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The History of EMTALA

The following are quotations from decided cases which describe the historical underpinnings of EMTALA.

From Cleland v. Bronson Health Care Group, Inc., 917 F.2d 266, 271 (6th Cir. 1990):

    It is undisputed that the impetus to this legislation came from highly publicized incidents where hospital emergency rooms allegedly, based only on a patient's financial inadequacy, failed to provide a medical screening that would have been provided a paying patient, or transferred or discharged a patient without taking steps that would have been taken for a paying patient. Apparently dissatisfied with the effect of laws that had been limited to hospitals that received funds from the government under the Hill-Burton Act, 42 U.S.C. 291 to 291 o -1, Congress chose to attempt to meet the perceived evil by enacting the quoted language. See 1986 U.S.Code Cong. & Admin.News 42, 579, 605; Note, Preventing Patient Dumping, 61 N.Y.U.L.Rev. 1186, 1187-88 and nn. 11-12 (1986).

From Gatewood v. Washington Healthcare Corp., 290 U.S. App. D.C. 31, 933 F.2d 1037 (D.C. Cir. 1991):
(This is a frequently quoted formulation)

    The Emergency Act was passed in 1986 amid growing concern over the availability of emergency health care services to the poor and uninsured. The statute was designed principally to address the problem of "patient dumping," whereby hospital emergency rooms deny uninsured patients the same treatment provided paying patients, either by refusing care outright or by transferring uninsured patients to other facilities. See H.R.Rep. No. 241, 99th Cong., 1st Sess., pt. 1, at 27 (1985); id., pt. 3, at 5; see also Cleland v. Bronson Health Care Group, Inc., 917 F.2d 266, 268 (6th Cir.1990) (discussing legislative history of Emergency Act); Note, Preventing Patient Dumping: Sharpening the COBRA's Fangs, 61 N.Y.U.L.Rev. 1186, 1187-88 (1986). Reports of patient dumping rose in the 1980s, as hospitals, generally unencumbered by any state law duty to treat, faced new cost containment pressures combined with growing numbers of uninsured and underinsured patients. See Note, supra, at 1189-96. Congress responded with the Emergency Act, which imposes on Medicare-provider hospitals a duty to afford medical screening and stabilizing treatment to any patient who seeks care in a hospital emergency room. . . [at 1040]

From Arrington v. Wong, 19 F. Supp. 2d 1151 (D.Hi. 1998):

    To provide emergency treatment to indigent and uninsured patients, Congress enacted the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA), commonly known as the Patient Anti-Dumping Act, 42 U.S.C. 1395dd, to prevent "hospitals . . . `dumping' [indigent ] patients . . . by either refusing to provide emergency medical treatment or transfer-ring patients before their conditions were stabilized." James v. Sunrise Hosp., 86 F.3d 885, 886 (9th Cir. 1996) (quoting Eberhardt v. City of Los Angeles, 62 F.3d 1253, 1255 (9th Cir. 1995) (internal quotation marks omitted). See also Gatewood v. Washington Healthcare Corp., 933 F.2d 1037, 1039 (D.C. Cir. 1991) (stating that EMTALA passed amid growing reports in the 1980's of hospitals denying emergency health care services to the poor and uninsured). The provisions of EMTALA are not limited to the indigent and uninsured, however. "Because [EMTALA] is clear on its face, we have held `that the Act applies to any and all patients, not just to patients with insufficient resources.' " James, 86 F.3d at 887 (quoting Brooker v. Desert Hosp. Corp., 947 F.2d 412, 414 (9th Cir. 1991)).


    The effects of patient dumping on the availability and quality of emergency services for indigent and uninsured patients are well documented. See Karen I. Treiger, Note: Preventing Patient Dumping: Sharpening the COBRA's Fangs, 61 N.Y.U. L. Rev. 1186, 1190 (1986) (cited by appellants).10


    10 Treiger discusses three recent studies analyzing patient dumping. See Karen I. Treiger, Note: Preventing Patient Dumping: Sharpening the COBRA's Fangs, 61 N.Y.U. L. Rev. at 1190-1191. One study reports that eighty-seven percent of hospitals transferring patients cited the lack of insurance as the sole reason for the transfer. Id. at 1190 (citing Schiff,

From Hardy v. New York City Health and Hospitals Corp., 164 F.3d 789 (2d Cir. 1999):

    In 1986, Congress enacted the Emergency Medical Treatment and Active Labor Act ("EMTALA"), 42 U.S.C. 1395dd. The purpose of EMTALA is to prevent "'patient dumping,' the practice of refusing to provide emergency medical treatment to patients unable to pay, or transferring them before emergency conditions [are] stabilized." Power v. Arlington Hosp. Ass'n, 42 F.3d 851, 856 (4th Cir. 1994); see Bryan v. Rectors and Visitors of the Univ. of Virginia, 95 F.3d 349, 351 (4th Cir. 1996); Correa v. Hospital San Francisco, 69 F.3d 1184, 1189 (1st Cir. 1995); see also H.R. Rep. No. 241, 99th Cong., 1st Sess. 27 (1986), reprinted in 1986 U.S.C.C.A.N. 42, 605, 726-27.

    EMTALA, which applies to all hospitals that participate in the federal Medicare program, imposes two primary obligations on those hospitals. First, when an individual shows up for treatment at a hospital's emergency room, "the hospital must provide for an appropriate medical screening examination . . . to determine whether or not an emergency medical condition" exists. 42 U.S.C. 1395dd(a). Second, if the screening examination indicates that an emergency medical condition does exist, the hospital ordinarily must "stabilize the medical condition" before transferring or discharging the patient. Id. 1395dd(b)(1)(A).

