Textualism and Culpability of the Reader

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Collin Hong[1]

 

Introduction

A great divide in statutory interpretation has been between purposivism and textualism.[2] Textualism has largely won this debate and has gained extensive popularity in contemporary legal culture over purposivism.[3] However, simply deciding to employ textualism over intentionalism does not fully resolve cases in many situations. In Bostock v. Clayton County, the majority, written by Justice Gorsuch, using the meaning of the language enacted by Congress in 1964, employed textualism to determine that Title VII’s prohibition on discrimination “because of  . . . sex” included discrimination based on sexual orientation.[4] The dissent, written by Justice Alito, argued that the majority was not employing textualism at all, and that textualism actually led to the opposite conclusion.[5]

This is not a new phenomenon. Throughout the Supreme Court’s recent history, different lawyers and judges have employed “plain meaning” differently based on their adopted definition of “plain meaning.”[6] In Smith, both Justice O’Connor’s majority opinion and Justice Scalia’s dissent claimed to be appealing to ordinary meaning.[7] Scalia interpreted the phrase “use a firearm” “during and in relation to” a drug trafficking crime as being limited to using a firearm as a weapon.[8] In contrast, the majority interpreted the statutory language “us[ing] a firearm” to not only include the use of the firearm as a weapon, but also the act of trading a firearm for drugs, expanding beyond Scalia’s interpretation.[9] Both the dissent and the majority characterized their interpretation as the ordinary meaning of the text despite having different outcomes.[10]

Similarly, as noted by scholars such as Victoria Nourse, textualists have not definitively determined what version of plain meaning they will use.[11] The common trend seems to lean towards expansive, legalist meaning.[12] An alternative to this expansive meaning is using prototypical meaning that represents the most common or first thought-of meaning in a given context.[13] The divide in Smith could be described as a divide between expansive and prototypical meaning, with using a firearm ‘as a weapon’ being the most prototypical meaning. The conclusion of Nourse’s article is the that textualists should clarify what type of plain meaning he or she is using when interpreting statutory text.[14]

The line between prototypical and expansive is often blurry. This paper proposes a different framing for the divide between the types of “plain meaning” in terms of the degree to which a typical reader would be aware of its meaning. This distinction implicates the culpability of the individual governed by the statute. Employing textualism should be informed by one of the primary benefits of textualism over intentionalism: fair notice to those under the statute.[15] The permissible meanings of a statute must therefore be in some way tied to the ability of the target of the statute to fairly determine the meaning. If a meaning is completely outside the reasonable contemplation of the target audience of a statute, then that target cannot be said to be fairly on notice as to the meaning of the statute. This would leave out highly unintuitive legalistic meanings that an ordinary reader of the statute could not reasonably contemplate. If a reasonable person would contemplate that meaning, even if that person was not sure whether that meaning is in the statute, then that would potentially be sufficient notice. This framing allows us to recognize a third category of textual meaning as well: a technical meaning that is the full logical extension of a phrase to the point where a reasonable person would not even contemplate that meaning.

I.  “Reasonable to Know” Meanings and “Reasonable to Contemplate” Meanings

When framed in terms of culpability, the divide between expansive and prototypical meaning can be described as a divide between a reasonable reader knowing that a particular act is covered and a reasonable reader knowing an act might be covered. A person would be culpable to some degree if she committed an act that a reasonable person would know to be forbidden or a reasonable person might not know but would contemplate that it might be forbidden. The former involves a higher level of culpability than the latter, but the latter is still nonzero culpability.

Therefore, there are two possible standards by which we can grant meaning to a statute. The first, which is similar to prototypical meaning, is that a statute simply means what a reasonable person would know it to mean. The second, similar to expansive meaning, would include anything a reasonable person would contemplate it encompassing. 

This difference can be elucidated by example. Say we have a statute: “One cannot sell fruits in this area.” A reasonable person would know with certainty that a strawberry was covered by the statute. Therefore, a strawberry would be covered by the statute by the narrower standard of “reasonable to know.” On the other hand, a reasonable person would pause at the question of whether tomatoes are covered. A reasonable person might not be sure that tomatoes are or are not covered. But if the reasonable reader were trying to sell tomatoes and knew of this statute, she would pause to consider the possibility and may seek counsel.

In both of these situations, the fruit seller can be said to have nonzero culpability if she proceeds with her act. If she attempted to sell strawberries while knowing of the statute, she would be at least negligent with respect to governing law. Not knowing that strawberries were covered would be negligent because a reasonable person would know that strawberries fall within the meaning of the word fruit. If she decided to sell tomatoes, she would be negligent if she did not pause at all because a reasonable person would know to pause and potentially investigate further. 

These two types of negligence are “reasonable to know” and “reasonable to contemplate.” The former type of negligence is of a higher degree of culpability than the latter, but both would fall under the Model Penal Code’s (MPC) definition of negligence, which is when a "reasonable person" would be aware of a "substantial and unjustifiable risk" that his or her conduct is of a prohibited nature, will lead to a prohibited result, and/or is under prohibited attendant circumstances, and the actor was not so aware but should have been.[16] Therefore, the reasonable person would not have to know that the conduct is prohibited, just know that there is a substantial risk that the conduct is prohibited.

This “reasonable to contemplate” standard is not as expansive as the most expansive usages of textualism. It would prevent any arcane and unknowable legalist meaning from controlling, unlike some formulations of expansive meaning that include technical meanings. It also prevents the intention of the legislature from controlling when that intent is not evident from the statute. 

Negligence is the bare minimum standard in terms of culpability.[17] However, when determining if a defendant is guilty of committing a crime, the standard of culpability is generally evaluated with respect to elements of the statute to determine if a defendant committed an “action” with the requisite mental state; to further clarify, whether a defendant is guilty of a crime is not determined by asking if the defendant knew her act was illegal. In criminal law generally mens rea with respect to governing law, or knowing that something is against the law, is not necessary to find culpability.[18] For example, one does not have to know that burglary is a crime to knowingly entering someone else’s property with intent to commit a crime. A reasonable person can generally be convicted of a crime without having personal knowledge of the law. This may be because there is now a presumption that there are too many laws for our system to always operate based on one having knowledge with respect to governing law, and that people in general are on notice to the fact that there might be a law governing a variety of actions. Additionally, it may be expected that a reasonable person knows what actions are generally considered immoral, such as burglary, without having to expressly know whether or not a statute exists to make such an action illegal.

However, there’s also a principle in criminal law that if one does look at a statute, or attempt to know what the governing law is, then that individual has the right to rely on the statute, or an official’s formulation of the law, under certain circumstances.[19] Further, laws can be void for vagueness if a law is so vague that a reasonable person could not know what the law covers.[20] Finally, the rule of lenity holds that ambiguous criminal statutes should be construed in favor of defendants, though it’s been limited to cases of “grievous ambiguity”.[21] So, while knowledge of governing law is not generally considered by courts when no effort was made by the criminal defendant to discover the law, courts do consider a criminal defendant’s ability to learn the law.[22] So, in the context of a retail store, since a statute barring the sale of fruit would not comport with generally understood morality, it may be more likely that some kind of warning other than just the statute’s existence should be present. Further, the United States Supreme Court has held that putting statutes behind a paywall or copyright is prohibited.[23] When one does decide to seek out the law, the law is required to be accessible — giving the reader at least some kind of constructive notice.

If a primary purpose of textualism and plain meaning is to further this principle of accessibility of law, “reasonable to contemplate” seems like the outer bounds of the meanings that would be permissible, preventing any really unknowable meanings from making it in. Textualists then must decide which, between these standards, “reasonable to know” or “reasonable to contemplate,” to employ. 

In Smith, Scalia’s meaning would fall under a “reasonable to know” formulation, as any reasonable person looking at the statute would know that using a firearm as a weapon would be covered.[24] There is a question of whether Justice O’Connor’s understanding of “use a firearm” in any way would be covered under a “reasonable to know” standard, but it would very likely be covered under a “reasonable to contemplate” standard.[25]

Another example in which the majority and the dissent were divided on the interpretation of the meaning of a statute is in Small v. United States.[26] In this case, the majority took “any court” to mean any court within the United States and not foreign courts.[27] The dissent, joined by Justice Scalia, was of the opinion that “any court” extended to foreign courts.[28] What is notable is that Justice Scalia seems to have joined an expansive meaning in Small whereas in Smith he subscribed to a prototypical meaning. This shows how imprecise even the same person asserting textual meaning without specifying what type of textual meaning can be.

Under expansive meaning, Justice Gorsuch’s textual reading of Title VII in Bostock v. Clayton Cnty., Ga is entirely valid.[29] Even at the time of its passage, it may have been reasonable to at least contemplate that Title VII would bar discrimination based on sex stereotyping. A reasonable employer is therefore on some level of notice if they were to read Title VII. If an employer were to read Title VII and proceed to discriminate based on sexual orientation alone, one may conclude that the employer would be acting with at least negligence. Therefore, discrimination on the basis of sexual orientation could fall under the textual meaning of the statute. 

II.  Technical Meaning as a Third Category of Meaning

It is possible for some logical extensions of meanings to be totally outside what is even reasonable to contemplate. For example, there may be some vegetable that current science is unaware is actually a fruit. Logically, that vegetable should be considered a fruit, just no one would reasonably be aware of that fact. Nourse grouped these technical meanings with expansive meanings,[30] but if we use the lens of culpability, we can distinguish expansive meanings that people have some notice of from meanings that a reasonable person would not even contemplate. 

Reasonable to contemplate meanings are therefore situated between prototypical and technical meanings in terms of accessibility and dependence on science. Therefore, we have not two, but actually three possible meanings that could all plausibly be called the textual meaning.   

In Smith, neither Scalia nor O’Connor asserted a technical meaning.[31] A technical meaning of this statute was asserted in Bailey vs. United States.[32] In Bailey, the government asserted that “use a firearm” included the defendant Robinson having a firearm in her apartment while she was conducting a drug trafficking transaction.[33] The government argued that she was “using” the firearm for self-defense in a passive sense in that it was present while she was trafficking drugs, even though the firearm was unloaded and locked in a trunk in the closet.[34] This meaning of “use a firearm” is arguably beyond what is “reasonable to contemplate.” O’Connor wrote for a unanimous court, but this time in favor of the more limited meaning of “use.”[35] The Court held that “use” in this context must involve “active employment.”[36] This is a meaning that is more expansive than Scalia’s Smith dissent equating “use” to “use as a firearm,”[37] but less expansive than using a firearm in a passive way as argued by the government in Bailey.[38] The below scheme is a framework to describe different textual meanings. 

Example Phrase Prototypical Meaning (reasonable to know)  Expansive Meaning (reasonable to contemplate)  Technical Meaning (reasonable person would not contemplate)
"use a firearm" Use a firearm as a weapon (Scalia) Use a firearm in an active way, e.g. trading it for drugs (O'Connor) Use a firearm in a passive way (government in U.S. v. Bailey)
Discrimination because of ... sex" Discrimination based on gender identity Discrimination based on sex stereotyping, including sexual orientation Discrimination based on aspects of sex yet unkown
Fruit  e.g. Strawberries e.g. Tomatoes Something which no one yet knows is a fruit 

[39] [40] [41] [42] 

III.  The Case for Expansive Meaning

Textualists generally disclaim use of technical meaning when they define textualism and, instead, favor defining textualism as using what meaning a reasonable person would understand the statute to mean.[43] When technical meaning is used, instead of what is reasonable to contemplate, we lose the culpability element since it is, at a minimum, seemingly unjust to find one culpable for what one cannot contemplate. Another reason we should not use these fully extended logical meanings is that Congress may not have the technical ability in each case to know the full logical meaning used by the court.

