Queen Essays

AIMS Public Health Volume 5, Issue 4, 366-377.

AIMS Public Health, 5(4): 366–377

DOI: 10.3934/publichealth.2018.4.366

Received: 24 May 2018

Accepted: 21 September 2018

Published: 08 October 2018

http://www.aimspress.com/journal/aimsph

Research article

Examining EMTALA in the era of the patient protection and

Affordable Care Act

Ryan M. McKenna 1, *, Jonathan Purtle

2 , Katherine L. Nelson

3 , Dylan H. Roby

4 ,

Marsha Regenstein 5 and Alexander N. Ortega

6

1 Department of Health Management and Policy, Dornsife School of Public Health, Drexel

University, 3215 Market Street, Nesbitt Hall, Philadelphia, PA 19104, USA 2 Department of Health Management and Policy, Dornsife School of Public Health, Drexel

University, 3215 Market Street, Nesbitt Hall, Philadelphia, PA 19104, USA 3 Department of Health Management and Policy, Dornsife School of Public Health, Drexel

University, 3215 Market Street, Nesbitt Hall, Philadelphia, PA 19104, USA 4 Department of Health Services Administration, School of Public Health, University of Maryland,

4200 Valley Dr # 2242, College Park, MD 20742, USA 5 Department of Health Policy and Management, Milken Institute School of Public Health, George

Washington University, 950 New Hampshire Ave NW, Washington, DC 20052, USA 6 Department of Health Management and Policy, Dornsife School of Public Health, Drexel

University, 3215 Market Street, Nesbitt Hall, Philadelphia, PA 19104, USA

* Correspondence: Email: [email protected]; Tel: +2673596188.

Abstract: Background: Little is known regarding the characteristics of hospitals that violate the

Emergency Medical Treatment and Labor Act (EMTALA). This study addresses this gap by

examining EMTALA settlements from violating hospitals and places these descriptive results within

the current debate surrounding the Patient Protection and Affordable Care Act (ACA). Methods: We

conducted a content analysis of all EMTALA Violations that resulted in civil monetary penalty

settlements from 2002–2015 and created a dataset describing the nature of each settlement. These

data were then matched with Thomson Healthcare hospital data. We then present descriptive

statistics of each settlement over time, plot settlements by type of violation, and provide the

geographic distribution of settlements. Results: Settlements resulting from EMTALA violations

decreased from a high of 46 in 2002 to a low of 6 in 2015, a decline of 87%. Settlements resulting

from violations most commonly occurred for failure to screen and failure to stabilize patients in need

367

AIMS Public Health Volume 5, Issue 4, 366-377.

of emergency care. Settlements were most common in hospitals in the South (48%) and in urban

areas (74%). Among Disproportionate Share Hospitals (DSH) with a violation, the majority (62%)

were located in the South or in urban areas (65%). Violating hospitals incurred annual

settlements of $31,734 on average, for a total $5,299,500 over the study period. Conclusions:

EMTALA settlements declined prior to and after the implementation of the ACA and were most

common in the South and in urban areas. EMTALA’s status as an unfunded mandate, scheduled cuts

to DSH payments and efforts to repeal the ACA threaten the financial viability of safety-net hospitals

and could result in an increase of EMTALA violations. Policymakers should be cognizant of the

interplay between the ACA and complementary laws, such as EMTALA, when considering changes

to the law.

Keywords: health policy; Affordable Care Act; emergency medicine; health reform; insurance reform

Abbreviations: ACA: Patient Protection and Affordable Care Act; CBO: Congressional Budget

Office; CMS: Centers for Medicare and Medicaid Services; DSH: Disproportionate Share Hospital;

ED: Emergency Department; EMTALA: Emergency Medical Treatment and Active Labor Act; OIG:

Office of the Inspector General

1. Introduction

Since its passage in 1986, the EMTALA has been one of the most comprehensive laws granting

nondiscriminatory access to emergency medical care [22, 32]. EMTALA was originally conceived as

a policy to prevent ―patient dumping‖, the refusal of EDs to treat patients who could not pay for

treatment [22]. EMTALA mandates that a hospital must appropriately screen, stabilize, and, if

necessary, transfer a patient regardless of insurance status or ability to pay. If it is deemed necessary

that the patient needs to be transferred, they must be transferred to a facility with appropriate care

and the receiving facility must accept the patient [31].

