The Emergency Medical Treatment and Labor Act as a federal health care safety net program.

Despite the greatest economic expansion in history during the 1990s, the number of uninsured U.S. residents surpassed 44 million in 1998. Although this number declined for the first time in recent years in 1999, to 42.6 million, the current economic slow-down threatens once again to increase the ranks of the uninsured. Many uninsured patients use hospital emergency departments as a vital portal of entry into an access-impoverished health care system. In 1986, Congress mandated access to emergency care when it passed the Emergency Medical Treatment and Labor Act (EMTALA). The EMTALA statute has prevented the unethical denial of emergency care based on inability to pay; however, the financial implications of EMTALA have not yet been adequately appreciated or addressed by Congress or the American public. Cuts in payments from public and private payers, as well as increasing demands from a larger uninsured population, have placed unprecedented financial strains on safety net providers. This paper reviews the financial implications of EMTALA, illustrating how the statute has evolved into a federal health care safety net program. Future actions are proposed, including the pressing need for greater public safety net funding and additional actions to preserve health care access for vulnerable populations.

Critical care transport: outcome evaluation after interfacility transfer and hospitalization.

STUDY OBJECTIVE: To test the hypothesis that interfacility transfer is not associated with increased mortality, duration of stay, or readmission within 7 days. METHODS: We matched 3,298 patients who were hospitalized for chest pain or related complaints in Kaiser Permanente medical centers after transfer from the emergency department of a nonplan hospital (transported patients) with 3,298 patients of the same gender and age (+/-5 years) and with the same principal diagnosis who were hospitalized within 6 months without transfer in the same Kaiser Permanente medical center (directly admitted patients). Patients were compared in terms of outcome measures: in-hospital deaths, continued care in another facility, readmission within 7 days, in-patient length of stay (LOS), and LOS in special care units. RESULTS: The adjusted odds ratios for in-hospital mortality and readmission within 7 days were 1.0 (95% confidence interval,.8 to 1.4) and.9 (95% confidence interval,.7 to 1.2), respectively. The adjusted mean difference in LOS was -.1 days (95% confidence interval, -.2 to.1). Transported and directly admitted cardiac patients were also compared for all examined outcome measures at each of 10 medical centers. At a few medical centers, we observed significant difference in LOS, special care LOS, and continued care in another facility. However, all these differences were small, and most were probably random errors. CONCLUSION: Conservative patient selection criteria, pretransfer stabilization, and the use of appropriate equipment and medical personnel have resulted in the interfacility transfer program's achieving its goal of transferring high-risk patients without adverse impact on clinical outcomes or resource use.