I submit that expansive meanings should not be written off like technical meanings and should be available for use. This is because a reader is still culpable with respect to governing law when they commit an act under expansive meaning. If culpability and accessibility of the law is to be the driving force in determining law, then the dividing line is between expansive meaning and technical meaning, not between prototypical meaning and expansive meaning.

Choosing between the prototypical meaning and the expansive meaning in any given case may come down to stare decisis, legislative history, or policy considerations. But if a court wanted to stick with just one type of meaning in every case, expansive meaning seems to be a better choice than prototypical meaning. 

It is somewhat difficult to find a formalist principle that actually distinguishes prototypical and expansive meaning in terms of what should be applied. Both standards would apply the MPC’s definition of negligence, “aware of a substantial and unjustifiable risk,” where applicable.[44]Prototypical meaning does not cover all the instances in which there would be a substantial risk of proceeding. Therefore, solely based on culpability of the reader, the most principled place to draw the line of textual meaning would be where a reasonable person would detect a substantial risk, meaning the expansive meaning.

Other instrumental advantages may go either way. Using “reasonable to know” would basically be like saying “if you’re unsure, then it’s not covered.” That would allow people to proceed without looking up their specific circumstance, which may be an instrumental advantage.

The line for what is reasonable to contemplate is at least marginally clearer than the line for what is reasonable to know. This is because what is reasonable to contemplate is aligned with the logical extension of the definitions of words, whereas what is reasonable to know depends more on subjective evaluations on what is the most common usage. The procedure for determining expansive meaning would be to figure out the furthest logical extension, then cut off the applications that a reasonable person would not even contemplate. 

Prototypical meaning is also at least marginally more variable between parts of the U.S. than expansive meaning is. In some parts of the U.S., it might be considered reasonable to know that a tomato is a fruit. However, that might not be the case everywhere. One may argue that the expansive meaning of “fruit” is more dependent on botany rather than common regional usages. Therefore, it’s clearer and more consistent to use the expansive, logical meaning. By the same token, it’s easier for Congress to use expansive meaning to legislate rather than trying to figure out what the prototypical meaning is. 

Conclusion

What is considered the textual meaning can vary depending on what level of typicality one adopts when reading. Using culpability of the reader as a lens allows us to discern three meanings with decreasing typicality: prototypical, expansive, and technical. What makes expansive meaning the best meaning to use is that it is the logical extension of a meaning up until the point where a reasonable person would not even contemplate it. The expansive meaning is easier to discern and uniform than the prototypical meaning because it is informed by the logical extension of the words to a greater degree than the prototypical meaning. However, it does not go so far as to be inscrutable, like the technical meaning. 

 


[I] J.D. Candidate, Stanford Law School, 2021. 

[2] Robert A. Katzmann, Judging Statutes.

[3] Jonathan T. Molot, The Rise and Fall of Textualism, 106 Colum. L. Rev. 1, 2, 29–30 (2006) (“Textualists have been so successful discrediting strong purposivism, and distinguishing their new brand of ‘modern textualism’ from the older, more extreme ‘plain meaning’ school, that they no longer can identify, let alone conquer, any remaining territory between textualism's adherents and nonadherents.”).

[4] Bostock v. Clayton Cnty., Ga., 140 S. Ct. 1731, 1737–39, 1741 (2020).

[5] Id. at 1755–56.

[6] See Michael L. Geis, The Meaning of Meaning in the Law, 73 Wash. U. L. Q. 1125, 1126 (1995).

[7] Id. at 1134 (“[T]hey each claim that they are proffering the ‘ordinary meaning’ of the phrase.”); Smith v. United States, 508 U.S. 223, 228, 242 (1993). 

[8] Smith, 508 U.S. at 245–46.

[9] Id. at 240–41 (“Both a firearm's use as a weapon and its use as an item of barter fall within the plain language of § 924(c)(1) . . . .”).

[10] Id. at 228, 242. 

[11] Victoria F. Nourse, Two Kinds of Plain Meaning, 76 Brook. L. Rev. 997, 997, 1005 (2011).

[12] Id. at 1003.

[13] Id. at 1000–01. 

[14] See id. at 1005.

[15] Note, Textualism as Fair Notice, 123 Harv. L. Rev. 542, 542 (2009).

[16] Model Penal Code §2.02 (Am. Law Inst. 2019).

[17] See id.

[18] United States v. Baker, 807 F.2d 427, 428–29 (5th Cir. 1986).

[19] Commonwealth v. Twitchell, 617 N.E.2d 609, 619 (Mass. 1993). 

[20] See Skilling v. United States, 561 U.S. 358, 402–03 (2010) (“To satisfy due process, ‘a penal statute [must] define the criminal offense [1] with sufficient definiteness that ordinary people can understand what conduct is prohibited and [2] in a manner that does not encourage arbitrary and discriminatory enforcement.’” (citing Kolender v. Lawson, 461 U.S. 352, 357 (1983))).

[21] Muscarello v. United States, 524 U.S. 125 (1998).

[22] See Baker, 807 F.2d at 428-29; Twitchell, 617 N.E.2d at 619. 

[23] Georgia v. Public.Resource.Org, Inc., 140 S. Ct. 1498, 1503–04, 1508 (2020).

[24] See Smith v. United States, 508 U.S. 223, 241–44 (1993).

[25] See id. at 240–41. 

[26] See 544 U.S. 385, 387–88 (2005).

[27] Id. at 387.

[28] Id. at 397–98. 

[29] See, 140 S. Ct. 1731, 1737-39 (2020).

[30] See Nourse, supra note 11, at 1002–03. 

[31] See Smith v. United States, 508 U.S. 223 (1993). 

[32] See Bailey v. United States, 516 U.S. 137 (1995).

[33] Id. at 142–43, 49.               

[34] Id. at 149.

[35] Id. at 149–150.

[36] Id. at 144. (“We conclude that the language, context, and history of § 924(c)(1) indicate that the Government must show active employment of the firearm.”).

[37] Smith v. United States, 508 U.S. 223, 242 (1993). 

[38] See Bailey, 516 U.Sat 148–149.

[39] See Smith, 508 U.S. at 242 (1993).

[40] See id. at 240.

[41] See 516 U.S. at 148–49. 

[42] See Bostock v. Clayton Cnty., Ga., 140 S.Ct. 1731, 1737 (2020).

[43] See John F. Manning, What Divides Textualists from Purposivists, 106 Colum. L. Rev. 70, 76  (2006) (“Textualists give precedence to semantic context—evidence that goes to the way a reasonable person would use language under the circumstances.”). 

[44] Model Penal Code §2.02 (2019).

Public University Professors: Employees or Appointees?

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Public University Professors: Employees or Appointees?

Alicia Gilbert[I]

Introduction

In the area of employment law, defining who is and is not an “employee” is often a perplexing task that comes with important distinctions. Misclassifying an employee could lead to serious implications for the employer and a variety of potentially missed protections for the worker. Specifically, many statutory benefits that are available for "employees" are not afforded to "non-employees."[2]

The 1915 Declaration of Principles on Academic Freedom and Academic Tenure (the “Declaration”) illustrates the complexity involved in defining the employment relationship between university and college professors that courts often overlook.[3] However, before analyzing the exact complexity found in the Declaration, it is important to understand the significance of the Declaration and its influence on American colleges and universities. 

The Declaration “became the first sustained articulation of the principles of academic freedom in America.”[4] The American Association of University Professors (“AAUP”) created the Declaration, and the Declaration formed “the ideological foundation of the AAUP’s doctrines.”[5] The purpose of the AAUP is to help “shape American higher education by developing the standards and procedures [to] maintain quality in education and academic freedom in this country’s colleges and universities.”[6] Therefore, the subject of the Declaration aims at defining what academic freedom means when applied to a professor.[7] The Declaration reveals, “[a]cademic freedom . . . comprises three elements: freedom of inquiry and research; freedom of teaching within the university or college; and freedom of extramural utterance and action.”[8] Since its enactment, the Declaration has become “one of the most influential definitions of academic freedom in America.”[9]

The relevant parts of the Declaration to the employment classification context reveal that “members of university faculties,” which include college professors, are “appointees” and “not in any proper sense the employees” of the university.[10] This refusal to label professors as employees portrays the AAUP’s goal, which is to showcase the importance of “professional autonomy and collegial self-governance” through the Declaration.[11] The Declaration goes further in explaining this refusal by saying, “faculty are not ‘employees’ answerable to the will of their employers but instead ‘appointees’” who are answerable to the public.[12] Moreover, professors are labeled “appointees” rather than employees because “[faculties] are ‘appointed’ to discharge the essential university function of producing knowledge” to the public.[13]

The Declaration explicitly states that professors should not be considered employees of their respective university.[14] Once appointed, the Declaration claims “the [professor] has professional functions to perform in which the appointing authorities have neither competency nor moral right to intervene.”[15] The appointing authority that the Declaration is referring to is the college or university employing the professor.[16]

Further, the Declaration reveals “ordinary institutions should be viewed as public trusts” that should not be able to resist the teachings of professors.[17] With professional autonomy and collegial self-governance at the heart of the AAUP, the Declaration states, “[u]niversity teachers should be understood to be, with respect to the conclusions reached and expressed by them, no more subject to the control of the trustees, than are judges subject to the control of the president, with respect to their decisions.”[18]

Although professors have historically been thought to be employees in terms of receiving statutory protections from their respective institutions, the Declaration urges against this classification.[19] Since the Declaration explicitly states that professors should not be considered employees, the proper label for professors is not entirely clear. 

The purpose of this Note is to examine the working relationship of university professors and the statutory protections afforded to employees and “non-employees.” This Note argues that despite the Declaration explicitly stating professors should not be considered employees, the employee categorization is the best classification available for professors. Part I will begin with a brief overview of the historic distinction between being an employee and an independent contractor. Part II will examine why classifying professors as “employees” and not appointees best suits their job duties. Finally, this Note will conclude by reiterating that regardless of how much the AAUP urges that professors are appointees, this classification is not plausible with how America has defined worker classifications.

I.  A Brief Historical Overview of the Distinctions Between Employees and Independent Contractors            

A.  The Common Law Control Test and The Economic Realities Test

Before the current employer-employee label developed to define an employment relationship, the precursor was the “master-servant” label.[20]Although the terms master and servant have largely been replaced with that of employer and employee, sometimes the old master-servant language is still used to refer to employment classifications.[21]

When courts analyze the employer-employee relationship, the “paramount consideration” for “determining the scope of . . . liability” is “the master’s control over [the] servant.”[22] The Restatement of Agency defines a master as “a principal who employs an agent to perform service in his affairs and who controls or has the right to control the physical conduct of the [worker] in the performance of the service.”[23] “A servant is [a person] employed by a master to perform service in his affairs whose physical conduct in the performance of the service is controlled or is subject to the right to control by the master.”[24] The master-servant relationship is not the only possible classification for a working relationship either.[25] The Restatement of Agency recognizes another well-known classification known as the employer-independent contractor relationship.[26] An “independent contractor is a person who contracts with another to do something for him but who is not controlled by the other nor subject to the other’s right to control with respect to his physical conduct in the performance of the undertaking.”[27] Defining the working relationship as either employer-employee or employee-independent contractor is important and courts, using various factors, have developed several tests to help aid in determining which classification is best. 