Federal enforcement of EMTALA is managed by two agencies, CMS and OIG. EMTALA

investigations are initiated with a complaint being filed with one of the 10 regional CMS offices

and typically submitted by patients, hospitals, or ED staff [1]. If a violation is confirmed by CMS

field investigators, hospitals must submit a plan to correct deficiencies highlighted by CMS within

90 days [2]. Hospitals that fail to implement acceptable corrective actions risk termination of their

Medicare provider agreements, which could result in a significant financial loss and lead to the

closure of the facility. If the plan is accepted by CMS, the investigation ends; however, the OIG may

still levy punitive fines on hospitals and physicians’ offices. Fines have a maximum of $50,000 per

hospital and physician and are not covered by physician malpractice insurance.

Since EMTALA’s implementation, the rate of reported patient dumping has dropped substantially,

with recent estimates from 2005–2014 showing rates as low as 1.7 violations for every 1,000,000 ED

visits [27]. While these rates represent a sharp departure from previous highs in the 1980s, EMTALA

violations suffer from underreporting and hospitals still face compliance issues [12]. Additionally,

while EMTALA represents an important safety net for those without insurance coverage, it does not

guarantee free care to the patient and is not intended as a substitute for routine care. Under EMTALA,

368

AIMS Public Health Volume 5, Issue 4, 366-377.

patients cannot be denied emergency care based on inability to pay, but may still be billed after

receiving care. This could result in bad debt for both the consumer (i.e., bankruptcy) and the provider

(i.e., uncompensated care). EDs already provide more uncompensated care to the uninsured than

hospitals or outpatient clinics combined and nationally this amounted to approximately $50 billion in

2013 (HHS.gov 2015).

The insurance expansion provisions of the 2010 ACA lowered the uninsured rate for individuals

ages 18–64 years from a high of 18.4% in 2013 to 10.2% in 2016, a reduction of 45% [4]. While

findings of the ACA’s impact on ED utilization are mixed, some recent studies have shown that the

ACA is associated with improvements in access to usual sources of care other than the ED and

primary care utilization, especially for low-income groups and racial/ethnic minorities [3,15,25].

The expansion altered the payer-mix of many providers away from self-pay, which resulted in

improved charge capture, reductions in uncompensated care, and potentially served to lower rates

of patient dumping [7,8]. Thus, after the national implementation of the ACA in 2014, we would

expect to observe a decline in patient dumping and settlements arising from EMTALA violations.

Several proposals to repeal and replace the ACA were estimated by the CBO to reverse nearly all

of the gains in coverage attributable to the ACA [5,6,13]. Although those proposals ultimately

failed to become law during the summer of 2017 legislative session, there are still proposals being

circulated to reverse the ACA’s insurance expansion through administrative action and by reducing

Medicaid spending via the federal budget.

Hospitals serving large numbers of Medicaid and uninsured individuals are eligible for federal

DSH payments, to help offset the costs of uncompensated care. Since the insurance expansion has

likely worked to reduce the burden of uncompensated care, the ACA has built-in cuts to DSH

payments to help reduce expenditures. These scheduled reductions to DSH payments will place

greater strain on safety net hospitals. This increased strain could lead to patient dumping in order

to avoid the increased shortfalls in revenue. The impact of DSH payments cuts will be magnified in

Medicaid non-expansion states that have many low-income adults in the ―coverage gap‖ [9,18].

The uninsured low-income population are more likely than their privately insured counterparts to

use EDs and impose a risk of uncompensated care for systems [14,20].

In the face of reform efforts that would increase the number of uninsured patients and the

scheduled cuts to DSH payments, it is important to understand the current prevalence of EMTALA

violations and their distribution across the country. Despite its importance as a federal law

mandating the provision of emergency medicine, little empirical work has been published on

EMTALA violations and virtually none has examined the impact of the law within the context of

the ACA and current debates about health care and insurance reform [1,22,26,30].

