Can Patients Without Insurance Get Cancer Care Under EMTALA?

A trio of doctors and nurses rush a patient to the emergency room.

18 Apr Can Patients Without Insurance Get Cancer Care Under EMTALA?

Posted at 08:00h in Finances, Health Insurance by Triage Cancer

Many people believe that if you don’t have health insurance, you can go to a hospital’s emergency room to get any medical care, including cancer care. There is a law called the Emergency Medical Treatment & Labor Act (EMTALA) that was intended to help people access emergency services regardless of their ability to pay for their care. This blog explains EMTALA, what services are covered by EMTALA, and whether EMTALA covers cancer care.

What is EMTALA?

EMTALA requires hospitals that offer emergency services and accept Medicare, to screen and then stabilize a patient with an emergency medical condition—regardless of a patient’s ability to pay.

EMTALA, does not, however, require hospitals to cure underlying medical conditions (e.g., cancer) or provide outpatient care (e.g., chemotherapy).

EMTALA is also not a substitute for health insurance. After treating a patient under EMTALA, a hospital may still bill the patient for services that they received.

Before EMTALA became law in 1986, hospitals had no federal requirement to treat uninsured patients.

What is an emergency medical condition?

An emergency medical condition has acute (lasting a short time) symptoms that place the patient’s health in immediate and serious jeopardy. For example, serious medical conditions can include shortness of breath, heart attack, stroke, appendicitis, a broken arm.

What services are covered by EMTALA?

If a patient has an emergency medical condition, the emergency room must then stabilize the patient. The term “stable/stabilized” patient has a special meaning under EMTALA.

A patient is stable if their condition will not “reasonably deteriorate” during a transfer (e.g., from one hospital to another) or discharge (e.g., returning to the patient’s home). Generally, a stable patient:

has stable vital signs for multiple hours;
is not in acute (lasting a short time) distress; and
is mobile.

A stabilized patient is not necessarily a cured patient.

Once a patient is stable, EMTALA no longer requires a hospital to treat or cure a patient regardless of the patient’s ability to pay.

A hospital may then discharge a stabilized patient even if the hospital has not completely treated the patient’s medical condition. Generally, this means that EMTALA does not require a hospital to:

cure a patient of their underlying condition (g., perform a surgical procedure that would reduce the possibility for future complications);
treat or rehabilitate a patient until full recovery (g., provide physical therapy for a patient treated for a broken leg)
provide outpatient services (g., provide chemotherapy for a patient with cancer or dialysis for a patient with liver failure).

How does EMTALA work for someone with pneumonia?

An example: Leila does not have health insurance. She goes to a local emergency room because she is having trouble breathing. Leila has pneumonia and her blood-oxygen levels are below acceptable levels. She is unable to leave the hospital on her own. Because the pneumonia is immediately life-threatening, EMTALA requires the hospital to stabilize her regardless of her ability to pay.

Leila is given antibiotics and once her blood-oxygen levels increase, she has been stabilized. The hospital may now discharge Leila because EMTALA does not require the hospital to treat a stabilized patient regardless of their ability to pay.

Does EMTALA cover cancer care?

An example: Robert has lung cancer but does not have health insurance, so he has not been able to get chemotherapy treatment. He goes to a local emergency room because he is having trouble breathing and wants to know if they can treat his cancer. Robert is diagnosed with pneumonia and his blood-oxygen levels are below acceptable levels. He is unable to leave the hospital on his own.

Because the pneumonia is immediately life-threatening, EMTALA requires the hospital to stabilize him regardless of his ability to pay. Robert is given antibiotics to increase his blood-oxygen levels, and stabilize him, so that he can go home. The hospital discharges Robert without treating his cancer, because they are not required to treat a stabilized patient regardless of their ability to pay.

Is there any case where EMTALA would cover cancer care?

There are very few situations in which EMTALA would require a hospital to treat a patient’s cancer. But in the rare situation where a patient can’t be stabilized without threatening their underlying cancer, EMTALA would require a hospital to treat a patient’s cancer. But only to the extent needed to stabilize the patient.

An example: Three months after discharge, Robert returns to the hospital with shortness of breath. A tumor is now blocking his airway and he is unable to maintain acceptable blood-oxygen levels unless the tumor is removed. He cannot be sent home without a serious risk to his immediate health. Because the hospital has not stabilized Robert, EMTALA requires that the hospital continue treatment.

After the surgery to remove the tumor, he can maintain acceptable blood-oxygen levels. He has been stabilized. The hospital may now discharge Robert because EMTALA does not require the hospital to treat a stabilized patient.

If I am uninsured what are my options to get care?

You may have access to a number of options for health insurance to get access to cancer care, including Medicaid and a Marketplace plan. Based on your income level, there may be financial help available to you. You can learn more about these options at TriageCancer.org/HealthInsurance.

We also offer a Legal and Financial Navigation Program that provides free one-on-one help in the areas of health insurance, disability insurance, employment, finances, medical decision-making, estate planning, and more at TriageCancer.org/GetHelp.

About Triage Cancer

Triage Cancer is a national, nonprofit providing free education to people diagnosed with cancer, caregivers, and health care professionals on cancer-related legal and practical issues. Through events, materials, and resources, Triage Cancer is dedicated to helping people move beyond diagnosis.

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