AANS Neurosurgeon | Volume 28, Number 4, 2019


Neurotrauma and Emergency Care: Who Pays?

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For 30 years, the Emergency Medical Treatment and Active Labor Act (EMTALA) has provided the foundation for emergency care in the U.S. Passed by a bipartisan Congress and signed by a Republican President, it has remained a fixture of health care policy, mostly unchallenged by hospitals and physicians.

The practice of “patient dumping” fueled the passage of EMTALA. Public anger over stories like Sharon Ford’s, a woman who lived in a working-class suburb of Oakland, Calif., and gave birth to a stillborn fetus in 1985 after being turned away from two private hospitals that incorrectly believed she lacked insurance. At one hospital, Ford was refused admission in spite of a fetal monitor detecting signs that her baby’s heart was beating irregularly. By the time she made it to a public hospital, which rushed to do an emergency Caesarean section, her baby had died.

Sadly, stories like Ford’s were not isolated. At the federal level, Democrats including Senator Edward M. Kennedy of Massachusetts and Rep. Pete Stark of California strongly supported a federal mandate to ensure care at hospitals.

Republicans including Senator Dave Durenberger of Minnesota, who served as the lead Senate author, also supported the legislation: “We cannot stand idly by and watch those Americans who lack the resources be shunted away from immediate and appropriate emergency care.”

Senator Robert Dole of Kansas said hospitals had an obligation to provide care. “We should expect nothing less,” he said. The bill was ultimately included in a massive budget compromise signed by President Ronald Reagan in 1986.

Laying the Ground Work
EMTALA has two basic tenets. First, emergency departments must evaluate and stabilize each patient in need of urgent care. Second, if a higher level of care is required, then hospitals must be willing to transfer or accept a transferred patient to provide optimal care.

EMTALA laid the ground work for the emergency department serving as a primary site of care for those without insurance. As the site of service that could not turn away a patient due to inability to pay, part of the stated drive behind passage of the Affordable Care Act (ACA) was to limit the overuse of emergency departments in providing routine health maintenance and preventative care visits for the uninsured.

Yet, despite passage of the ACA, there remain the uninsured who experience brain and spine trauma and are in need of emergency care.

Health insurance premiums for exchange plans have dramatically risen in several markets; 29 percent in Denver, 26 percent in Portland, Ore. and 27 percent in Nashville, Tenn. The individual mandate penalty for not having health insurance in 2016 is $695 per adult; depending upon the local exchange plans, this cost may be less than the cost of an annual premium. For individuals who are independent contractors, carpenters, drivers, electricians and mechanics, the cost of health insurance may be solely borne by the individual. Given the type of work engaged in day-to-day, the risk of facing neurotrauma in these fields is theoretically higher than other corporate jobs.

The aftermath of neurotrauma also appears to have a strong relationship to whether an individual is insured. For instance, discharge to rehabilitation following a traumatic brain injury (TBI) is strongly associated with insurance status, not surprisingly. Given the motor and occupational therapy required to return to function or at the very least improve function, uninsured status can undermine an individual’s recovery and ultimately, his or her return to being a productive member of the workforce. 

Ultimately, neurosurgeons who care for trauma patients must not only consider the surgical and management issues involved with the primary trauma but also must recognize the socioeconomic drivers that influence how successful care can be.

1. Noam, N. Levey Trauma in the ER: Who covers the uninsured? Los Angeles Times, June 18, 2012.

2. Asemota, A.O., George, B.P., Cumpsty-Fowler, C.J., Haider, A.H., & Schneider, E.B. (2013). Race and insurance disparities in discharge to rehabilitation for patients with traumatic brain injury. Journal of neurotrauma, 30(24), 2057-2065.

3. Kaiser Family Foundation analysis of 2017 insurer rate filings to state regulators. https://kff.org/health-reform/issue-brief/analysis-of-2017-premium-changes-and-insurer-participation-in-the-affordable-care-acts-health-insurance-marketplaces/

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