Structural Racism and Discrimination in Emergency Department Transfers: Unintended Consequences of the Emergency Medical Treatment and Labor Act (EMTALA)

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PROJECT SUMMARY Because hospitals transfer emergency department patients when they lack capability, in order to ensure that access to emergency care is equitable, it is critical that these transfers do not vary by race, ethnicity, or payer. This goal is enshrined in the Emergency Medical Treatment and Labor Act (EMTALA), which requires Medicare- participating hospitals to provide emergency care to all patients, regardless of race, ethnicity, or insurance status. Yet disparities in emergency department transfers exist. The hypothesis of the proposed study is that these disparities reflect structural racism and discrimination; hospitals may circumvent the goals of EMTALA by leveraging the “nondiscrimination provision” of that law, which requires that hospitals with specialized capabilities accept EMTALA transfers if they have capacity. The project will examine strategic use of the nondiscrimination provision in the following three aims: (1) measure differences in ED length of stay for minority versus White non- Hispanic transfer patients, and determine whether differences in length of stay are associated with disparities in patient outcomes; (2) assess whether minority, versus White non-Hispanic, ED patients requiring specialized care are less likely to be transferred to hospitals within the same ownership system; and (3) determine whether minority ED patients, compared with White non-Hispanic patients, are more likely to be transferred to a safety- net hospital. All analyses will examine differences by race/ethnicity and by race/ethnicity for patients with the same payer. The proposed research is innovative because it identifies structural racism and discrimination through variations in organizational behavior, and permits us to disentangle differences by race/ethnicity versus payer. Furthermore, it allows us to examine not just whether minorities are less likely to experience an ED transfer than White non-Hispanic patients, but also whether there are differences in the timing of the ED transfer and whether minority patients are more likely to be transferred to different hospitals than White non-Hispanic patients. The proposed project is significant because these insights may be used to improve policy by providing evidence whether improving the equity of ED transfers might be best addressed by promulgating regulations to promote non-disparate emergency department transfers, or expanding protocolization of these transfers.