This study adds to the current health reform debate by analyzing the content of all settled

EMTALA violations from the OIG between 2002–2015 and identifying the prevalence and

correlates of these cases. While settled fines do not constitute the universe of violations they are

one of the few publically available markers by which to measure EMTALA violations.

Additionally, while our findings are not causal in nature, we offer a descriptive analysis of these

settlements and discuss the implications of results within the broader context of the current health

care reform debate surrounding the ACA.

2. Methods

369

AIMS Public Health Volume 5, Issue 4, 366-377.

This study is a retrospective analysis of settled OIG civil monetary penalty settlements related

to EMTALA violations from the OIG. Not every complaint which generates an EMTALA

investigation results in a monetary settlement, thus we do not observe the entire universe of

EMTALA complaints, only settled violations (approximately 7.9% of all violations [32]). In the

event that a violation was found, CMS forwards the case to OIG, where the OIG decides if a

monetary fine is warranted. We rely on settled cases as there are few reliable sources of data to

assess patient dumping and cases settled by OIG have been used in prior work [30]. For brevity,

we hereby refer to settlements that resulted from EMTALA violations as ―settlements‖ in the

manuscript.

The OIG website provides a one paragraph description about every EMTALA settlement

since 2002. We conducted a content analysis of this information for all 191 settlements posted on

the OIG website through 2015. A coding instrument was created in Qualtrics, a web-based survey

tool, and each settlement was coded according to the nature of the violation and the characteristics

of the patients involved [19]. We coded each settlement according to the year it occurred, the total

dollar amount fined, the number of patients involved, and the type of violation that resulted in the

settlement (i.e., failure to provide appropriate screening, failure to accept transfer, failure to

provide appropriate transfer, failure to provide appropriate stabilization, or unknown). Settlements

that occurred but had an unclear cause in the OIG reports were coded as ―unknown‖ in our type of

violation measure.

Hospital financial and geographic data from Thomson Healthcare Profile of US Hospitals

were merged with the OIG EMTALA violation data by hospital name and address using Microsoft

Excel 2016 [27]. The Thomson data include each hospital’s unique Medicare ID, US Census

region (Midwest, Northeast, South, West), geographic status (urban, rural), DSH status, and

number of beds.

The merged dataset was imported into R [20] statistical software version 3.4.1 for analyses.

First, annual trends in EMTALA settlements were plotted and stratified by type of violation which

resulted in a settlement. Second, descriptive statistics were generated to describe hospital and

geographic characteristics of violating hospitals. Third, 2010 Census data were used to calculate

per-capita average fines at the state-level [30]. Results were plotted on a map of the US to visually

explore geographic heterogeneity in EMTALA settlements and fines.

3. Results

We identified 191 EMTALA settlement agreements, which resulted in settlements that

occurred between 2002–2015. A total of 24 hospitals could not be uniquely identified from the

settlement reports or had active data in the Thompson database and were excluded from the

analyses, for a total of 148 unique hospitals. After merging the settlements with the Thompson

data, we had a sample of 167 settlements with associated hospital characteristics, none of which

involved individual physicians.

Figure 1 shows annual trends in settled EMTALA violations from 2002–2015. The Figure is

right skewed, which reflects a decline in the overall number of EMTALA settlements that range

from a high of 46 in 2002 to a low of 6 in 2015, or a decline of 87%. Settlements did increase by

50% in 2013 relative to 2012, driven mostly by failure to appropriately screen. The shaded bar in

Figure 1 indicates the national implementation of the ACA in 2014, which corresponds with a

370

AIMS Public Health Volume 5, Issue 4, 366-377.

continued decline in overall settlements from 16 in 2014 to 6 in 2015. Throughout the 2002–2015

study period, the most common reason for a settlement was failure to appropriately screen

followed by failure to stabilize.

Figure 1. Settled EMTALA Violations by Type, Office of Inspector General 2002–2015.

General (OIG) ―patient dumping‖ settled violation case summaries from 2002–2015. These

violations reflect settled cases, not all alleged EMTALA violations. The shaded bar

represents the national implementation of the Patient Protection and Affordable Care Act.

