Reagan's healthcare mandate

In 1986, the GOP icon signed a law that requires hospitals to treat poor people and undocumented immigrants


Alex Seitz-Wald
July 5, 2012 7:30PM (UTC)

As the Romney campaign debates itself about whether the Affordable Care Act's individual mandate is an evil tax or an unconstitutional penalty, it's worth remembering that Republican presidential icon Ronald Reagan imposed his own national healthcare mandate on the country. The mandate is well know today -- it requires emergency rooms to treat anyone in need, regardless of their ability to pay -- but the fact that Reagan signed it into law is often forgotten.

By the mid 1980s, so-called patient dumping had became a major concern. The practice involved hospitals transferring patients in need of medical attention to other institutions to avoid footing the bill, or even discharging them before they were properly treated. One influential study of Cook County, Ill., which contains Chicago, found that patients transferred because they lacked insurance were twice as likely to die as those treated at the transferring hospital. The vast majority of these transfers were for the hospitals' financial reasons, even though it delayed care and jeopardized patients' health. Physician organizations had policies in place mandating that hospitals treat everyone “regardless of race, creed, sex, nationality, or sources of payment for care,” as the bylaws from the Joint Commission on Accreditation of Hospitals read, but without the force of law behind them, they were often ignored and people went without care.

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In 1986, Congress passed the Consolidated Omnibus Budget Reconciliation Act, which contained the Emergency Medical Treatment and Active Labor Act. The law requires hospitals to treat patients in need of emergency care regardless of their ability to pay, citizenship or even legal status. It applies to any hospital that takes Medicare funds, which is virtually every hospital in the country.

“It is very clearly a mandate -- that is a good point,” said MIT health economist Jonathan Gruber, who advised both the Romney and Obama administrations on their similar healthcare laws. “Mandates are part of our history, under both Republican and Democratic presidents,” he explained in an email to Salon. (Incidentally, the larger Omnibus law is now known commonly as COBRA and lets people stay on their former employers' health insurance -- another healthcare mandate signed by Reagan.)

“Although only 4 pages in length and barely noticed at the time, EMTALA has created a storm of controversy over the ensuing 15 years, and it is now considered one of the most comprehensive laws guaranteeing nondiscriminatory access to emergency medical care and thus to the healthcare system,” Dr. Joseph Zibulewsky wrote in the Baylor University Medical Center Proceedings. The law has helped millions of people seek treatment and likely saved countless lives, but it has also shifted the cost of some treatment for poor people away from the states and onto private hospitals, as the government provided zero funds to accommodate the extra coverage it mandated. According to the American College of Emergency Physicians, which has some qualms with the law as it exists today, “As a result, local and state governments began to abdicate responsibility for charity care, shifting this public responsibility to all hospitals. EMTALA became the de facto national healthcare policy for the uninsured. Congress in 2000 made EMTALA enforcement a priority, with penalties more than $1.17 million, nearly as much as in the first 10 years (about $1.8 million) of the statute combined.” Many observers argue that the law drives up the costs for everyone else, as hospitals have to raise their prices on paying customers in order to cover the costs of their charity care.

The law was often mentioned during the Obamacare debate, as both sides noted that Americans are already paying for poor people's medical care, either directly or indirectly through this law. But one wonders if the conservatives today would support Reagan’s health mandate, considering that it imposes restrictions on hospitals, shifts costs to the private sector and individual insurance holders, and explicitly mandated the treatment of undocumented immigrants.


Alex Seitz-Wald

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