To help determine worker classification, the court in McCary v. Wade outlined the common law approach, which focuses on how much control the employer has over a worker to determine worker classification.[28] The court in McCary provides an example of how the control test can be applied with various factors of a court’s choosing to help determine worker classification status.[29] The common law approach is not the only test to determine worker classification though. Eventually, another worker classification test, known as the economic realities test, developed.[30] Instead of focusing on control as the paramount consideration the economic realities test looks to the totality of the circumstances to determine worker classification.[31]

Under this test, one factor that courts can look to is how integral “the performance of the [worker’s] duties” is to “the employer’s business.”[32]By looking at not only how much the worker relies on the employer, but also how much the employer relies on the worker is a shift from the common law approach.[33] However, like the common law control test, not all courts apply the same factors.[34] Overall, “figuring out whether or not a person is an employee of an organization (as opposed to a contractor, for example) is complicated.”[35]

II.  Why Employee Status Makes Sense and Appointee Status Just Doesn’t Work

This Note argues that although the 1915 Declaration insists that university professors are appointees of their respective universities that classification is not appropriate. There currently is not a test to determine whether a worker is an appointee rather than an employee or independent contractor.[36] It is quite surprising that the Declaration is such an influential document in terms of defining academic freedom for public professors; however, courts have not considered labels other than that of an employee or independent contractor when analyzing the professor worker classification.

Moreover, some courts appear to be so confident that a professor is an employee that other classifications, such as independent contractor status, are usually not considered.[37] When looking at the bigger picture, it makes the most sense to label university faculty into a category that already exists rather than creating a new category of appointees in the employment context. 

Although the Declaration demands that university professors be considered appointees, appointees do not fall into the common worker categories. Generally speaking, workers are either classified as employees or independent contractors.[38] In addition, courts will be less inclined to consider a professor as an appointee when that categorization requires reworking worker classifications within employment law. Appointees of a university may be viewed differently than say, for example, a political appointee. However, it’s unclear whether both would fall under the new label of appointee and it certainly does not make sense to burden courts with creating a new employee classification that only applies to public university professors. Keeping the main labels of an employee or independent contractor is the most practical solution because it is what courts, employers, and workers are used to. 

Since categorizing a professor as an appointee is not an available alternative, it is important to consider whether a professor should be labeled as an employee or an independent contractor. When an employer classifies a worker as an employee rather than an independent contractor it requires the employer to pay minimum wage and overtime[39], follow occupational safety laws[40], and follow federal anti-discrimination laws, to name a few.[41] However, these same protections are not afforded to independent contractors.[42] Employers “do not generally have to withhold or pay any taxes on payments to independent contractors.”[43] Title VII of the Civil Rights Act of 1964 prohibits discrimination based on race, color, religion, sex or national origin but even these protections only apply to employees, not independent contractors.[44] Applying the economic realities test and the common law approach to the university professors’ duties will help explain why the employee classification is best suited for university professors. 

A.  Applying the Economic Realities Test to a Public Professor’s Job Duties

The economic realities test looks to the totality of the circumstances to determine worker classification.[45] The court in Fitzgerald v. Mobil Oil Corp. reiterated the idea that the economic realities test is a highly fact-intensive inquiry and that “the language of a written [employment] agreement . . . is not controlling.”[46] The elements of the economic realities test that the court in Fitzgerald used include: “(1) control of a worker’s duties, (2) the payment of wages, (3) the right to hire and fire and the right to discipline, and (4) the performance of the duties as an integral part of the employer’s business towards the accomplishment of a common goal.”[47]

Applying the economic realities test to professors’ job first requires consideration of the control the university has over the professor’s duties.[48]Public universities and colleges that employ professors generally exert little control over them.[49] According to the American Association of Undergraduate Professors, who authored the Declaration, teachers are entitled to freedom in research, in publication, and the classroom as long as they are following their academic duties.[50] Professors have the freedom to inquire into new topics; however, they are still engaged in the university by teaching certain courses.[51] Furthermore, though professors have the freedom to explore new topics, the university benefits every time a professor's work is published by gaining publicity and sometimes by even gaining a monetary benefit.[52]

Also, in terms of control, universities’ control could take the “form of ‘goals’ subject to annual review, such as . . . writing goals for law professors.”[53] Nevertheless, professors still enjoy “considerable discretion over the hours they work,” which cuts against the finding of an employment relationship.[54] The more autonomy a professor enjoys, the more they resemble an independent contractor.[55]

The next element of the economic realities test factors in the payment of wages.[56] University faculty professors are provided with a salary from their respective public institutions.[57] Since pay is provided by the university, this leans more toward professors being employees. The reason for this is because “[a]n employment relationship involves being placed on the employer’s payroll” and “[e]mployees [are] . . . paid a pre-determined amount” such as a salary.[58]

The third element pertains to the rights of the worker in question in being able to hire, fire, and discipline other workers.[59] Though such occasions may be rare, universities are certainly free to discipline their faculty.[60] This reveals that professors resemble an employee because employers hiring independent contractors are encouraged not to conduct “performance reviews or tak[e] disciplinary action” as they would with an employee.[61]

The last element concerns mutual dependence.[62] The more dependent a worker is on the employer, the more likely the worker is considered an employee.[63] Although faculty and the university seem somewhat dependent on each other, the fact that professors depend on the university for their salary and workplace shows they are probably still best suited to be an employee.[64]

B.  Applying the Common Law Control Test to a Public Professor’s Job Duties

The common law control test approach “focuses on the employer’s right to control the employee/independent contractor” as a paramount consideration.[65] Similar to the economic realities test, “labels placed on employees, are not controlling and the entire circumstances must be examined.”[66]

Under the common law control test approach, the elements considered are:

The extent of control which . . . the master may exercise over the details of the work; whether or not the one employed is engaged in a distinct occupation or business; the kind of occupation, with reference to whether, in the locality, the work is usually done under the direction of the employer or by a specialist without supervision; the skill required in the particular occupation; whether the employer or the workman supplies the instrumentalities . . . and the place of work for the person doing the work; the length of time for which the person is employed; the method of payment . . . ; whether or not the work is a part of the regular business of the employer; whether or not the parties believe they are creating the relation of master and servant; and whether the principal is or is not in business.[67] 

University professors are given a considerable amount of control over their work, which makes them similar to independent contractors. For example, professors typically have the freedom to teach their subjects in a manner in which they choose and professors have plenty of freedom to inquire into new topics.[68] Although university professors are not supervised daily like the average employee, they should still be considered independent contractors because university professors typically do their job without supervision when it comes to inquiring into new research topics, publishing their work, and controlling their classroom.[69]

Furthermore, lack of supervision should not always equate to independent contractor status. In today’s world, “it is increasingly typical for a business to rely on a large number of . . . professional workers, employed on a regular basis, but without close supervision and instruction.”[70] A university’s control might take “the form of ‘goals’ subject to annual review, such as . . . writing goals for law professors.”[71] Professors, in general, do not need a lot of daily supervision from their employer because universities want their professors to be able to teach the material in a way that the professor sees fit.[72] Having a university supervise how a professor teaches and engages in academic writing would be counterintuitive because professors are hired to engage in original thought.[73] Therefore, when looking at the employment relationship as a whole, it appears the proper label for university professors, under the control test, is employees. 

Also, it is worth mentioning that courts rarely analyze the worker status of university professors.[74] Consider the Supreme Court case of Garcetti v. Ceballos regarding a teacher’s right to free speech.[75] The Supreme Court held “[w]hen public employees make statements pursuant to their official duties, [they] are not speaking as citizens for First Amendment purposes, and the Constitution does not insulate their communications from employer discipline.”[76] The Court went on to say “[t]his ostensible domain beyond the pale of the First Amendment is spacious enough to include even the teaching of a public university professor.”[77] Although the Court does not engage in an analysis regarding the employment classification of public university professors, this case could at least imply that the Court may consider a university professor to be an employee.[78]

Even in the rare instance that the courts engage in the employee analysis, it’s not in regards to the typical university faculty professor.[79] For example, the court may engage in the analysis for an adjunct professor, but an adjunct professor is obviously different than being a full-time professor of a university.[80] “Adjunct professors are hired by schools on a contractual, part-time basis as opposed to the traditional university model of full-time employment”;[81] therefore, it makes sense that courts would engage in the worker classification analysis.

Regardless of whether courts typically engage in the worker categorization analysis in regard to university professors, the courts seem to have it right, as the Declaration is not viable in terms of it defining professors as appointees. 

Conclusion

In conclusion, university and college professors should be labeled as employees under worker classification labels. Although the influential Declaration demands that professors should be considered appointees and not employees, the employee label provides university faculty with the most statutory protections.[82] In addition to statutory protections, university faculties do not fit under the category of “non-employees,” often referred to as independent contractors. 

Furthermore, it is not practical to consider university professors appointees when appointees are not a category in the worker relationship – the options are generally limited to employee or independent contractor.[83] Courts have traditionally labeled those in an employment relationship as employees or non-employees, typically referred to as independent contractors. Creating a whole new category for university faculty does not seem like a plausible solution. 

Overall, it makes the most sense to label university faculty as employees. University professors enjoy considerable independence in their work, but the university still exerts control over the faculty through various other areas of the worker relationship. The courts, by bypassing analyzing the employment relationship and regarding university professors as employees, seem to have gotten it right. Despite this, the Declaration should still be considered viable for its overall definition of academic freedom in America, but it is certainly not viable in terms of defining the employment relationship between that of the university and the professor. Essentially, the language of the appointee classification should be removed as a label for public university professors.


[I] J.D. expected 2020, University of Kentucky J. David Rosenberg College of Law; B.A.; Eastern Kentucky University (2017).

[2] See generally 29 U.S.C. § 203 (2018); 42 U.S.C. § 2000e-2 (1991) (defining particular unlawful employment practices that only apply to employees).

[3] Am. Ass’n of Univ. Professors, 1915 Declaration of Principles on Academic Freedom and Academic Tenure (1915), https://www.aaup.org/NR/rdonlyres/A6520A9D-0A9A-47B3-B550-C006B5B224E7/0/1915Declaration.pdf [https://perma.cc/29T2-TWC5].

[4] David Randall, Charting Academic Freedom: 103 Years of Debate, National Association of Scholars (Jan. 15, 2018), https://www.nas.org/reports/charting-academic-freedom-103-years-of-debate/full-report [https://perma.cc/6E6L-X6C5].

[5] John K. Wilson, AAUP’s 1915 Declaration of Principles: Conservative and Radical, Visionary and Myopic, 7 AAUP J. Acad. Freedom 1, 1 (2016), https://www.aaup.org/sites/default/files/Wilson_1.pdf [https://perma.cc/PG4E-MW96]. 

[6] About the AAUP, AAUP, https://www.aaup.org/about-aaup [https://perma.cc/M8DE-FAXU] (last visited Mar. 1, 2020).

[7] Am. Ass’n of Univ. Professors, supra note 3, at 291, 292. 

[8] Id. at 292. 

[9] Wilson, supra note 5, at 1.

[10] Am. Ass’n of Univ. Professors, supra note 3, at 295.

[11] See Mark L. Adams, The Quest for Tenure: Job Security and Academic Freedom, 56 Cath. U.L. Rev. 67, 79 (2006) (citation omitted). 

[12] Matthew W. Finkin & Robert C. Post, For the Common Good: Principles of American Academic Freedom 34 (2009).

[13] Id. at 35.

[14] Am. Ass’n of Univ. Professors, supra note 3, at 295. 