Table 1 presents descriptive statistics of settled EMTALA settlements, as well as

characteristics of violating hospitals. Nearly half of the settlements (47.9%) occurred at hospitals

in the South, with the fewest settlements occurring in the Northeast (5.39%). Hospitals in urban

areas (74.3%) were more likely than hospitals in rural areas (25.7%) to incur a settlement.

Violating hospitals that had a settlement incurred an annual average fine of $31,734, for a total

$5,299,500 over the study period. No hospital in the sample had its Medicaid provider agreement

terminated as the result of an EMTALA settlement. Information on DSH status was unavailable in

the Thomson data for 70 hospitals in the sample. For the hospitals for which their DSH status

could be determined, sub analyses were conducted. Over a fifth of the hospitals (22.16%) had DSH

status, with 62% of these hospitals located in the South and 65% located in urban areas.

Figure 2 displays distribution of average fines at the state-level adjusted by each state’s

population size. With the exceptions of Vermont and Iowa, per-capita fines are concentrated in the

South and the Western US. As a robustness check, and to assess whether changes in the rate of

EMTALA settlements might have resulted from differences in enforcement arising from changes to

the OIG’s budget, we calculated inflation-adjusted OIG budgets in from 2007–2015. We found that

inflation-adjusted OIG budgets did not substantially decline over the 2007–2015 period and actually

reached their highest levels in 2015.

371

AIMS Public Health Volume 5, Issue 4, 366-377.

Table 1. Descriptive Statistics of Settled EMTALA Violations, Office of Inspector General 2002–2015.

2002

(27)

2003

(25)

2004

(17)

2005

(15)

2006

(11)

2007

(13)

2008

(8)

2009

(5)

2010

(7)

2011

(8)

2012

(6)

2013

(12)

2014

(10)

2015

(3)

Total

(167)

Region

Midwest 3.70

(1)

8.00

(2)

41.18

(7)

20.00

(3)

45.45

(5)

30.77

(4)

25.00

(2)

20.00

(1)

14.29

(1)

25.00

(2)

50.00

(3)

41.67

(5)

30.00

(3)

0.00

(0)

23.35

(39)

Northeast 0.0

(0)

8.00

(2)

5.88

(1)

6.67

(1)

9.09

(1)

0.00

(0)

0.00

(0)

20.00

(1)

0.00

(0)

0.00

(0)

16.67

(1)

0.00

(0)

20.00

(2)

0.00

(0)

5.39

(9)

South 48.15

(13)

52.00

(13)

41.18

(7)

46.67

(7)

27.27

(3)

38.46

(5)

62.50

(5)

40.00

(2)

71.43

(5)

62.50

(5)

33.33

(2)

58.33

(7)

40.00

(4)

66.67

(2)

47.90

(80)

West 48.15

(13)

32.00

(8)

11.76

(2)

26.67

(4)

18.18

(2)

30.77

(4)

12.50

(1)

20.00

(1)

14.29

(1)

12.50

(1)

0.00

(0)

0.00

(0)

10.00

(1)

33.33

(1)

23.35

(39)

Urban 66.67

(18)

76.00

(19)

58.82

(10)

80.00

(12)

81.82

(9)

84.62

(11)

75.00

(6)

100.00

(5)

100.00

(7)

75.00

(6)

66.67

(4)

66.67

(8)

70.00

(7)

66.67

(2)

74.25

(124)

Violations*

Screening 74.07

(20)

84.00

(25)

76.47

(13)

100.00

(15)

90.91

(10)

76.92

(10)

75.00

(6)

80.00

(4)

57.14

(4)

50.00

(4)

66.67

(4)

83.33

(10)

90.00

(9)

100.00

(3)

79.64

(133)

Accept

Transfer

18.52

(5)

4.00

(1)

5.88

(1)

6.67

(1)

9.09

(1)

0.00

(0)

25.00

(2)

20.00

(1)

42.86

(3)

37.50

(3)

0.00

(0)

8.33

(1)

20.00

(2)

0.00

(0)

12.57

(21)

Provide

Transfer

18.52

(5)

16.00

(4)

58.82

(10)

13.33

(2)

9.09

(1)

