In December 2022, the University Hospital of Louisville in Louisville, Kentucky, allegedly abandoned an aging female patient on the sidewalk near the hospital. Her bare legs were exposed, and she was breathing hard with a blanket draped over her face. A hospital employee told WAVE News that she had seen hospital security wheeling the patient onto the sidewalk and abandoning her and her belongings on the street.
WAVE investigated the claim and witnessed other instances of hospital security leaving behind patients desperately needing medical attention. They witnessed a woman being escorted out by three security staff and abandoned in the same area as the older woman. She told WAVE she has COPD and diabetes. She said the security employees didn’t explain why she was being escorted onto the street.
This crisis affects older people, people with psychiatric conditions, and people with disabilities the most.
Is this a recent phenomenon? Does the law protect patients? What is causing hospitals to forsake their patients?
History
In an 1877 article, “The Death of Michael Connolly,” The New York Times documented one of the first known cases of patient dumping. While pneumonia was the official cause of Connolly’s death, authorities at Bellevue Hospital, where he was being treated, “alleged that death was accelerated by the removal of the patient from Chambers Street Hospital [where he was initially dropped off].”
The federal government cut corners with patient spending in the early 1980s, dramatically increasing improper patient discharge.
Legislation
The Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1983, ensures that people with urgent medical needs can receive care regardless of their ability to pay. Recently, there has been an increase in hospitals abandoning patients. There’s even a term for this behavior; “patient dumping”.
EMTALA outlines four protections for appropriately transferring and discharging patients. The hospital must provide medical treatment to its capacity and move patients smoothly and without additional harm. Patients must be stable to be transferred or discharged. This is a gray area since “stable” conditions often deteriorate quickly and don’t consider other chronic health conditions. If someone has cancer, for instance, they wouldn’t be able to have that cancer treated at a hospital. They could only stabilize the patient’s vitals and wouldn’t treat the cancer.
Dekalb Medical Center reached a $260,000 settlement with the Office of the Inspector General after an investigation into allegations of the hospital dumping 24 patients. The basis of the lawsuit violated EMTALA. In each case, the Office of the Inspector General found that Dekalb Medical Center “failed to provide an appropriate medical screening examination or stabilizing treatment to these individuals within the capability of its ED [Emergency Department].”
According to the American College of Emergency Physicians, “Approximately 95.2% of emergency physicians provide some EMTALA-mandated care in a typical week…”
A Government Accountability Office to Congress report states, “They [hospital representatives] are troubled that there is no procedure for hospitals to challenge or appeal a violation decision before the termination process begins.”
Does EMTALA actually work?
A 2014 letter to President Obama from The United States Commission on Civil Rights (USCCR) identified several issues with EMTALA enforcement. Among the problems were:
- Poor patient data collection.
- Lack of regulatory oversight.
- Insufficient funds to comply with EMTALA.
- The need for more training and education for hospitals and their staff.
In the letter, Staci Pratt of the ACLU of Nevada testified that the federal government is responsible for ensuring civil rights and protection for EMTALA patients, especially given that they rarely have access to a private attorney.
Regarding regulatory oversight, the USCCR found that EMTALA violations are mostly complaint-driven, meaning that the patients receiving inadequate care are the ones informing the system. USCCR concluded that EMTALA violation numbers may be influenced by the fact that disabled people – specifically people with a psychiatric condition- may have a difficult time reporting violations due to “diminished capacity or access to resources.”
The 2010 Affordable Care Act (ACA) involved an individual mandate that required Americans to have medical insurance. This served as an expansion of Medicaid. In 2014, new ACA insurance provisions were made. Such provisions included:
- Increasing the age of adults to stay on their parent’s insurance to 26.
- Expanding Medicaid in participating states.
- Introducing health insurance marketplaces.
Following these provisions, the number of uninsured emergency department visits and discharges (for people aged 18-64) decreased from approximately 20% in 2006-2013 to 11% in 2016. This can be tied to implementing the ACA and its provisions. However, this number has increased in subsequent years, leading to the government’s need to prioritize Americans’ healthcare rights.