[15] Id. 

[16] See id.

[17] Donald J. Weidner, Academic Freedom and the Obligation to Earn It, 32 J.L. & Educ. 445, 448 (2003).

[18] Am. Ass’n of Univ. Professors, supra note 3, at 295. 

[19] Seee.g., Urofsky v. Gilmore, 216 F.3d 401, 425 (4th Cir. 2000) (holding that “there is no constitutional right of free inquiry unique to professors or any other public employee") (second emphasis added); Risa L. Lieberwitz, The Corporatization of the University: Distance Learning at the Cost of Academic Freedom?, 12 B.U. Pub. Int. L.J. 73, 89–90 (2002) (noting public university faculty have First Amendment rights as public employees).

[20] Restatement (Second) of Agency § 220(1) cmt. g (Am. Law Inst. 1958); Gerald M. Stevens, The Test of the Employment Relation, 38 Mich. L. Rev. 188, 189 (1939).

[21] See Restatement (Second) of Agency § 220(1).

[22] John Bruntz, The Employee/Independent Contractor Dichotomy: A Rose is Not Always a Rose, 8 Hofstra Lab. & Emp. L.J. 337, 338–39 (1991).

[23] Restatement (Second) of Agency § 2(1) (Am. Law Inst. 1958).

[24] Id. § 2(2).

[25] See Id. § 2(3).

[26] Id. 

[27] Id.

[28] McCary v. Wade, 861 So. 2d. 358, 361, 363 (Miss. Ct. App. 2003); How To Apply the Common Law Control Test in Determining an Employer/Employee Relationship, Social Security Administration, https://www.ssa.gov/section218training/advanced_course_10.htm#4 [https://perma.cc/YU6S-DFTT] (last visited Mar. 5, 2020).

[29] McCary, 861 So. 2d. at 361.

[30] Jane P. Kwak, Note, Employees Versus Independent Contractors: Why States Should Not Enact Statutes That Target the Construction Industry, 39 J. Legis. 295, 296–97 (2012–2013).

[31] Fitzgerald v. Mobil Oil Corp., 827 F. Supp. 1301, 1303 (E.D. Mich. 1993).

[32] Id.

[33] See id.; McCary v. Wade, 861 So. 2d. 358, 361, 363 (Miss. Ct. App. 2003).

[34] Classification Tests, WorkerClassification.com, https://www.workerclassification.com/classification-tests [https://perma.cc/LWH3-MDFS] (last visited Mar. 15, 2019).

[35] Coverage, U.S. Equal Employment Opportunity Commission, https://www.eeoc.gov/employers/coverage.cfm [https://perma.cc/K2T3-MAPL] (last visited Mar. 12, 2019).

[36] See Independent Contractor (Self-Employed) or Employee?, internal Revenue Service, https://www.irs.gov/businesses/small-businesses-self-employed/independent-contractor-self-employed-or-employee [https://perma.cc/2544-9XFX] (last visited Mar. 13, 2019) (explaining that business owners must either classify their workers as employees or independent contractors).

[37] See Garcetti v. Ceballos, 547 U.S. 410, 438 (2006) (Souter, J., dissenting).

[38] Worker Classification: Employee vs. Independent Contractor, Pine tree legal assistance, https://ptla.org/worker-classification-employee-vs-independent-contractor# [https://perma.cc/44CV-7QP3] (last visited Mar. 13, 2019).

[39] Fair Labor Standards Act, 29 U.S.C. §§ 206-207 (1983).

[40] The Occupational Safety and Health Act (OHSA) requires employers only to provide safe workplaces for “employees.” 29 U.S.C.A. § 654(a) (1970). 

[41] 42 U.S.C. § 2000e-2 (1991).

[42] Kwak, supra 30, at 295.

[43] Independent Contractor (Self-Employed) or Employee?, supra note 36.

[44] 42 U.S.C. § 2000e-2 (1991); Brown v. J. Kaz, Inc., 581 F.3d 175, 177 (3d Cir. 2009).

[45] Fitzgerald, 827 F. Supp. at 1303.

[46] Id.

[47] Id. (citation omitted). 

[48] Id. at 1303–04.

[49] See Donna R. Euben, Academic Freedom of Professors and Institutions 2 (May 2002), https://www.aaup.org/issues/academic-freedom/professors-and-institutions [https://perma.cc/A5A9-CCB2].

[50] Id.

[51] See generally, Marshall Shepherd, Professors Are Often Asked ‘What Do You Teach?’ But They Do Far More, Forbes (July 19, 2018, 11:02 AM), https://www.forbes.com/sites/marshallshepherd/2018/07/19/professors-are-often-asked-what-do-you-teach-they-do-far-more/#1c7d96301745 [https://perma.cc/HTF5-UBRN] (explaining the variety of roles that professors take on beyond the courses they teach for the university).

[52] Id.

[53] Richard R. Carlson, Why the Law Still Can't Tell an Employee When it Sees One and How it Ought to Stop Trying, 22 Berkeley J. Emp. & Lab. L. 295, 341 (2001).

[54] Id. at 346.

[55] Independent Contractors vs Employees, Funding Circle (Dec. 12, 2019), https://www.fundingcircle.com/us/resources/independent-contractors-vs-employees/ [https://perma.cc/7B5B-RK9U].

[56] Fitzgerald, 827 F. Supp. at 1303.

[57] See Colleen Flaherty, AAUP: Faculty salaries up slightly, but budgets are balanced ‘on the backs’ of adjuncts and out-of-state students, inside higher ed (Apr. 11, 2017), https://www.insidehighered.com/news/2017/04/11/aaup-faculty-salaries-slightly-budgets-are-balanced-backs-adjuncts-and-out-state [https://perma.cc/8MB8-JULJ]. 

[58] Independent Contractors, University of Hawai’i at Mãnoa, http://manoa.hawaii.edu/careercenter/files/Independent_Contractors.pdf (last visited Mar. 11, 2019).

[59] Fitzgerald, 827 F. Supp. at 1303.

[60] Donna R. Euben, AAUP Staff Counsel & Barbara Lee, Rutgers University, Faculty Misconduct and Discipline, Presentation to the National Conference on Law and Higher Education at the Stetson University College of Law (Feb. 20–22, 2005), https://www.aaup.org/issues/appointments-promotions-discipline/faculty-misconduct-and-discipline-2005 [https://perma.cc/QAF4-E5EC].

[61] Working with Independent Contractors: Know the IRS Rules and Regulations, efile4Biz, https://www.efile4biz.com/working-with-independent-contractor-irs-rules-and-regulations [https://perma.cc/727U-FZS9] (last visited Mar. 12, 2019).

[62] Fitzgerald, 827 F. Supp. at 1303.

[63] Kelso L. Anderson, Independent Contractors Might Actually Be Employees, aba (Nov. 23, 2018), https://www.americanbar.org/groups/litigation/publications/litigation-news/featured-articles/2018/independent-contractors-might-actually-be-employees/ [https://perma.cc/7K82-MK2Y].

[64] Id.

[65] Deanne M. Mosley & William C. Walter, The Significance of the Classification of Employment Relationships in Determining Exposure to Liability, 67 Miss. L.J. 613, 632 (1998).

[66] Mitchell H. Rubenstein, Employees, Employers, and Quasi-Employers: An Analysis of Employees and Employers Who Operate in the Borderland Between an Employer-and-Employee Relationship, 14 U. PA. J. Bus. L. 605, 617 (2012).

[67] Restatement (Second) of Agency § 220(2).

[68] Euben, supra note 49.

[69] Id.

[70] Carlson, supra note 53, at 341.

[71] Id.

[72] See Euben, supra note 49. 

[73] Id. (citing Keyishian v. Board of Regents, 385 U.S. 589 (1967)).

[74] See generally Garvey v. Dickinson Coll., 761 F. Supp. 1175 (M.D. Pa. 1991); Kortyna v. Lafayette Coll., 47 F. Supp. 3d 225, 235 (E.D. Pa. 2014) (examples of cases where a professor’s status as an employee is not in dispute). 

[75] See Garcetti, 547 U.S. at 410. 

[76] Id. at 421 (emphasis added).

[77] Id. at 438 (emphasis added).

[78] Id.

[79] Id.

[80] Id. 

[81] Alisa Bates, How to Become an Adjunct Professor, Room 241 Blog (Oct. 30, 2019), https://education.cu-portland.edu/blog/teaching-careers/adjunct-professor/ [https://perma.cc/35BR-PWVN].

[82] See supra note 39.

[83] See supra note 36.

Reexamining the Civil Money Penalties of EMTALA and Their Effect on Inner-City Hospitals

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Reexamining the Civil Money Penalties of EMTALA and their Effect on Inner-City Hospitals

 Rachele Taylor Yohe[I]

Introduction

 Hospitals and medical facilities are often thought of as safe places for everyone, regardless of an individual’s race, gender, sexual orientation, or social standing. After all, physicians are required to swear to and abide by the Hippocratic Oath—right? In actuality, physicians are not required to swear an oath upon entering the medical profession; and for those that do swear such an oath, the terms are not legally binding.[2] Nevertheless, even if a physician is not bound by words like “first do no harm,”[3] surely a hospital or medical facility is required to uphold this standard—right? Historically speaking though, a hospital possessed no affirmative duty to provide treatment or any standard of care.[4] This is likely an alarming revelation as the idea of being turned away from a medical facility, despite suffering from a life-threatening illness, seems utterly unfathomable. Thankfully, early hospitals did not make a habit of refusing treatment to those in need and provided necessary, charitable care.[5] It was not until the mid-twentieth century, when the costs of healthcare dramatically increased and medical facilities began to take shape as a business, that it became clear that physicians and hospitals possessed no affirmative duty to provide treatment—much to the detriment of the uninsured.[6]

With the innovation of technology and diagnostic procedures, hospitals began to take shape as centralized medical facilities responsible for entire populations.[7] Prior to this growth, hospitals were generally used as “custodial institutions for undesirables” including the sick, indigent, and mentally unbalanced.[8] The nineteenth and twentieth centuries, however, saw the introduction of life-saving drugs and treatments that ultimately transformed the American medical profession from needing an estimated additional 200,000 beds in 1947[9] to staffing 931,203 beds in 2019.[10] This growth, of course, increased the cost of healthcare[11] and physicians and medical facilities were incentivized to turn away patients unable to pay their medical bills.[12] One terrifying example of this occurred in 1980, when an uninsured man presented to an emergency room in St. Louis, Missouri with a steak knife lodged in his spine.[13] The hospital and its staff refused to remove the weapon until the man could produce $1,000.00 in cash.[14] By forcing the uninsured—who are more often than not homeless, indigent, or immigrants—to pay up front or not be treated at all, a hospital is able to avoid the financial burden of caring for patients who will never be able to pay their soaring medical bills. This avoidance became known as “patient dumping,” a practice where hospitals turned away poor patients or “dumped” them off at bus stations, public hospitals, or homeless shelters.[15]