23.08

(3)

12.50

(1)

40.00

(2)

0.00

(0)

0.00

(0)

0.00

(0)

16.67

(2)

0.00

(0)

0.00

(0)

17.96

(30)

Stabilization 51.85

(14)

60.00

(15)

64.71

(11)

26.67

(4)

27.27

(3)

69.23

(9)

62.50

(5)

60.00

(3)

57.14

(4)

62.50

(5)

83.33

(5)

41.67

(5)

50.00

(5)

100.00

(3)

54.49

(91)

Violation Not

Clear

7.41

(2)

12.00

(3)

0.00

(0)

0.00

(0)

0.00

(0)

0.00

(0)

12.50

(1)

20.00

(1)

0.00

(0)

0.00

(0)

0.00

(0)

0.00

(0)

0.00

(0)

0.00

(0)

4.19

(7)

Teaching

Hospital

51.85

(14)

44.00

(11)

35.29

(6)

20.00

(3)

54.55

(6)

53.85

(7)

62.50

(5)

60.00

(3)

42.86

(3)

75.00

(6)

33.33

(2)

41.67

(5)

60.00

(6)

0.00

(0)

46.11

(77)

Continued on next page

372

AIMS Public Health Volume 5, Issue 4, 366-377.

2002

(27)

2003

(25)

2004

(17)

2005

(15)

2006

(11)

2007

(13)

2008

(8)

2009

(5)

2010

(7)

2011

(8)

2012

(6)

2013

(12)

2014

(10)

2015

(3)

Total

(167)

DSH** 2.40

(4)

5.39

(9)

2.99

(5)

1.80

(3)

1.12

(2)

1.12

(2)

1.12

(2)

0.00

(0)

0.00

(0)

0.60

(1)

0.60

(1)

2.99

(5)

1.20

(2)

0.60

(1)

22.16

(37)

Average Fine 23,815

(27)

23,300

(25)

25,882

(17)

29,800

(15)

40,000

(11)

22,788

(13)

34,688

(8)

59,000

(5)

37,714

(7)

39,438

(8)

43,833

(6)

36,666

(12)

42,075

(10)

58,333

(3)

31,733

(167)

Mean Beds 299.81 299.81 311.65 201.20 310.73 286.62 440.38 257.40 389.29 490.13 331.00 353.50 216.70 233.00 302.54

Note: All values are averages, with counts shown in parentheses. These violations reflect settled cases, not all alleged EMTALA violations.

*Hospitals may have had more than one type of violation, thus the number of violations will be greater than the number of hospitals in the sample.

**Information on DSH status could not be obtained for 70 hospitals in the sample.

Figure 2. Per-capita Average Annual EMTALA Fines by State, 2002–2015. All fines are weighted by each state’s population, as measured

from the 2010 US Census.

373

AIMS Public Health Volume 5, Issue 4, 366-377.

4. Discussion

In this study, we have observed a reduction in EMTALA settlements since 2002 and

descriptively characterized that these settlements are most common among hospitals in the South and

hospitals in urban areas. Since taking effect in 1986, EMTALA has been the only law granting

universal access to emergency medical care regardless of ability to pay [22,32]. While the ACA’s

insurance expansion significantly reduced the uninsured rate in the US, efforts to repeal the ACA

threaten these reductions and could incentivize the utilization of EMTALA among the newly

uninsured. In this study, we report trends in EMTALA settlements resulting in settlements and their

geographic distribution before and after the national implementation of the ACA. Below, these

findings are discussed within the context of the current health care reform debate to better understand

the potential interplay between the ACA and complementary laws, such as EMTALA.

