Santa Ana, California, 11/9/1997: A non-English-speaking patient presented to the ER of Coastal Communities Hospital. He gave his insurance card to an admitting clerk and was told that the hospital did not have a contract with his HMO and that he would have to go to another facility. He asked for an interpreter, but the clerk did not understand his request and failed to obtain an interpreter for him. He presented to another hospital and was admitted with the diagnosis of acute myocardial infraction, or heart attack.

When a medical emergency strikes -- a heart attack, a sudden fall, a mysterious ailment -- a hospital emergency department often provides the first line of defense in the fight for life. The local ER is such a vital contributor to public health and safety that we rightly expect it to serve anyone who arrives through the sliding glass doors in their hour of need, regardless of race, income, disability or other circumstances.

Yet recently, the Washington, DC-based consumer-advocacy group Public Citizen released a report that details how hundreds of ERs across the country have illegally refused or delayed treatment for uninsured or minority patients.

In 1986 Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA). It requires that hospitals provide necessary medical screening and stabilizing treatment to any person who arrives at an emergency department, and also that a patient be stabilized as much as possible before being transferred to another hospital. Denying or delaying such services or failing to follow certain administrative regulations is called "patient dumping" and is a violation of federal law.

Between 1996 and 2000, according to the Public Citizen report, 527 hospitals were reported as violating EMTALA regulations, and California led the pack with 77 offending hospitals. In addition, many cases of patient dumping are never reported to authorities, in part because many patients are unaware of their rights under the law. Although some violations were administrative in nature, such as failing to post signs notifying patients of their rights, many involved denying or delaying needed emergency screening or treatment. Public Citizen also concluded that most hospital staff were aware of EMTALA requirements but violated them anyway.

In recent years Washington has levied over $1 million annually against hospitals for violations of the act. However, according to Dr. Sidney Wolfe, medical director of Public Citizen, individual hospitals are usually fined relatively low amounts ($10,000 to $15,000 is typical) or not at all. "The sad truth is that it's cheaper for a hospital to break the law and pay a fine than to treat an uninsured patient," says Wolfe. "Hospitals know that the risk of getting caught is low, and even if they are caught, the risk of being fined is even lower, and the fines are minuscule compared to hospitals' operating budgets."

"Providing for the basic needs of all members of the community is a reasonable expectation for any just society," says medical-ethics expert Dr. Charles D. Kay, who serves on the ethics committee of Mary Black Hospital and is a professor of philosophy at Wofford College in South Carolina.

"There has been a growing concern about this issue in recent years," he says. "The numbers have improved considerably since federal legislation was introduced, but enforcement is still a problem, and the limited threat of action has lead to a gradual increase in recent years. Since such behavior can lead to serious harm or even death, even a few incidents would be too many, and of course for the person suffering such treatment, the experience is unforgettable."

Fresno, California, 2/21/98: An uninsured patient presented to the emergency department of Fresno Community Hospital following a skiing accident the same morning. An X ray documented fractures of both bones of the right lower leg. One of the bone fractures was documented as comminuted, meaning a segment of bone was essentially pulverized.

The patient received pain medication and his leg was splinted, but an orthopedic surgeon contacted by the ER physician refused to admit him. The patient was informed that he would have to come up with at least $15,000 for the required surgery. Four days later the patient went to another hospital's ER, where he was evaluated and admitted; he received surgical treatment there.

The most common reason for dumping a patient is because he or she does not have the means to pay, whether through lacking health insurance or because the insurance company will not authorize reimbursement. All too often, ER staffers will advise such "private pay" individuals to get back in their cars and take their injuries to the local county hospital, which is often treated as a dumping ground for indigent patients. "You don't find hospitals turning away patients when their wallets are full of hundred-dollar bills," says Kay.