In 1986, Congress recognized the threat of patient dumping and enacted a comprehensive statutory scheme known as the Consolidated Omnibus Budget Reconciliation Act (“COBRA”).[16] The vast majority of COBRA is unrelated to the concerns of patient dumping, focusing on insurance and healthcare plans; within COBRA, however, is the Emergency Medical Treatment and Active Labor Act (“EMTALA”), a series of regulations imposing standards of care on physicians and hospitals that must be met when an individual presents to an emergency room and requests treatment.[17] Fittingly, EMTALA is referred to as the “antidumping statute,”[18] as it is a targeted attempt at ensuring that hospitals do not engage in patient hot potato with each other. At its inception, Congress believed that it would be a weapon for victims of patient dumping.[19] In practice, however, the Act bred far more problems than solutions, in part because it places the entirety of fault on the wrong party—the hospital. Recognizing and combatting the problem of patient dumping cannot be one-sided; Congress must look at why hospitals send the uninsured away, which is assuredly not because of a cold-hearted desire to watch the uninsured suffer. It is far more likely that the true reasoning for sending patients away is the rising costs of healthcare, which EMTALA does nothing but exacerbate. Under EMTALA, it is the hospital that is required to provide a level of treatment to all individuals—regardless of their ability to pay.[20] Hospitals are forced to pay out millions of their own funds to cover the treatment costs of the uninsured[21] and as the statute is an unfunded mandate, these hospitals are never reimbursed for these payments.[22] As one can imagine, this is a significant financial burden on our medical facilities which is why scholars have railed against the effects of EMTALA since its enactment.[23]  

Importantly, this Note does not seek to build on past discussions of the financial burdens associated with EMTALA compliance, but rather it explores the consequences of a medical facility’s failure to meet its standards, including what is known as “civil money penalties.”[24] EMTALA’s civil money penalties are levied against violating hospitals not equally, but based on the facilities’ capacity—its total number of beds.[25] Under this facially-discriminatory punishment, the more beds a facility houses, the greater the penalty it faces for violations.[26] The civil money penalties were recently adjusted for inflation in 2017, and it is this increase that sparked the arguments herein. Specifically, Part I reviews the general requirements of EMTALA and the possible penalties that physicians and medical facilities face for violations. Part II will briefly explain the 2017 inflation increase, noting how the civil money penalties have more than doubled as a result. Part III analyzes how EMTALA’s capacity-based penalties pose a significantly higher burden on inner-city hospitals given the increased population of uninsured individuals in major cities in comparison to rural areas. Part IV offers a solution to this burden by arguing that the capacity-based penalty should be abolished. It also considers the possible ramifications of said solution and concludes that regardless of the risks, EMTALA’s capacity-based penalty structure must be reevaluated in light of its burden to inner-city hospitals. 

I.  The Emergency Medical Treatment And Labor Act 

As stated above, the Emergency Medical Treatment and Labor Act (“EMTALA”), codified as 42 U.S.C. § 1395dd, was enacted in 1986 to prevent medical facilities from withholding life-saving treatment based on a patient’s ability to pay. Importantly though, EMTALA was specifically targeted and structured to burden hospitals’ emergency rooms, the primary providers of treatment for the uninsured both then and now.[27] Given that its requirements are only imposed on facilities with emergency rooms—and in addition to that, only those facilities who participate in the federal Medicare program[28]—one might assume that EMTALA and its requirements are not widespread in their enforcement. This is incorrect. The vast majority of medical facilities participate in the Medicare program and operate emergency rooms, which thus, subjects them to EMTALA’s provisions.[29] And in fact, since EMTALA’s creation, many Medicare-participating facilities have closed their emergency rooms altogether to avoid the financial burdens of EMTALA.[30] As this Part discusses below, those financial burdens take shape through EMTALA’s requirements and penalties. 

A.  The Requirements Of EMTALA: 42 U.S.C. § 1395(a)–(c)

The requirements of EMTALA are codified in its first three provisions, 42 U.S.C. § 1395dd(a)–(c).[31] At its simplest, the statute provides that when an individual comes to an emergency room of a Medicare-participating facility for examination or treatment, the facility must “provide for an appropriate medical screening examination within the capability of the hospital’s emergency department” in order to determine if an “emergency medical condition” exists.[32] Then, if such a condition exists, the facility must provide, within its capabilities, whatever is necessary to “stabilize the medical condition”[33] or, in the alternative, the facility must provide transfer to another, better-equipped facility.[34] Notably, however, a transfer is conditioned on the patient’s written consent and a physician’s signed certification that the benefits at another facility outweigh the risks of a transfer.[35] Interestingly, the receiving hospital must accept the patient being transferred if it is within its capacity and specialized capability[36]—regardless of whether or not it has an emergency room to subject it to the provisions of EMTALA.[37] Thus, even though EMTALA’s requirements bind only those facilities who participate in the Medicare program and operate an emergency room, EMTALA can still affect all medical facilities. 

What should be evident upon reading the aforementioned provisions is that a hospital’s compliance with EMTALA is a substantial financial burden. For example, the requirement that a hospital perform a medical screening alone can represent a spectrum of procedures from “a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures.”[38] Similarly, what constitutes “stabilization” of an existing emergency medical condition can be “brief or long depending on the condition [of the patient].”[39] Recall that EMTALA is an unfunded mandate, and regardless of what is needed to “screen” and “stabilize” the patient, the hospital is required to furnish the entire bill.[40] Perhaps one of the most controversial political topics of American twenty-first century debate is whether healthcare needs to be government-mandated or continue to be privatized;[41] however, if you put the debate in the context of EMTALA, the public would realize that we already enjoy a version of universal, government-mandated healthcare—one that places the entire financial burden not on the taxpayers, but on the medical facility itself.[42]

As noted above, the focus of this Note is not to add to the existing scholarship discussing the financial burdens of EMTALA’s requirements, but to focus instead on the penalties of EMTALA. Nevertheless, it is important to understand the basic requirements and the financial costs imposed on medical facilities in complying with EMTALA in order to see the offset of financial costs imposed for a hospitals’ non-compliance. The Center for Medicare and Medicaid Services (“CMS”), a division of the United States Department of Health and Human Services, is responsible for enforcing and regulating medical facilities’ compliance with the aforementioned provisions of EMTALA.[43] In the event that a medical facility violates the provisions of EMTALA, the statute provides the CMS—and even the actual victims of patient dumping—a number of possible punishments and remedies to invoke that are explained in this Part below. 

B.  The Penalties Of EMTALA: 42 U.S.C. § 1395dd(d)

While the prior section summarized the requirements of EMTALA’s first three provisions, this section illustrates the five penalties for a hospitals’ failure to meet said requirements, all of which are codified in EMTALA’s fourth provision, 42 U.S.C. § 1395dd(d).[44] As will be shown, each EMTALA penalty imposes its own unique financial burden on a medical facility and its physicians, evidencing Congress’s strong intentions with respect to curtailing all instances of patient dumping. It should be noted that none of the following available penalties are exclusive, and a hospital may be held responsible under each penalty for each violation depending on the given circumstances.[45]

The first possible penalty of EMTALA, which is arguably the most severe, is the termination of a hospitals’ Medicare provider agreement as provided for in 42 U.S.C. § 1395dd(d)(1)(B). Scholars recognize this as the “real economic weapon” of EMTALA,[46] as the termination of a hospitals’ Medicare agreement can cost the facility millions of dollars in funding and loss of reputation.[47] In fact, for a majority of hospitals, Medicare funding represents more than thirty percent of the budget and roughly fifty-five percent of the revenue.[48] Its loss can constitute a death sentence for many facilities.[49] Under EMTALA, however, this penalty is reserved for “gross and flagrant” violations or repeated violations, and therefore is not routinely invoked.[50] Notwithstanding its rarity, it remains the loaded gun of EMTALA that bullies facilities into compliance or shutting their emergency departments down altogether. 

A second possible penalty codified by EMTALA is one against the individual physician, as provided for in 42 U.S.C. § 1395dd(d)(1)(B). In the event that a physician negligently violates a requirement of EMTALA, that individual physician is subject to a civil money penalty of up to $50,000.00 for each of his or her violations.[51] Much like the previous penalty of EMTALA, this penalty is a rarity. In 2017, a study was published analyzing 196 civil money penalty settlements made over a thirteen-year period.[52] Of these settlements, only eight (roughly four percent) were made against the individual physician and the penalty ranged from $10,000.00 to the full $50,000.00.[53] Only one physician was penalized with the full $50,000.00 fine, which was levied for failure to respond to a request to evaluate a patient who later died.[54] Thus, while this penalty is clearly not enforced often, the statistics of the 2017 study nonetheless prove that EMTALA’s head enforcer, the Office of the Inspector General (“OIG”), is not opposed to penalizing individual physicians. Consequently, the threat of a lofty individual penalty remains an “often-feared consequence” of EMTALA for physicians.[55]

The third possible penalty of EMTALA is the private statutory cause of action provided for in 42 U.S.C. § 1395dd(d)(2)(A),[56] which allows victims of patient dumping to bring a direct action against the violating hospital for monetary remedies. Importantly, however, this remedy has its limitations. For one, the action may only be brought against the hospital—not the physician.[57] Also, the existence of a private, federal cause of action does not necessarily preempt the existing, substantive law of a given state.[58] For example, EMTALA does not compete with state medical malpractice law as EMTALA itself is not a federal malpractice statute.[59] Congress did not intend for EMTALA to address injuries already covered by state law.[60] Nevertheless, plaintiffs still tack on EMTALA claims in conjunction with state malpractice actions simply because the alleged incident occurred in an emergency room.[61] The crucial distinction between these claims is that a hospital is ordinarily not liable for its physicians’ malpractice, but it is liable for its physicians’ EMTALA violations.[62] Thus, by adding an EMTALA cause of action pursuant to 42 U.S.C. § 1395dd(d)(2)(A), a plaintiff may force a hospital into malpractice litigation that it would not otherwise be a party to, costing the hospital thousands in attorney’s fees and costs. This third penalty of EMTALA has drastically altered the nature of medical law, allowing EMTALA to reach beyond a simple patient dumping case.[63]

A fourth EMTALA penalty, codified in 42 U.S.C. § 1395dd(d)(2)(B), is a second statutory, civil cause of action available to medical facilities. In the event that a hospital suffers damages due to another hospitals’ violation of EMTALA, the injured hospital may bring suit to recover its damages.[64] After much research, however, it is important to note that there exists little evidence that this penalty is ever utilized by injured hospitals. The reason for this rarity is likely because hospitals—and the medical profession as a whole—are historically united in their disdain for EMTALA and its unreasonable burdens.[65] It is also possible that hospitals rarely invoke this penalty because their damages are simply too difficult to quantify or to discover in the two-year statute of limitations imposed by EMTALA.[66] Since the statute of limitations begins to run from the date of the violation, it is entirely possible that hospitals simply do not discover the violation in time to sue. Another possible reasoning for hospitals’ decisions to not invoke this penalty may simply be that they have a desire to keep amicable and fruitful relationships with their neighboring facilities.[67] Nevertheless, regardless of the reasoning, this fourth penalty of EMTALA remains toothless by practice. 