Over the study period, there was an overall strong downward trend in violations resulting in

EMTALA settlements with the lowest number of settlements occurring after national

implementation of the ACA. The overall downward trend in settlements prior to the ACA lends

descriptive support to EMTALA’s ability to reduce patient dumping. Furthermore, while a causal

relationship cannot be determined from the present analysis, it is possible that the ACA helped to

reduce patient dumping through two avenues, potentially even helping to reduce the observed

spike in settlements occurring in 2013. First, in shifting hospitals’ payer mix away from self-pay,

the insurance expansion of the ACA reduces the risk of uncompensated care to systems. This

reduced risk likely decreased the financial motivation for patient dumping. Second, the ACA

helped improve access to health care at facilities other than the ED. While the findings of the

relationship between ED utilization and the ACA are somewhat mixed, trends demonstrate that the

ACA has helped to improve access to sources of care other than the ED [25,26]. Furthermore,

while our results are descriptive in nature, the OIG budget remained stable over this time, lending

support to the notion that the observed decline was not due to a reduction in the OIG’s

enforcement capabilities. However, it is important to note that these results are only descriptive

and not causal in nature.

Despite these improvements, settled violations resulting in EMTALA settlements and patient

dumping still occur, albeit at a low incidence. Our results suggest that settlements resulting in

settlements most frequently occur for failure to screen and stabilize patients. A prior study found a

decrease in violations from nonclinical error over time, suggesting that the violations we observe

from failure to screen and stabilize are reflective of true patient dumping [27]. We also find

violations to be geographically concentrated in the Southern US and in urban areas. Settlements are

likely more common in the South, as hospitals in Southern states in our sample were more likely to

be disproportionate share hospitals in our observations.

While the ACA has been effective in reducing the burden of uncompensated care, several issues

remain that might lead to hospitals dumping patients. First, if the ACA is repealed, the Congressional

Budget Office projects that as many as 32 million US citizens could lose insurance coverage by

2026, the majority of which are low-income individuals [6]. EDs will likely bear a significant burden

of uncompensated care resulting from the significant increase in the number of uninsured persons

seeking care.

Second, scheduled cuts to DSH payments threaten the financial stability of safety-net

hospitals, particularly those in non-expansion states [23]. Originally scheduled to take effect in

374

AIMS Public Health Volume 5, Issue 4, 366-377.

2014, the 2015 Medicare Access and CHIP Reauthorization Act delayed DSH cuts until fiscal year

2018. This delay prevented dependent hospitals from immediately foregoing reductions to the $11

billion used to cover uncompensated care, which is temporarily shielding hospitals from the

reduction in revenue [7]. DSH payments will be reduced by $2 billion in 2018 and reduced by an

additional $1 billion annually. Cuts will terminate in 2025 and will reach a maximum of $8 billion in

both 2024 and 2025.

Given that DSH payments already fail to keep up with the rate of health care cost inflation,

these cuts will serve to widen the DSH funding gap [16]. In the absence of federal or state

assistance, shifting the financial burden of uncompensated care from the federal government to

safety net hospitals could threaten the financial viability of these hospitals and potentially lead to

patient dumping [16,24]. Both an increase in the number of uninsured individuals and the pending

cuts to DSH payments threaten the financial stability of hospitals, particularly safety-net hospitals.

In response to increased financial strain and pressure, patient dumping may increase in EDs,

specifically among the most financially vulnerable systems.

Patient dumping was once a huge problem and has the potential to resurface as the health care

system goes through the shocks of health reform. Given the potential for an uptick in rates of

patient dumping, it is paramount to continue to monitor EMTALA settlements. While settled cases

represent one such metric to monitor the problem, information on both settled cases and

complaints should be available to policy makers to gauge rates of patient dumping in the era of

health reform.

This study has at least four main limitations. First, there is no uniform or transparent metric for

measuring patient dumping. While we rely upon official OIG EMTALA settlement reports, it is

likely that these underestimate the true incidence of settlements, as most complaints originate from

hospital staff who may be reluctant to ―blow the whistle‖ on a transferring hospital for fear of

retribution. Second, we do not observe the universe of all EMTALA investigations. We only observe

instances where a settlement occurred and resulted in a monetary fine by OIG. This prevents us from

examining characteristics of hospitals that had investigations but were not found guilty of a violation,

or which a monetary fine was not levied, which would be a useful comparison group to the violating

hospital population. Additionally, this may result in a time lag between when the initial violation

occurred and what we observe in our data, when the settlement was reached. However, these data

still allow us to observe trends over time and these data have been used in comparable studies [28].

