Impact of EMTALA on Access to and Quality of Emergency Care

Project Summary Before the 1986 enactment of the Emergency Medical Treatment and Labor Act (EMTALA), emergency departments (EDs) could legally turn away patients with emergency conditions based upon condition or ability to pay. EMTALA imposed a duty to treat, requiring that all patients presenting to an ED receive a timely medical screening evaluation, stabilization, and transfer if specialized stabilizing services are needed, regardless of condition or ability to pay. Hospitals are required to accept transfer of patients from other EDs if the receiving facility has specialized services required to stabilize their condition. Compliance with EMTALA is a condition of Medicare participation, and failure to comply with EMTALA can result in termination of a hospital's Medicare provider agreement, a serious consequence that can result in hospital closure. EMTALA is actively enforced with a quarter of U.S. hospitals cited for violating the law within the past decade. Faced with an EMTALA citation, hospitals have two principal options to improve EMTALA compliance. First, they could enhance policies, procedures and service availability - improving access to and quality of care. Alternatively, hospitals could eliminate service lines reducing both responsibilities under EMTALA as well as access to care for the population served by the hospital. Indirect evidence suggests that some hospitals have responded to EMTALA enforcement in ways that might paradoxically reduce access to or quality of emergency care, likely exacerbating disparities. However, no publications directly evaluate how EMTALA enforcement impacts access to or the quality of emergency care. Nor is it known how hospitals responded to EMTALA enforcement in the wake of the COVID- 19 pandemic. To address this knowledge gap, we propose to build on an existing dataset and create a file including all EMTALA citations from 2011-present and link with data from the Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD), the State Inpatient Databases (SID), Hospital Compare data to complete a study with the following Aims: (1) To evaluate whether access to emergency care improves following EMTALA citation (2) To assess whether disparities in access to care change in response to EMTALA citation, (3) To determine if quality of emergency care changes in response to EMTALA citations, (4) To quantify whether these effects varied during the COVID-19 pandemic, and finally (5) To characterize corrective action plans proposed by hospitals in response to citation to determine which actions and operational changes are associated with change in access to or quality of care. Understanding whether EMTALA enforcement impacts access to and quality of emergency care, and which corrective action plans serve as likely mechanisms for observed changes will be imperative to informing future efforts to enhance or improve the statute to ensure access to quality emergency care for historically underserved populations, and in particular low-income and minority groups, all AHRQ priority populations.