The final possible penalty of EMTALA—and the fuse for this Note—is the civil money penalty imposed on violating facilities pursuant to 42 U.S.C. § 1395dd(d)(1)(A). Prior to 2017, if a hospital violated EMTALA, it faced a civil money penalty of either $25,000.00 or $50,000.00 depending on its bed capacity.[68] Those medical facilities with less than 100 beds received the lesser penalty of $25,000.00; and those facilities with more than 100 beds would face the full $50,000.00 penalty.[69] Given this facial discrepancy, imagine the following scenario: an inner-city hospital with 115 beds treats patients that are roughly ninety percent uninsured, while a rural hospital with eighty beds treats patients that are roughly ten percent uninsured. Despite the difference in patient insurance coverage, the inner-city hospital is punished twice as severely simply because it has more than 100 beds. Notably, the difference in penalty has nothing to do with the circumstances of the actual violation—meaning that the rural hospital will still receive the lesser punishment even though its violation resulted in the death of a patient, while the urban facility will still receive the higher penalty even though its patient survived.[70]

In the event that a hospital violates the requirements of EMTALA, the OIG levies these civil money penalties through discretionary, administrative actions.[71] Notably, of the preceding five possible EMTALA penalties, this fifth penalty is arguably the most invoked. In fact, a 2001 study demonstrated that from 1995 to 2000, the OIG collected more than five million in fines from violating hospitals and physicians.[72] More recently, a 2017 study found that from 2002-2015 more than a quarter of hospitals were cited for violations.[73] Noticeably lacking from both studies, however, is any consideration or analysis of the capacity-based structure of this fifth penalty.[74] It is currently unknown how many of these cited hospitals housed more or less than 100 beds as both studies focus on the actual assessment of this penalty and not the penalty assessed itself. As will be discussed later in Part III, this is an oversight in EMTALA scholarship as the capacity-based structure of this fifth penalty is discriminatory to inner-city hospitals, which has only been exacerbated by the 2017 inflation adjustment described in this next Part. 

II.  The 2017 Civil Money Penalty Increase Due To Inflation 

In accordance with the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015, the Department of Health and Human Services (“DHHS”), which oversees the Center for Medicare and Medicaid Services (“CMS”), began updating its regulations for inflation—including EMTALA and its civil money penalties.[75] Its claimed reasoning was to “improve the effectiveness of civil monetary penalties” and to ultimately maintain their deterrent effect.[76] As a result, the civil monetary penalty for an EMTALA-violating hospital is now $52,414.00 for facilities with less than a hundred beds and $104,826.00 for those facilities with more than a hundred beds.[77] Notably, these new figures are more than twice the amount of the previous EMTALA penalties; though, given that EMTALA was first enacted over thirty years ago, it is not unheard of that an inflation adjustment would double the original penalty. Nevertheless, it is a fair assumption that this drastic increase to EMTALA’s penalties will not minimize the financial burdens of the statute discussed in Part I, but rather exacerbate its many faults—including the unfortunate closing of many facilities.

A 2017 study found that in the past decade, “more than twice as many hospitals were closed or downgraded emergency services as a result of EMTALA violations” as compared to those individually fined physicians.[78] Scholars posit that the overall burdens of EMTALA’s requirements and penalties are responsible for these closures and downgrades.[79] What is rarely considered, however, is which hospitals are being burdened the most and why. Is the eighty-bed rural facility from our example in Part I more impacted by EMTALA’s financial costs, or is the 115-bed urban facility the true sufferer at risk of closure? Only a handful of researchers recognize that EMTALA, as a whole, disproportionately burdens inner-city facilities because such facilities carry the brunt of caring for this country’s uninsured population.[80] This Note joins this discussion, but also goes a step further and argues that the capacity-based fifth penalty of EMTALA, as shown in Part I to unfairly penalize larger facilities more so than smaller ones, discriminatorily impacts inner-city facilities and should consequently be abolished. 

III.  The Burden On Highly Populated, Inner-City Regions

As noted in Parts I and II, the civil money penalties of EMTALA are levied against medical facilities based on their overall bed capacity—those facilities with less than a hundred beds are fined up to $52,414.00 for each violation, and those with more than a hundred beds are fined up to $104,926.00 for each violation. Yet, despite the plethora of scholarship currently existing on EMTALA’s requirements and burdens, scholars have never examined the effect that this capacity-based penalty has on medical facilities, particularly those located in highly populated, inner-city regions. In light of the penalty’s recent inflation adjustment, this Note (and more specifically this Part) breaches that gap in scholarship and posits that the capacity-based penalty is facially discriminatory to inner-city facilities that are, by virtue of their location and size, entirely responsible for the medical care of this country’s uninsured population.

For clarity, the logic of this Part can be condensed as follows: First, a sizeable population of uninsured Americans—a great majority of which are homeless—currently live in the United States. Second, statistics show that this uninsured, homeless population likely live in highly populated, inner-city regions. Third, hospitals with more than a hundred beds likely are located in highly populated, inner-city regions in order to accommodate their vast populations. Accordingly, inner-city hospitals treat the majority of the country’s uninsured and homeless; yet, by virtue of their size alone, these hospitals face double the penalty for violating EMTALA than that of a smaller facility that treats little to no uninsured patients. As EMTALA was enacted to prevent medical facilities from turning away the uninsured population, the capacity-based penalty of EMTALA is therefore unfairly discriminating against inner-city facilities who treat said population. 

With respect to the first point, as of 2016, the United States Census determined that roughly twenty-seven million people living in the United States lacked health insurance coverage.[81] This figure alone is enough to support the arguments herein; however, it should be noted that it represents only those the United States Census surveyed.[82] Historically speaking, the Census is notorious for its inability to accurately determine the number of homeless and indigent people living in the United States,[83] and therefore it is likely that this figure is much larger in actuality.[84] Moreover, since the new administration took office, statistics show that the uninsured population has spiked upward for the first time since the Affordable Care Act (“ACA”) was enacted in 2010.[85] In the coming years, the number will likely continue to increase in light of this administration’s hostility toward the ACA.[86] Nevertheless, it is important to recognize how the population of the uninsured affects medical facilities and their compliance with EMTALA. For one, the uninsured are more likely to be younger and minorities—the “two subpopulations that are disproportionately represented among the homeless.”[87] It is the homeless population that frequents emergency departments as their “primary or only source of health care.”[88] Consequently, hospitals who treat the uninsured homeless are more at risk for EMTALA violations because these individuals cannot pay for their care. 

But which hospitals treat the highest rates of uninsured, and by extension, are more at risk for violating EMTALA? The answer depends on where the uninsured, homeless population live. With respect to the second point of this argument, a 2018 study broke down the rates of homelessness by city, finding that “[h]alf… of all people experiencing homelessness are in one of five states – California (129,972 people), New York (91,897), Florida (31,030), Texas (25,310) and Washington (22,304).”[89] Tellingly, California, Texas, Florida, and New York rank as the top four most populous states in the country.[90] The 2018 study further found that the ten cities with the highest rates of homelessness included: New York City, New York; Los Angeles, California; Seattle, Washington; San Diego, California; San Jose, California; District of Columbia, DC; San Francisco, California; Phoenix, Arizona; Boston, Massachusetts; and Las Vegas, Nevada.[91] All of these cities fall within the thirty most-populated cities in the United States.[92] Thus, the most highly populated, inner-city regions in this country are home to the largest homeless, uninsured populations. It naturally follows that their medical facilities would treat said population and be at the greatest risk for EMTALA violations.  

As highly populated, inner-city regions are home to the largest uninsured, homeless populations, it is no coincidence that these same areas are also home to the largest medical facilities, which brings this Part to its third point. Hospitals with more than a hundred beds are more often located in more populous cities in order to accommodate their population.[93] In fact, of the twenty-five largest hospitals in the United States (measured by bed capacity), eleven are located in Florida, New York, and Texas.[94] Keep in mind that all twenty-five of these hospitals have more than 1,000 beds each.[95] Expanding further on this, of the fifty largest hospitals (measured by bed capacity), twenty-two are located in the same states, the smallest having 861 beds.[96] New York City alone houses seven of the largest fifty hospitals[97] and of its total sixty-two acute care facilities, only three have less than a hundred beds.[98] Consequently, these numbers reflect the fact that medical facilities located in highly populated, inner-city areas house the most beds in addition to the largest homeless, uninsured populations. Yet, despite the fact that these facilities are disproportionately forced treat the uninsured, EMTALA nevertheless penalizes said facilities for violating its requirements solely based on their capacity, and not the given circumstances. The statute itself provides no reasoning for this capacity-based distinction and, as will be discussed in the following Part, it should be abolished altogether. 

IV.  Abolishing The Capacity-Based Penalty

The existing scholarship with respect to EMTALA is a plethora of legal and medical arguments regarding its constitutionality and practicality. Perhaps justifiably, scholars and researchers predominately focus on the overall impacts and effects of EMTALA, leaving its minor nuances and provisions alone.[99] The reason for this is likely because a great many scholars do not propose amendments to the statute, but rather that EMTALA should be abolished as unconstitutional. Others focus on methods of funding EMTALA so that it is no longer an unfunded mandate.[100] This Note, though not necessarily in disagreement with prior scholarship’s approach to EMTALA, proposes differently and argues that EMTALA should be amended to abolish its capacity-based civil money penalty as it discriminates against highly populated, inner-city facilities that are forced to bear the brunt of this country’s uninsured population.

EMTALA was designed to be a deterrent to hospitals that might be prone to patient dumping.[101] Its requirements and burdens reflect Congress’s sincere intention to stamp out the practice altogether and to ensure that medical facilities will think twice before sending a patient away. Given this, it makes no logical sense that Congress would draw a distinction based on bed capacity when levying EMTALA’s civil money penalties against a violating hospital. Recall the example from Part I where a rural hospital with eighty beds could intentionally violate EMTALA resulting in the death of a patient and still only be subject to a maximum civil money penalty of $52,414.00. In contrast, an urban facility with 115 beds could negligently violate EMTALA without causing the death of their patient and be subject to a maximum penalty of $104,926.00. Notwithstanding the vast difference in circumstances, the urban facility will be liable for twice the penalty as the rural facility solely because of its bed capacity. This conclusion lacks reasoning and ultimately reflects the irrelevance of the capacity-based penalty. 

Upon review of the legislative material for EMTALA, there appears to be no stated reasoning for the capacity-based penalty. Presumably though, it was enacted to ensure that larger hospitals that, as illustrated herein, treat the majority of the uninsured population would be more deterred from participating in patient dumping. It is also possible that Congress feared that the larger penalty would cripple smaller facilities; though the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015, which requires that agencies adjust their penalties for inflation annually,[102]defeats such protection. Nevertheless, the reasoning seems inconsequential when scholars are in almost universal agreement that the sole deterrent of patient dumping comes from a single provision of EMTALA—the termination of a hospitals’ Medicare provider agreement as provided for in 42 U.S.C. § 1395dd(d)(1)(B).[103] Thus, the discrimination of EMTALA’s civil money penalties is unnecessary and need only be eliminated by an act of Congress. With a plethora of penalties available, levying a uniform civil money penalty against violating hospitals will have little to no consequences.

While abolishing the capacity-based structure of EMTALA’s civil money penalties will likely have no negative consequences, it may also be argued that it will not have any positive consequences and is therefore unnecessary. For example, under EMTALA, the OIG does not have to impose the maximum civil money penalty and can arguably choose to levy a smaller penalty against a hospital with more than a hundred beds. A 2016 study found that of 192 EMTALA settlement agreements from 2002-2015, the fines levied against medical facilities averaged to about $33,435.00.[104]Note that during this time period, the maximum penalty for a hospital with more than a hundred beds was $50,000.00; and one might argue that this figure evidences that the OIG was not levying the maximum penalty available. Importantly, however, this study does not clarify whether these settlement agreements were reached with hospitals with more or less than a hundred beds, or some combination thereof. It is entirely possible that the full $50,000.00 fine was levied on some, if not all, medical facilities with more than a hundred beds. Future research will have to be conducted, taking into account the capacity-based structure of the penalty, in order to better understand its implementation and effect. Until this can be done, the positive consequences, or lack thereof, of abolishing EMTALA’s capacity-based penalty will remain unknown.