Many health-industry organizations counter that EMTALA amounts to an "unfunded mandate" that places an unfair financial burden on hospitals, especially in rural areas. According to the American Hospital Association, for instance, the federal government provides practically no financial reimbursement to hospitals for providing EMTALA-mandated emergency care for the uninsured. The AHA's official position is that "to ensure that EMTALA-related emergency services remain available, the federal government has an obligation to help hospitals meet their EMTALA obligations."

For-profit hospitals are more likely than nonprofit hospitals to dump patients, according to the Public Citizen report. Make no mistake, the profit motive has inspired private health-industry companies to invent new miracle cures and high-tech lifesaving devices that have turned once-fatal injuries and illnesses into routine procedures. But that same profit motive sometimes leads to cutbacks -- legal or otherwise -- in emergency medical services that are traditionally viewed as important to a community as police and fire services.

Kay offers an historical perspective. "A century ago, health care was considered to be a public service, and hospitals were almost exclusively funded by the state or the church. The concept of for-profit health care is a relatively new one, and we have yet to realize all of its consequences. Recent scandals with HMOs and profit-making hospital chains show us that we have not yet introduced adequate safeguards into the system."

However, lest we place all the blame on the private sector, we should remember that for-profit hospitals are not the only ones that engage in patient dumping. "Even nonprofit hospitals are under big pressures to balance budgets, and care for the uninsured and underinsured can cost millions annually," says Kay.

Merced, California, 10/20/98: A 49-year-old mentally retarded black male patient was brought by ambulance to Mercy Hospital's ER with symptoms of abdominal distress and shortness of breath. The ER physician suspected an abdominal condition requiring surgery. As the patient deteriorated, the physician twice called an on-call surgeon, asking that he come in immediately.

The surgeon repeatedly refused to come in, advising that the patient be admitted for him to see in the morning. As the patient's blood pressure and pulse rate dropped to life-threatening levels, the ER physician contacted hospital administrators in an apparent effort to compel the surgeon to come in.

The patient suffered a cardiac arrhythmia and died despite a resuscitation attempt. The surgeon arrived during the resuscitation effort. Documentation also revealed that the surgeon made disparaging remarks related to this patient's mental retardation, including the statement that "no one would miss him if he died," as he had lived in a board-and-care home for 15 years.

While the 800-pound gorilla of financial pressures dominates most health-care controversies, some hospital staffers have been known to dump patients for other reasons, especially discrimination on the basis of race, age, gender, disability or other reasons. "Doctors are no better or worse than the rest of us in this regard, and sometimes this shows up in the ER as well," says Kay. "This is a social problem, and reflects the fact that doctors are human, too."

Many people who work in hospital emergency departments are overworked and underpaid, and yet they nonetheless have a sincere desire to serve their community. But even a few bad apples can bring permanent tragedy and heartache to innocent patients and their families. Even more frightening is how the introduction of free-market economics into America's hospitals has created an entire class of patients who no longer "deserve" to have their lives saved.

One solution to the problem of "patient dumping" would be to provide hospitals with financial incentives to treat uninsured and minority emergency patients while imposing severe penalties for denying or delaying care. Perhaps an effective model would include increasing fines and threatening to withhold other federal funds from hospitals that violate EMTALA requirements, and criminally prosecuting hospital staffers who discriminate against ER patients.

In addition, the American Hospital Association proposes that Washington help pay for EMTALA-related emergency services for uninsured patients, have Medicaid fully fund EMTALA-related screening and stabilization services and monitor Medicaid and Medicare managed-care plans to ensure that they reimburse hospitals for EMTALA-related screening and stabilization services.

Kay also suggests a solution: "If society provided adequate universal health insurance, hospitals would actively compete with each other to take these patients in. Practical problems may be posed, but clearly a better system of health insurance would relieve the pressure for dumping."

If you or someone you know is a victim of patient dumping, contact a regional office of the Centers for Medicare and Medicaid to report it as a possible EMTALA violation.

David Bragi

David Bragi, a freelance journalist who lives in El Cerrito, California, is Editor of the multicultural webzine New Tribal Dawn.