Third, our analyses are descriptive which precludes the ability to establish causation. Lastly,

settlement data prior to 2002 were unavailable, and thus we are not able to examine trends in

settlements since the inception of EMTALA in 1986.

5. Conclusions

Patient dumping once represented a substantial problem in emergent care, but has since been

significantly reduced over recent decades. The insurance expansions of the ACA likely aided in

this effort by shifting the payer-mix of many hospitals towards increased insurance coverage. This

allowed for greater charge capture and likely worked to reduce patient dumping. However, while

the frequency of patient dumping has declined, there is the potential for patient-dumping to

reemerge as a problem. EMTALA’s status as an unfunded mandate, the scheduled cuts to DSH

payments, and the potential repeal of the ACA all threaten the financial viability of hospitals,

375

AIMS Public Health Volume 5, Issue 4, 366-377.

specifically safety-net hospitals that received DSH payments. Shifting responsibility for

uncompensated care from the federal government to local health systems could result in increased

rates of patient dumping, reversing the observed downward trend in dumping over the past decade.

In efforts to repeal the ACA, policymakers should be cognizant of the interplay between reform

efforts and complementary laws, such as EMTALA. Reform efforts (e.g., Medicaid block grants or

reductions in the generosity of insurance benefits or actuarial value) that significantly increase the

number of uninsured individuals could have a deleterious impact on the financial stability of EDs,

and could result in an increase in EMTALA violations.

Acknowledgements

RM helped to conceptualize the study design, cleaned and analyzed the data, helped to draft the

manuscript and approved the final manuscript as submitted. JP contributed to the conceptualization

of the study, assisted in the analyses, reviewed and revised the manuscript, and approved the final

manuscript as submitted. KN contributed to the conceptualization of the study, cleaned the data,

reviewed and revised the manuscript, and approved the final manuscript as submitted. DR

contributed to the design of the study, reviewed and revised the manuscript, and approved the final

manuscript as submitted. MR contributed to the design of the study, reviewed and revised the

manuscript, and approved the final manuscript as submitted. AO conceptualized the study, reviewed

and revised the manuscript, and approved the final manuscript as submitted.

Conflict of interest

RM, JP, KN, DR, MR, and AO have no conflicts of interest.

References

1. Ballard DW, Derlet RW, Rich BA, et al. (2006) EMTALA, two decades later: A descriptive

review of fiscal year 2000 violations. Am J Emerg Med 24: 197–205.

2. Care E (2001) EMTALA Implementation and enforcement issues. United States General

Accounting Office, 1.

3. Chen J, Vargas-Bustamante A, Mortensen K, et al. (2016) Racial and Ethnic Disparities in

Health Care Access and Utilization Under the Affordable Care Act. Med Care 54: 140–146.

4. Clarke T, Norris T, Schiller J (2017) Early release of selected estimates based on data from the

2016 National Health Interview Survey. National Center for Health Statistics.

5. Congressional Budget Office (2017a) H.R. 1628 Better Care Reconciliation Act of 2017.

6. Congressional Budget Office (2017b) H.R. 1628, Obamacare Repeal Reconciliation Act of 2017.

7. Cunningham P, Rudowitz R, Young K, et al. (2016) Understanding Medicaid Hospital

Payments and the Impact of Recent Policy Changes. Kaiser Family Foundation.

8. Dranove D, Garthwaite C, Ody C (2016) Uncompensated care decreased at hospitals in

medicaid expansion states but not at hospitals in nonexpansion states. Health Aff 35: 1471–1479.

9. Garfield R, Damico A, Stephens J, et al. (2016) The coverage gap: Uninsured poor adults in

states that do not expand medicaid—an update. Menlo Park, CA: Kaiser Family Foundation.

376

AIMS Public Health Volume 5, Issue 4, 366-377.

10. HHS.gov. (2015) Insurance Expansion, Hospital Uncompensated Carem and the Affordable

Care Act, Retrieved August, 2017. Available from:

https://aspe.hhs.gov/system/files/pdf/139226/ib_UncompensatedCare.pdf.

11. Hiltzik M (2018) Anthem Expands its Policy of Punishing Patients for ―Inappropriate‖ ER

Visits. Los Angeles Times. Available from:

http://www.latimes.com/business/hiltzik/la-fi-hiltzik-anthem-er-20180124-story.html.