Conclusion

The overall financial burdens of EMTALA are severe regardless of whether a facility complies with the statute or not. Facilities are faced with a choice to either meet the standards of EMTALA and dole out millions in uncompensated care, fail to meet the standards of EMTALA and suffer millions in penalties, or simply submit to the closure of their facility and/or emergency services to avoid financial costs altogether. It can be argued that these burdens are the price of participating in the federal Medicare program. Hence—you take the government’s money; you play by its rules. This argument is fair considering that hospitals do have a choice to not participate in the Medicare program. In practice, however, the choice to participate in the Medicare program is not much of a choice at all. As illustrated in Part I, Medicare often represents a significant portion of a facility’s funding.[105] For many urban facilities, it accounts for fifty percent of its revenue.[106] Thus, simply severing its Medicare agreement can have devastating consequences. This is likely the reason why so many facilities have either closed altogether or downgraded their services and eliminated emergency care.[107] Neither result bodes well for the uninsured population of the United States.

Unlike existing EMTALA scholarship, this Note does not put forth an argument that the statute must either be repealed or funded by Congress—though these arguments certainly have merit. Rather, this Note argues that EMTALA’s capacity-based structure for its civil money penalties is unnecessary and unfairly discriminatory against inner-city facilities who are forced to carry the brunt of this country’s uninsured population. After all, the difference of a single bed should not be the deciding factor for whether a medical facility is subject to a fine of $52,414.00 or a fine of $104,926.00. The true determination should depend on the circumstances of a given case and relevant factors including whether the patient died, whether the facility’s actions were intentional or negligent, or whether the facility has since implemented preventative measures to avoid the incident’s reoccurrence. Moreover, removing the capacity-based structure of EMTALA’s civil money penalty should not negatively impact Congress’s intention to curtail patient dumping, the severity of which this Note does not seek minimize or ignore. Nonetheless, it cannot be said that EMTALA has not unfairly burdened the medical profession by forcing it to fund a version of universal healthcare. While a more in-depth reexamination of EMTALA is needed to protect hospitals and medical facilities from its burdens, abolishing the capacity-based structure of EMTALA’s penalty will provide some relief to these facilities—specifically those inner-city hospitals who treat the majority of America’s uninsured population.


[I] Production Editor, Kentucky Law Journal, Vol. 108; J.D. Candidate, The University of Kentucky College of Law (2020); B.A., The University of Kentucky (2017).

[2] Robert H. Shmerling, First, do no harm, Harv. Health Pub.: Harv. Med. Sch. (Oct. 13, 2015, 8:31 AM), https://www.health.harvard.edu/blog/first-do-no-harm-201510138421 [https://perma.cc/6DYF-44FF].

[3] See Michael Kowalski, Applying the “Two Schools of Thought” Doctrine to the Repressed Memory Controversy, 19 J. Legal Med. 503, 505 (1998) (recognizing that “first do no harm” is a “phrase recognized as one of the most significant admonitions from the Hippocratic Oath.”). 

[4] Karen I. Treiger, Preventing Patient Dumping: Sharpening the COBRA’s Fangs, 61 N.Y.U. L. Rev. 1186, 1191–92 (1986). 

[5] Id.

[6] Id. at 1193–94.

[7] Michael A. Wolff, Charity Means Business: Medicare Reimbursement for Hospitals’ ‘Free Care’ Obligations, 25 St. Louis U. L.J. 389, 393 (1981). 

[8] Id. 

[9] Id. at 392.

[10] Fast Facts on U.S. Hospitals, 2020, Am. Hosp. Ass’n, https://www.aha.org/statistics/fast-facts-us-hospitals [https://perma.cc/99CT-LT85] (last modified Jan. 2020). 

[11] Wolff, supra note 7, at 393. 

[12] Treiger, supra note 4, at 1193–94; see generally Maria O’Brien Hylton, The Economics and Politics of Emergency Health Care for the Poor: The Patient Dumping Dilemma, 1992 BYU L. Rev. 971, 972–73 (1992) (discussing the needs of the uninsured in a healthcare system that works as a business rather than a caretaker).

[13] George J. Annas, Your Money or Your Life: ‘Dumping’ Uninsured Patients from Hospital Emergency Wards, 76 Am. J. Pub. Health 74 (1986).

[14] Id. 

[15] Will Jay Pirkey, A Shameful Practice, 39 L.A. Law. 20, 21 (2016). Importantly, it should be noted that patient dumping is not a new concern, as the term was first coined in the late 1870s. Id. at 20. It was not until the 1980s however, that the public outrage for patient dumping grew when several highly publicized patient dumps hit the press. See Beverly Cohen, Disentangling EMTALA from Medical Malpractice: Revising EMTALA’s Screening Standard to Differentiate Between Ordinary Negligence and Discriminatory Denials of Care, 82 Tul. L. Rev. 645, 650–54 (2007). When the public learned of such “cold, unconscionable disregard for human life,” concern grew, and Congress was forced to act. Thomas A. Gionis et al., The Intentional Tort of Patient Dumping: A New State Cause of Action to Address the Shortcoming of the Federal Emergency Medical Treatment and Active Labor Act (EMTALA), 52 Am. U. L. Rev. 173, 175 (2002).

[16] Gionis et al., supra note 15, at 181. 

[17] Id. at 182–84; 42 U.S.C. § 1395dd (2012). It should be noted that the standards of EMTALA garnered decades of jurisprudence over both the constitutionality of the Act and the scope of its language. See generally E. H. Morreim, EMTALA Turns 30: Unconstitutional from Birth, 28 Health. Law. 32 (2015) (discussing how EMTALA violates the Fifth Amendment’s Taking Clause); Lawrence E. Singer, Look What They’ve Done to my Law: COBRA’s Implosion, 33 Hous. L. Rev. 113, 162–63 (1996) (discussing how the language of EMTALA implicates not just intentional actions, but also negligent actions). 

[18] Decanda M. Faulk, EMTALA: The Real Deal, 16 Health Law. 10, 10 (2003). 

[19] Andrew Jay McClurg, Your Money or Your Life: Interpreting the Federal Act Against Patient Dumping, 24 Wake Forest L. Rev. 173, 175–76 (1989). 

[20] See 42 U.S.C. § 1395dd.

[21] Morreim, supra note 17, at 32. 

[22] Thomas K. Hyatt, Access to Health Care: 50 Years of Growth, but an Uncertain Future, 10 J. Health & Life Sci. L. 88, 101 (2017).

[23] E.g., Tiana Mayere Lee, An EMTALA Primer: The Impact of Changes in the Emergency Medicine Landscape on EMTALA Compliance and Enforcement, 13 Annals Health L. 145, 166–68 (2004). 

[24] 42 U.S.C. § 1395dd(d)(1).

[25] Id; 45 C.F.R. § 102.3 (2018).

[26] See id. 

[27] Jack Vihstadt, EMTALA’s Impact on Patients’ Rights in Colorado Emergency Rooms, 89 U. Colo. L. Rev. 219, 224 (2018). In fact, the Centers for Disease Control and Prevention posted a study of United States emergency room visits finding that in 2016, there were more than 145 million visits. National Center for Health Statistics: Emergency Department Visits, Ctrs. for Disease Control & Prevention, https://www.cdc.gov/nchs/fastats/emergency-department.htm [https://perma.cc/5AG9-ADCJ] (last visited Nov. 1, 2019). Note that for 39% of these visits, roughly 56 million, the patient was seen in fewer than fifteen minutes, which likely means the patient was not critically injured. Id.

[28] 42 U.S.C. § 1395cc(l) (2012); Hyatt, supra note 22, at 101. 

[29] Hyatt, supra note 22, at 101.  

[30] Jeffrey A. Singer, No Discharge: Medicaid and EMTALA, 37 Reg. 52, 56–57 (2014). 

[31] 42 U.S.C. § 1395dd(a)–(c) (2011). 

[32] § 1395dd(a). EMTALA provides a definition of “emergency medical condition,” stating that it is a condition that the “absence of immediate medical attention could reasonably be expected to result in . . . placing the health of the individual . . . in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part[.]” § 1395dd(e)(1).

[33] § 1395dd(b)(1)(A). Currently there exists a circuit split on what constitutes “stabilizing” the patient. Specifically, the Fourth and Ninth Circuit Courts view this requirement met when the patient is admitted to the hospital as an inpatient. Bryan v. Rectors, 95 F.3d 349, 352 (4th Cir. 1996), Bryant v. Adventist Health Sys./West, 289 F.3d 1162, 1164 (9th Cir. 2002). In contrast, the Sixth Circuit reasons that the frequent use of the term “emergency room” in EMTALA was a reference to Congress’s desire to ensure patients received emergency care regardless of admittance or not. Thornton v. Southwest Detroit Hosp., 895 F.2d 1131, 1135 (6th Cir. 1990). 

[34] 42 U.S.C. § 1395dd(b)(1)(B). 

[35] § 1395dd(b)(3). While it may not be evident by reading the statutes alone – the costs of meeting EMTALA’s standards are significant. There does, however, exist a small saving grace for hospitals – especially rural hospitals with limited resources. Specifically, EMTALA provides that the required treatment must only be “within the capability of the hospital’s emergency department,” thus protecting rural hospitals that might be unable to match the capabilities of an urban facility. § 1395dd(g). Scholars have pointed to this language as helpful to rural hospitals that cannot match the capabilities of an urban facility. See, e.g., Diane S. Mackey, The Emergency Medical Treatment and Active Labor Act: An Act Undergoing Judicial Development, 19 U. Ark. Little Rock L.J. 465, 478 (1997). Of course, however, if a hospital cannot provide the necessary treatment, it must foot the financial burden of transferring the patient to a facility that can. See id at 470.

[36] E. H. Morreim, EMTALA: Medicare’s Unconstitutional Conditions on Hospitals, 43 Hastings Const. L.Q. 61, 62 n.5 (2015).

[37] 42 C.F.R. § 489.24(f) (2013).

[38] U.S. Department of Health and Human Services, Medicare Medicaid State Operations Manual, Appendix V, at 36 (1998). By this language, the screening requirement of EMTALA is satisfied simply because the individual met with a physician; depending on the circumstances, further tests and evaluations may be required to determine with reasonable certainty if there is an emergency medical condition. Wendi Campbell Rogaliner et al., Health Care Providers Balance Patient Rights and Law Enforcement Authority in the Hospital Setting, 11 J. Health & Life Sci. L. 42, 52 (2018).

[39] Sara Rosenbaum & Brian Kamoie, Finding a Way Through the Hospital Door: The Role of EMTALA in Public Health Emergencies, 31 J. L. Med. & Ethics 590, 592 (2003).

[40] See Hyatt, supra note 22, at 101.

[41] E.g., James Pramuk, ‘Medicare-for-all’ vs. the public option: How health care could shape the Democratic primary race to take on Trump in the 2020 election, CNBC (Mar. 10, 2019, 8:00 AM), https://www.cnbc.com/2019/03/06/2020-democratic-primary-candidates-weigh-medicare-for-all-public-option.html [https://perma.cc/3CML-KBB5].

[41] 42 U.S.C.A. § 1395dd(d) (2012).

[42] By enacting EMTALA, the statute became the “de facto” healthcare insurance for the uninsured. See EMTALA Fact Sheet, Am. Coll. Emergency Physicians,https://www.acep.org/life-as-a-physician/ethics--legal/emtala/emtala-fact-sheet/ [https://perma.cc/9YG6-2DPN] (last visited Mar. 15, 2019).

