D223 Task 2 Federal and State Policy Comparison Example

Two Laws on Access to Care: EMTALA and Massachusetts's 2006 Health Reform Compared, With a Plan for Nurse Advocacy

Student Name

Leavitt School of Health, Western Governors University

D223: Healthcare Policy and Economics, Task 2

Course Instructor

Month Day, Year

Two Laws on Access to Care: EMTALA and Massachusetts's 2006 Health Reform Compared, With a Plan for Nurse Advocacy

Introduction

Access to care in the United States is shaped by federal and state law working side by side. This paper compares a federal law, EMTALA, the 1986 statute that governs emergency medical treatment and active labor, with a state law, Massachusetts's Chapter 58 of the Acts of 2006, known as An Act Providing Access to Affordable, Quality, Accountable Health Care. Both were written to stop people from going without care, but they take opposite routes: EMTALA requires hospitals to treat emergencies regardless of payment, while Chapter 58 tried to make sure people had insurance before they needed it. The paper describes each law, compares their effects on patient care and healthcare delivery, and closes with my plan to advocate for patients and the nursing profession.

Federal Policy: EMTALA, Enacted in 1986

EMTALA was passed in 1986 in response to reports of hospitals refusing or transferring uninsured patients in unstable condition, a practice known as patient dumping. The law applies to every hospital that participates in Medicare and has an emergency department. It requires three things: a medical screening examination for anyone who comes to the emergency department and requests care, stabilizing treatment for an emergency medical condition, including active labor, within the hospital's capability, and an appropriate transfer when the hospital cannot provide the needed care, with the receiving hospital's acceptance and the necessary records (Zibulewsky, 2001). Hospitals may not delay screening to ask about insurance. Violations can lead to civil fines and loss of Medicare participation.

EMTALA affects patient care directly. Anyone, insured or not, citizen or not, can walk into an emergency department and be evaluated. For nurses, it shapes triage and transfer practice: every patient must be seen, documentation of the screening and stabilization must be complete, and transfers follow a defined process. It also has a well-known gap. The law guarantees care but provides no funding for it, so hospitals absorb the cost of uncompensated emergency care, and emergency departments have become the place where many uninsured people receive care that could have been given earlier and more cheaply elsewhere.

State Policy: Massachusetts Chapter 58 of the Acts of 2006

Massachusetts enacted Chapter 58 in April 2006 to move the state close to universal coverage. The law combined several mechanisms: an expansion of the state Medicaid program, called MassHealth; subsidized private coverage for lower-income adults through a new program called Commonwealth Care; a state-run marketplace, the Health Connector, where individuals and small businesses could buy plans; a requirement that most adults have coverage if affordable plans were available, with tax penalties for going without; and a requirement that larger employers contribute to coverage for their workers. The design later served as a model for the federal Affordable Care Act (Long et al., 2012).

The effects on patient care were measurable. By 2010, uninsurance in the state remained very low, access to care remained strong, and self-reported health improved, though affordability continued to be a concern for many residents (Long et al., 2012). A quasi-experimental study comparing Massachusetts with similar counties in other states found that the reform was associated with a 2.9% decrease in all-cause mortality among adults and a 4.5% decrease in deaths from causes amenable to health care, with larger effects in counties with lower incomes and higher prereform uninsurance (Sommers et al., 2014). For hospitals and nurses, more insured patients meant more patients with a primary care home, more follow-up after discharge and less uncompensated care.

Comparison of the Two Policies

The two laws share a goal, keeping people from being denied necessary care, and both place obligations on the healthcare system. They differ in timing, scope and financing. EMTALA acts at the moment of crisis, guaranteeing that an emergency will be evaluated and stabilized, but it does nothing about the months before the emergency or the care needed afterward. Chapter 58 acts upstream, trying to make sure people have coverage and a regular source of care so that fewer problems become emergencies. EMTALA is an unfunded mandate on hospitals; Chapter 58 paid for coverage through state and federal Medicaid funds, subsidies, employer contributions and individual premiums, while also placing obligations on individuals.

Their effects on healthcare delivery differ as well. EMTALA made the emergency department the safety net of last resort, which contributes to crowding and to the use of emergency care for problems that could be managed in primary care. Chapter 58 was followed by fewer emergency department visits and inpatient stays in its early years (Long et al., 2012), suggesting that coverage moved some care out of the emergency department. For nurses, EMTALA governs daily practice in every emergency department in the country, while Chapter 58 changed the kind of patients nurses in one state see: fewer who arrive late in the course of an illness because they could not afford earlier care. Neither law solved rising costs, and both show that access is shaped by who pays as much as by who is required to provide care.

Nurse Advocacy Engagement

Studying these laws has made me see policy as part of nursing practice rather than something that happens far away. I will advocate for patients and the profession in four specific ways. First, I will join the American Nurses Association and my state nurses association within the next three months, so that I receive legislative updates and can take part in their advocacy days. Second, I will follow bills in my state legislature related to coverage and emergency care, and contact my state representative at least twice this year to share how a bill would affect the patients I care for, using de-identified examples from my practice. Third, I will volunteer for my hospital's patient experience or community benefit committee, where decisions about financial assistance policies and outreach are made. Fourth, I will share one short policy update each month at my unit's staff meeting, because many nurses do not know how laws like EMTALA and coverage programs shape their work.

These actions are modest but concrete, and they match the time I have while finishing my degree and working full time. Advocacy by nurses carries weight because nurses see the effects of policy directly, at the bedside and at discharge, and legislators and administrators rarely do.

References

Long, S. K., Stockley, K., & Dahlen, H. (2012). Massachusetts health reforms: Uninsurance remains low, self-reported health status improves as state prepares to tackle costs. Health Affairs, 31(2), 444-451. https://doi.org/10.1377/hlthaff.2011.0653

Sommers, B. D., Long, S. K., & Baicker, K. (2014). Changes in mortality after Massachusetts health care reform: A quasi-experimental study. Annals of Internal Medicine, 160(9), 585-593. https://doi.org/10.7326/M13-2275

Zibulewsky, J. (2001). The Emergency Medical Treatment and Active Labor Act (EMTALA): What it is and what it means for physicians. Baylor University Medical Center Proceedings, 14(4), 339-346. https://doi.org/10.1080/08998280.2001.11927785