Basic Health Care Needs
According to the European Society of Emergency Medicine’s analysis of emergency department visits across the European Union (EU) in 2016, the average amount of hospital visits was 30.4 out of 100. In the United States, the number of ED visits per 100 people is 42.7, according to the CDC.
The European Union is similar to the United States in terms of industrialization. The critical difference is that almost all EU countries provide free healthcare. Residents have the privilege of visiting doctors as needed. Data from the US Census shows that the average non-family household income was $ 45,070 in 2022. Combining the cost of procedures, the room, labor, medications, or anesthesia quickly brings the cost of an outpatient procedure such as a pap smear or blood test to over $1000, much more than most people can afford.
According to The American Hospital Association’s 2019 Annual Survey of Hospitals, emergency departments (ED) provided $41.6 billion in uncompensated care in 2019 alone. This puts an undue financial burden on hospital EDs and staff.
Atlanta Medical Center closed its doors for good in 2022, citing shrinking revenue as the cause. This closure of a 450-bed hospital was a significant loss for the city of Atlanta and speaks to the larger problem of uncompensated care.
Doctors for America, a non-governmental organization pushing for universal healthcare, says, “We know affordable healthcare for all is a medical imperative, an economic imperative, and a moral imperative.”
Solutions
Aside from our urgent need for universal healthcare, there are more immediately effective solutions available.
There’s a need for more stringent data collection to assess the scope of patient dumping. Creating a specialized task force to analyze the data and conduct research would mitigate this issue. It is essential to monitor hospitals for their EMTALA compliance.
Congress should create mandatory EMTALA training and guidelines for hospital staff. Education on evidence-based procedures to handle emergency department admissions of disabled, seniors, and people with psychiatric conditions would also tackle this problem.
Mental and chronic health conditions exist beyond the basic stabilization of a patient’s vitals and emergency physical condition. Alternatives such as transferring patients to rehabilitation centers are better than discharging or dumping them. EMTALA should be amended to include these considerations.
Since healthcare and dignity are civil rights, steps should be taken to better oversee EMTALA complaints. For example, cases should be monitored by institutions such as The Office for Civil Rights for the potential of a civil rights violation.
References
AHA: Hospitals provided $41.6 billion in uncompensated care in 2019 | AHA News. (2021, January 21). American Hospital Association. Retrieved November 10, 2023, from https://www.aha.org/news/headline/2021-01-21-aha-hospitals-provided-416-billion-uncompensated-care-2019
European Emergency Medicine in Numbers. (n.d.). Eusem. Retrieved November 10, 2023, from https://eusem.org/images/European_EM_in_numbers.pdf
Fast Facts on U.S. Hospitals, 2023 | AHA. (n.d.). American Hospital Association. Retrieved November 10, 2023, from https://www.aha.org/statistics/fast-facts-us-hospitals
FastStats – Emergency Department Visits. (n.d.). CDC. Retrieved November 10, 2023, from https://www.cdc.gov/nchs/fastats/emergency-department.htm
Guzman, G., & Kollar, M. (n.d.). Income in the United States: 2022. U.S. Census Bureau. Retrieved November 10, 2023, from https://www.census.gov/content/dam/Census/library/publications/2023/demo/p60-279.pdf
Miró, Ò. (2010, December 8). State of emergency medicine in Spain – PMC. NCBI. Retrieved November 10, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047875/
SEPTEMBER 2014. (2014, September 19). U.S. Commission on Civil Rights. Retrieved November 10, 2023, from https://www.usccr.gov/files/pubs/docs/2014PATDUMPOSD_9282014-1.pdfSinger, A., Thode, H., & Pines, J. (n.d.). US Emergency Department Visits and Hospital Discharges Among Uninsured Patients Before and After Implementation of the Affordable Care Act. JAMA Emergency Medicine. doi:10.1001/jamanetworkopen.2019.2662