12. Hsuan C, Horwitz JR, Ponce NA, et al. (2018) Complying with the Emergency Medical Treatment

and Labor Act (EMTALA): Challenges and solutions. J Healthc Risk Manage 37: 31–41.

13. Mach AL (2017) HR 1628: The American Health Care Act (AHCA).

14. Mcdonnell WM, Gee CA, Mecham N, et al. (2013) Does the emergency medical treatment and

labor act affect emergency department use? J Emerg Med 44: 209–216.

15. Mckenna RM, Alcala HE, Le-Scherban F, et al. (2017) The Affordable Care Act Reduces

Hypertension Treatment Disparities for Mexican-heritage Latinos. Med Care 55: 654–660.

16. Neuhausen K, Davis AC, Needleman J, et al. (2014) Disproportionate-share hospital payment

reductions may threaten the financial stability of safety-net hospitals. Health Aff 33: 988–996.

17. Office of Inspector General (2017) OIG Budget. Retrieved March 10th, 2017.

18. Ossei-Owusu S (2017) Code Red: The Essential Yet Neglected Role of Emergency Care in

Health Law Reform. Am J Law Med 43: 344–387.

19. Qualtrics I (2013) Qualtrics. com: Qualtric Research Suite Provo, UT.

20. R Core Team (2017) R: A language and environment for statistical computing. Vienna, Austria

R Foundation for Statistical Computing. Available from: http://www.R-project.org/.

21. Rosenau AM, Augustine JJ, Jones S, et al. (2015) The growing evidence of the value of

emergency care. Acad Emerg Med 22: 224–226.

22. Rosenbaum S (2013) The enduring role of the emergency medical treatment and active labor act.

Health Aff 32: 2075–2081.

23. Rosenbaum S, Cartwright-Smith L, Hirsh J, et al. (2012) Case studies at Denver Health: ―patient

dumping‖ in the emergency department despite EMTALA, the law that banned it. Health Aff

31: 1749–1756.

24. Sommers BD (2013) Stuck between health and immigration reform—care for undocumented

immigrants. New Engl J Med 369: 593–595.

25. Sommers BD, Gunja MZ, Finegold K, et al. (2015) Changes in Self-reported Insurance

Coverage, Access to Care, and Health Under the Affordable Care Act. Jama 314: 366–374.

26. Taubman SL, Allen HL, Wright BJ, et al. (2014) Medicaid Increases Emergency-Department

Use: Evidence from Oregon’s Health Insurance Experiment. Science 343: 263–268.

27. Terp S, Seabury SA, Arora S, et al. (2017) Enforcement of the Emergency Medical Treatment

and Labor Act, 2005 to 2014. Ann Emerg Med 69: 155–162.

28. Terp S, Wang B, Raffetto B, et al. (2017) Individual Physician Penalties Resulting From

Violation of Emergency Medical Treatment and Labor Act: A Review of Office of the Inspector

General Patient Dumping Settlements, 2002–2015. Acad Emerg Med 24: 442–446.

29. Thomson Healthcare (2007) Profiles of U.S. Hosptials, 2007. Ann Arbor, MI: Thomson Healthcare.

30. United States Department of Commerce. Bureau of the, C. (2012) Census of Population and

Housing, 2010 [United States]: National Summary File of Redistricting Data. Available from:

http://doi.org/10.3886/ICPSR33442.v1.

377

AIMS Public Health Volume 5, Issue 4, 366-377.

31. Zibulewsky J (2001) The Emergency Medical Treatment and Active Labor Act (EMTALA):

What it is and what it means for physicians. Proceedings 14: 339.

32. Zuabi N, Weiss LD, Langdorf MI (2016) Emergency Medical Treatment and Labor Act

(EMTALA) 2002-15: Review of Office of Inspector General Patient Dumping Settlements.

West J Emerg Med 17: 245.

© 2018 the Author(s), licensee AIMS Press. This is an open access

article distributed under the terms of the Creative Commons

Attribution License (http://creativecommons.org/licenses/by/4.0)