Crozet Annals of Medicine: The Cobra that Tamed the ER


“The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America. After all, you just go to an emergency room.”

—President George W. Bush, July 7, 2007

I watched the recent debate on repealing and replacing the Affordable Care Act with a great deal of (vested) interest. This is because I am part of the 4 percent of US doctors who work in Emergency Departments. That 4 percent of us manage a full two-thirds of all the acute care provided to the uninsured in the United States. So the prospect of increasing the rolls of the uninsured by 24 million people naturally interested me.

We 4 percent also manage 28 percent of all acute care visits in the US, and half of all the acute care provided to Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries.

Fifty-five percent of our care is uncompensated. As President Bush and many others have observed, we see all comers, regardless of citizenship status or ability to pay. Admirable, no doubt, fiscally questionable to be sure, but it wasn’t always this way and we didn’t come to it out of nobility.

In the 1980s there was a big problem in the nation’s delivery of emergency care. A quarter of a million patients a year were denied needed emergency care at private hospitals and transferred to public hospital ERs because of lack of insurance. Eighty-nine percent of these patients in one study were African American or Hispanic. Twenty-four percent of these patients were unstable at the time of transfer. Their mortality rate was triple that of other patients. Many were women in active labor, some of who were put into taxis or private autos and then delivered en route. Messy. Those of us at public hospitals called this patient dumping and said that the patients had failed a wallet biopsy.

In 1986, after an exposé about patient dumping on the news show 60 Minutes, Congress passed the Emergency Treatment and Labor Act (EMTALA) as part of the Consolidated Omnibus Budget Reconciliation Act better known as COBRA. The EMTALA law mandates that all hospital ERs provide medical screening exams on all patients who present to the ER to screen for an emergency medical condition. The hospitals are then required to stabilize any emergency condition either within the ER or in the hospital as an inpatient, regardless of the patient’s ability to pay for the care. If the facility cannot provide the type of specialty services the patient needs for stabilization, neurosurgery for example, the patient can be transferred without full stabilization.

Violations of EMTALA by physicians can lead to a $50,000 fine that is not covered by malpractice insurers or employment contracts. Hospitals can also be fined $50,000 for a violation.

There is no provision in the law to provide payment for the doctors or hospitals for providing the federally mandated emergency screening and stabilization care—hence all the uncompensated care we provide.

For many years ER docs called the anti-dumping act the ominous sounding “COBRA” law because it was so widely feared by us. Not only could the transferring doctors be cited, but the receiving doctors could also be fined for refusing a transfer request, no matter how unreasonable. There is no limitation on the distance of the transfer. I am obligated to take transfers from any other state in the U.S. if requested and if my hospital has capacity–and we always have capacity since we can always squeeze one more patient into our perpetually overcrowded ER. Some have blamed ER wait times and crowding on EMTALA but that is a more complicated issue to analyze.

A recent study of all EMTALA claims shows just how far we have come though since 1986. From a high of 250,000 economically motivated transfers in 1986 we now have an EMTALA violation rate of 1.7 per million ER visits. That is a rate of 0.00017 percent of ER visits that result in an EMTALA violation. Essentially, a never event.   

In fact over the years the EMTALA obligation to treat all comers regardless of ability to pay has been so ingrained in the ER culture that we have actually stopped teaching it to the medical students and new MDs. It has simply become the normal way to do business in the ER. I kind of like it. See and treat all, regardless of situation or circumstance. Accept all transfers.

I do agree with George Bush on one thing though. I would like it even more if everyone had insurance.

Home is the place where, when you have to go there,

They have to take you in.

        I should have called it

       Something you somehow haven’t to deserve.

—Robert Frost,  The Death of the Hired Man


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