was not unwarranted. Studies showed that in the early 1980’s of transfers to public or Veteran’s Administration (VA) hospitals, 87% were for economic reasons, only 6% gave informed consent, 24% were unstable at the time of transfer, mortality was 3 times that of other patients, and there were 250,000 such transfers occurring annually 3,4,5,6
Congress has amended and expanded the scope of EMTALA five times. For example, until 1989, EMTALA did not require hospitals or physicians to provide on-call services nor did it require hospitals with specialized services to accept patients in transfer. Over the years additional amendments enhanced the ability to impose fines, increased penalties, provided whistleblower protections, and expand the reach of the law and mandated duties of providers.
Despite passage in 1986, there was little enforcement of EMTALA for the first 10 years 7,8
. Enforcement increased significantly after the Centers for Medicare & Medicaid Services (CMS, formerly the Health Care Financing Authority or HCFA) published rules for the enforcement of
EMTALA in the Code of Federal Regulations (CFR) in 1994 [42CFR§489.xx]. By 1999 there had been more than 2000 EMTALA investigations and more than 1000
confirmed violations 9.
In June 1996 a diverse national EMTALA Task Force was formed to clarify the regulations with new Interpretive Guidelines published in July 1998. Interpretive Guidelines do not carry the force of law and, while well-intention, left many issues vague. As a result, federal and state civil courts continued to have a significant influence on EMTALA interpretation. Consequently EMTALA now has little
resemblance to its original intent of regulating economically motivated transfers. 10