    EMTALA is not a substitute for state law on medical malpractice. See Power, 42 F.3d at 856. It "was not intended to guarantee proper diagnosis or to provide a federal remedy for misdiagnosis or medical negligence." Id. Instead, EMTALA was enacted to fill a lacuna in traditional state tort law by imposing on hospitals a legal duty (that the common law did not recognize) to provide emergency care to all. See Brooks v. Maryland Gen. Hosp., Inc., 996 F.2d 708, 714-15 (4th Cir. 1993); Bryan, 95 F.3d at 351 ("[EMTALA's] core purpose is to get patients into the system who might otherwise go untreated and be left without a remedy because traditional medical malpractice law affords no claim for failure to treat."); Gatewood v. Washington Heathcare Corp., 933 F.2d 1037, 1041 (D.C. Cir. 1991) (finding EMTALA creates "a new cause of action, generally unavailable under state tort law, for what amounts to failure to treat").

    The legislative history of EMTALA demonstrates that "Congress never intended to displace state malpractice law." Brooks, 996 F.2d at 714. This intent to supplement, but not supplant, state tort law is evident in EMTALA's limited preemption provision. See 42 U.S.C. 1395dd(f); see also Brooks, 996 F.2d at 715. EMTALA provides: "The provisions of this section do not preempt any State or local law requirement, except to the extent that the requirement directly conflicts with a requirement of this section." 42 U.S.C. 1395dd(f).

    EMTALA's deference to state law is also apparent in its express adoption of state law as to the damages recoverable. Id. 1395dd(d)(2)(A); Brooks, 996 F.2d at 715. EMTALA provides that a plaintiff, in a civil action against a hospital, may "obtain those damages available for personal injury under the law of the State in which the hospital is located, and such equitable relief as is appropriate." 42 U.S.C. 1395dd(d)(2)(A).

    Significantly, EMTALA's legislative history demonstrates that Congress questioned "the potential impact" of EMTALA on "the current medical malpractice crisis"; Congress also expressed concern that an unbridled EMTALA could unduly burden hospitals and thereby "result in a decrease in available emergency care" rather than the intended increase in such care. H.R. Rep. No. 241, 99th Cong., 1st Sess. 27 (1986), reprinted in 1986 U.S.C.C.A.N. 42, 728. New York's notice-of-claim law, by promoting timely settlement of claims and protecting municipal hospitals from unnecessary or excessive litigation expenses, helps to alleviate these concerns.

    In determining whether federal law preempts a state statute, "our sole task is to ascertain the intent of Congress." California Fed. Sav. & Loan Ass'n v. Guerra, 479 U.S. 272, 280 (1987); see Burgio and Campofelice, Inc. v. New York State Dep't of Labor, 107 F.3d 1000, 1008 (2d Cir. 1997). When Congress expressly defines a statute's preemptive reach, and the definition provides "a reliable indicium" of congressional intent as to what should be left to state authority, there is a "reasonable inference" that Congress did not intend to preempt matters beyond that reach. Freightliner Corp. v. Myrick, 514 U.S. 280, 288 (1995) (discussing Cipollone v. Liggett Group, Inc., 505 U.S. 504, 517 (1992)); see also Toy Mfrs. of Am., Inc. v. Blumenthal, 986 F.2d 615, 623 (2d Cir. 1993). This is based on the familiar principle of expressio unius est exclusio alterius, the mention of one thing implies the exclusion of the other. See Cipollone, 505 U.S. at 517.

    EMTALA specifically envisions that some procedural matters are better left to state discretion: "The provisions of this section do not preempt any State or local law requirement, except to the extent that the requirement directly conflicts with a requirement of this section." 42 U.S.C. 1395dd(f) (emphasis added). As the Fourth Circuit has recognized, "EMTALA is quite clear that it is not intended to preempt state tort law except where absolutely necessary." Bryan, 95 F.3d at 352. We need only determine whether New York's notice-of-claim requirement "directly conflicts" with EMTALA.

From Reynolds v. Mainegeneral Health, 218 F.3d 78 (1st Cir. 2000):

    Congress enacted EMTALA in 1996 [sic], in the face of "the increasing number of reports that hospital emergency rooms are refusing to accept or treat patients with emergency conditions if the patient does not have medical insurance." H.R. Rep. No. 241(I), 99th Cong., 1st Sess. 27 (1986), reprinted in 1986 U.S.C.C.A.N. 42, 605. EMTALA created a remedy for patients in certain contexts in which a claim under state medical malpractice law was not available. Although the exact scope of the rights guaranteed to patients by EMTALA is still not fully defined, it is clear that at a minimum Congress manifested an intent that all patients be treated fairly when they arrive in the emergency department of a participating hospital and that all patients who need some treatment will get a first response at minimum and will not simply be turned away. See Baber v. Hospital Corp. of America, 977 F.2d 872, 880 (4th Cir. 1992) ("The avowed purpose of EMTALA was not to guarantee that all patients are properly diagnosed, or even to ensure that they receive adequate care, but instead to provide an 'adequate first response to a medical crisis' for all patients and 'send a clear signal to the hospital community . . . that all Americans, regardless of wealth or status, should know that a hospital will provide what services it can when they are truly in physical distress.'") (quoting 131 Cong. Rec. S13904 (Oct. 23, 1985) (statement of Sen. Durenberger)). Appellants' argument that because Mr. Reynolds was in a hospital room receiving treatment for his injuries when the risk of DVT became manifest, it would be unreasonable to deny him the protections of subsection (a) is unpersuasive. The fact that Mr. Reynolds was in the hospital receiving treatment is a prima facie showing that the purpose of subsection (a) was satisfied; any failures of diagnosis or treatment were then remediable under state medical malpractice law.