Government Mandates in the Emergency Department : Since 1986


When a patient rolls into any Emergency Department in America they expect to be seen, treated, and sent home in better condition then which they arrived, hopefully. They expect to be cared for, not hassled over insurance information and payment. The hospital’s administration sees the situation differently. They just hope to break even on all the money spent for doctors, nurses, scans, and the equipment required to get that patient stabilized. Hospitals must triage all patients and treat emergencies regardless of insurance and citizenship, and it isn’t strict adherence to the Hippocratic Oath that causes these centers to do it. Hospitals, as it turns out, have had the government mandating their operations even before Barack Obama ever arrived at Harvard Law School.
They are mandated by The Emergency Medicine and Active Labor Act passed in the 1986 Omnibus Bill (COBRA). The language is simple, just a few pages. Any Hospital that has an emergency department and accepts Medicare must admit patients to the Emergency Department as if money was no object (my translation). Its purpose was to eliminate “dumping,” a practice when poor patients would be directed to other hospitals to avoid potential financial losses.


One benefit of the mandate is the safety net it created; it is common knowledge that in the case of a car accident, everyone will go to the hospital, but This bill has also played a role in the unstable condition of our nation’s hospitals; In debt and losing money. The downsides are the ways the nation pays for this safety net. In effect the hospital is mandated by the government to lose money treating the uninsured and illegal. It is widely known that the hospital doesn’t write off the full amount as a loss, instead the hospital charges insured patients more to make up a percentage; it's a practice called cost-shifting. This is what is described in the media as the “Hidden Tax on Business.” Since businesses pay most of the expense of health insurance they bear the grunt of paying the higher premiums caused by cost-shifting. The insured pay for the bill in other ways too. Emergency departments that lose money for the hospital are kept artificially small. There is little reason to expand the capacity if it is only going to result in greater loss. The risk of low capacity Emergency Rooms is divergence. It occurs when an emergency room can take no new patients and instead patients are driven to hospitals further away. It is a potentially deadly fact-of life that does not get adequate attention.

Dr. Guy Clifton, Professor of Neurosurgery at University of Texas Health Science Center at Houston (where Gabby Giffords was further stabilized) and former adviser to Senator Hatch of Utah, writes about the practice in his book Flatlined: resuscitating American Medicine.

Improving this phenomenon of Emergency Medicine is one way universal coverage could benefit all, even those who will pay more for the insurance they already have, by improving access to emergency medicine. The story of Malyia Jeffers, a 2 year old girl from California, highlights the avoidable dangers that could be avoided by better emergency access. In November 2010 Malyia was brought to Methodist Hospital in Sacramento, CA because of a fever. Her and her patients sat patiently in the waiting room as hours ticked away. Malyia was declared low priority which allowed others to be admitted before her. Although unknown to everyone, her liver was quickly failing due to Hepatitis A. Malyia ended up on life support and lost her left hand and fingers on her right. Her story is just one reminder that these “waiting room” tragedies due to long waits are very real. The realities Methodist Hospital  that day were no different than thousands of other facilities around the nation.

A 2004 report, "Emergency Room Loses" done by the California Medical Association showed Methodist ER lost $400,000, which by California Standards was a banner year. That year California hospitals combined to lose $460million through the emergency room, with some hospitals accounting for 10million on their own. If Malyia Jeffers story can happen in a  financially stable Emergency Room then what could be expected in a multi-million dollar loser?


Regardless of the end result to the constitutional battle that lies before the health care law we can look to current laws, like EMTALA, to see how effective government mandates in Health Care are.