[43] See Laura D. Hermer, The Scapegoat: EMTALA and Emergency Department Overcrowding, 14 J.L. & Pol’y 695, 701 (2006).

[44] 42 U.S.C. § 1395dd(d) (2011).

[45] See generally Shannon Fruth, Medical Repatriation: The Intersection of Mandated Emergency Care, Immigration Consequences, and International Obligations, 36 J. Legal Med. 45, 51 (2015). See also 42 U.S.C.A. § 1395dd ( there is no provision dictating that the penalties under EMTALA are exclusive). A hospital can be fined by the OIG, sued by a neighboring hospital, sued by a private plaintiff, and lose its Medicare funding all at once depending on the circumstances. 

[46] Michael J. Frank, Tailoring EMTALA Better Protect the Indigent: The Supreme Court Precludes One Method of Salvaging a Statute Gone Awry, 3 DePaul J. Health Care L. 195, 218 (2000) (citations omitted). 

[47] Christopher J. Young, Emergency! Says Who?: Analysis of the Legal Issues Concerning Managed Care and Emergency Medical Services, 13 J. Contemp. Health L. & Pol’y 553, 562–63 (1997).

[48] Morreim, supra note 17, at 38.

[49] Unsurprisingly, those hospitals where Medicare represents roughly fifty-five percent of its revenue are more likely to be urban facilities. Mark R. Whitmore & J. Scott Anderson, Decisions of the Supreme Court and DHHS Continue to Expand Hospital Liability Under EMTALA, 11 Health Law. 14, 14 (1999).

[50] 42 U.S.C. § 1395dd(d)(1)(B) (2011).

[51] Id. 

[52] Sophie Terp et al., Individual Physician Penalties Resulting From Violation of Emergency Medical Treatment and Labor Act: A Review of Office of the Inspector General Patient Dumping Settlements, 2002–2015, 24 Acad. Emergency Med. 442, 442 (2017).

[53] Id. at 444 (providing a breakdown of the eight penalized physicians by chart).

[54] Id. 

[55] Id. While this particular penalty is levied against individual physicians, it still poses a financial burden to the hospital the physician works for. For instance, what if a physician violates EMTALA, but he or she is under contract with their hospital? EMTALA could force a hospital into litigation with its doctors and raise recruitment costs to replace violating doctors. Thus, this individual penalty has likely “as applied” costs to the hospitals.

[56] 42 U.S.C. § 1395dd(d)(2)(A) (2018); See also Julie A. Braun et al., Recent Developments in Medicine and Law, 36 Tort & Ins. L.J. 463, 469–70 (2001). 

[57] Young, supra note 45, at 563.

[58] See 42 U.S.C.A. § 1395dd(f) (2018); See also Elizabeth Y. McCuskey, Body of Preemption: Health Law Traditions and the Presumption Against Preemption, 89 Temp. L. Rev. 95, 129 (2016). 

[59] See Julia Ai, Does EMTALA Apply to Inpatients Located Anywhere in a Hospital?, 32 Rutgers L.J. 549, 571 (2001) (citing Summers v. Baptist Med. Ctr. Arkadelphia, 91 F.3d 1132, 1137 (8th Cir. 1996)).

[60] Alicia K. Dowdy et al., The Anatomy of EMTALA: A Litigator’s Guide, 27 St. Mary’s L.J. 463, 512 (1996).

[61] Ai, supra note 57, at 572. 

[62] Dowdy et al., supra note 58, at 468–69.

[63] Ai, supra note 57, at 572.

[64] 42 U.S.C. § 1395dd(d)(2)(B) (2018).

[65] See Frank, supra 44, at 235. 

[66] 42 U.S.C. § 1395dd(d)(2)(C) (2018); See also Kim C. Stanger, Private Lawsuits Under EMTALA, 12 Health Law. 27, 33 (2000).

[67]After working two years at a state medical facility, I witnessed firsthand how hospitals work to keep their relationships smooth and cooperative for the sake of their patients.

[68] 42 U.S.C.A. § 1395dd(d)(1).

[69] Id. 

[70] Importantly, EMTALA’s civil money penalties are per violation, and not per patient. Robert A. Bitterman, Feds Increase EMTALA Penalties against Physicians and Hospitals, Emergency Physicians Monthly (Oct. 17, 2017), http://epmonthly.com/article/feds-increase-emtala-penalties-physicians-hospitals/ [https://perma.cc/C76V-JQSU]. This is significant because multiple EMTALA violations can occur with a single patient. Id. 

[71] Brian Kamoie, EMTALA: Dedicating an Emergency Department Near You, 37 J. Health L. 41, 45 (2004); See also Charlotte Fillenwarth, Note, Beyond the Emergency Room Doors: Rejecting Patient Admittance as Satisfaction of Hospital Obligations Under EMTALA, 11 Ind. Health L. Rev. 791, 805 (2014) (“. . . the CMS may terminate the hospital’s Medicare agreement and the OIG determines whether to impose civil penalties.”) (emphasis added).

[72] Kamoie, supra note 71, at 45. 

[73] Terp, supra note 52, at 444.

[74] See id.See also U.S. Gov’t Accountability Off., GAO-01-747, Emergency Care: EMTALA Implementation and Enforcement Issues (2001).

[75] Annual Civil Monetary Penalties Inflation Adjustment, Fed. Reg. (Jan. 30, 2017), https://www.federalregister.gov/documents/2017/02/03/2017-02300/annual-civil-monetary-penalties-inflation-adjustment [https://perma.cc/7K7Q-8HFS]. Importantly, it should be noted that the 2017 inflation adjustment to EMTALA’s civil money penalties is technically no longer current. The adjustment was made pursuant to the Federal Civil Penalties Inflation Adjustment Act, signed into law by Barack Obama on November 2, 2015. Civil Monetary Penalties (Annual Adjustments), CMS.gov (Feb. 12, 2019 7:20 AM), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Civil-Monetary-Penalties-Annual-Adjustments [https://perma.cc/R6EF-B3EG]. Under this Act, agencies are required to continuously update their penalties for inflation annuallyId. Thus, in 2018 EMTALA’s civil money penalty was adjusted again to be a $106,965.00 penalty if the facility houses more than 100 beds and $53,484 if it houses less than 100 beds. Id. These numbers are nominally different from the 2017 inflation adjustment, which more than doubled EMTALA’s original penalties in a single year. The doubling effect of the 2017 adjustment is why only the 2017 numbers are discussed.

[76] Id. 

[77] 45 C.F.R. § 102.3 (2018). These numbers took effect February 3, 2017 unless the alleged violation occurred prior to November 2, 2015 or the penalty was assessed prior to September 6, 2016, in which case the prior figures were still in effect. Annual Civil Monetary Penalties Inflation Adjustmentsupra note 75.

[78] Terp, supra note 52, at 445. 

[79] E.g., Svetlana Lebedinski, EMTALA: Treatment of Undocumented Aliens and the Financial Burden it Places on Hospitals, 7 J. L. Society 146, 154–55 (2005). Moreover, with any hospital closure, neighboring hospitals become burdened with more patients and overcrowded emergency rooms, which causes the neighboring hospitals to be in danger of closure. See Vivian L. Regehr, Please Resuscitate! How Financial Solutions May Breathe Life into EMTALA, 30 U. La Verne L. Rev. 180, 187–88 (2008).

[80] E.g., Lebedinski, supra note 79, at 155.

[81]Edward Berchick, Who are the Uninsured?, U.S. Census Bureau (Sept. 14, 2017), https://www.census.gov/newsroom/blogs/random-samplings/2017/09/who_are_the_uninsure.html [https://perma.cc/4V3G-QE9U]. This number increased to twenty-eight million in 2017. Edward Berchick, Who Are the Uninsured?, U.S. Census Bureau (Sept. 12, 2018), https://www.census.gov/library/stories/2018/09/who-are-the-uninsured.html [https://perma.cc/BL48-CBB2].

[82] See Berchick (Sept. 14, 2017), supra note 81.  

[83] Ann M. Burkhart, The Constitutional Underpinnings of Homelessness, 40 Hous. L. Rev. 211, 275 (2003).

[84] See id. at 274–75 (“Registration requirements disproportionately affect the homeless in at least three ways. First, the cost and effort to register generally are greater for the poor than for those who are more affluent, whether due to the necessity for a bus ride or other inconvenience of the registration time or place. Second, only nine states’ election laws expressly enfranchise the homeless. In those jurisdictions that do not, registration officials often refuse a homeless person the right to register. In some cases, election registrars prevent homeless persons from voting even if they have registered. Finally, many states check on the continued residence of registered voters by mailed notice, and any addressee who does not respond to the notice is purged from the registration list. This practice obviously presents greater difficulties for the homeless than for those with a home. The cumulative impact of these obstacles is as impossible to determine as determining the exact number of homeless persons.” (internal footnotes omitted)).

[85] E.g., Rachana Pradhan, Number of uninsured Americans rises for the first time since Obamacare, POLITICO (Sept. 10, 2019, 10:59 AM), https://www.politico.com/story/2019/09/10/health-insurance-rate-1719381 [https://perma.cc/4ARR-Y3VG].

[86] See id. 

[87] Committee on Health Care for Homeless People, Homelessness, Health, and Human Needs 79–80 (1988).

[88] Ruirui Sun et al., Characteristics of Homeless Individuals Using Emergency Department Services in 2014, Healthcare Cost & Utilization Project (Oct. 17, 2017), https://www.hcup-us.ahrq.gov/reports/statbriefs/sb229-Homeless-ED-Visits-2014.pdf [https://perma.cc/ZL97-RL5L].

[89] Niall McCarthy, The U.S. Cities with the Most Homeless People in 2018, Forbes (Dec. 20, 2018, 7:00 AM), https://www.forbes.com/sites/niallmccarthy/2018/12/20/the-u-s-cities-with-the-most-homeless-people-in-2018-infographic/#517363b31178 [https://perma.cc/28NW-KX97].

[90] Florida Passes New York to Become the Nation’s Third Most Populous State, Census Bureau Reports, U.S. Census Bureau (Dec. 23, 2014), https://www.census.gov/newsroom/press-releases/2014/cb14-232.html [https://perma.cc/BMD9-322S].

[91] McCarthy, supra note 89. 

[92] Marian White, The Top 10 Largest U.S. Cities by Population, Moving Tips (Mar. 16, 2018), https://www.moving.com/tips/the-top-10-largest-us-cities-by-population/ [https://perma.cc/P8AP-U9D3].

[93] See 50 Largest Hospitals in America, Becker’s Hospital Rev. (Oct. 26, 2010), https://www.beckershospitalreview.com/lists/50-largest-hospitals-in-america.html [https://perma.cc/RR73-WSRH]; see also Kelly Gooch, 25 Largest Hospitals in America, Becker’s Hospital Rev. (Jan. 18, 2017), https://www.beckershospitalreview.com/lists/25-largest-hospitals-in-americajan-18.html [https://perma.cc/6D2V-7ZVH].

[94] Gooch, supra note 92. Note that these three states are among the five states with the largest homeless populations. 

[95] Id. 

[96] See 50 Largest Hospitals in Americasupra note 93. 

[97] Id. 

[98]62 acute care hospitals in New York City, Becker’s Hospital Rev. (July 15, 2015), https://www.beckershospitalreview.com/lists/62-acute-care-hospitals-in-new-york-city.html [https://perma.cc/EQZ7-8AX5].

[99] See, e.g., E.H. Morreim, Dumping the “Anti-Dumping” Law: Why EMTALA is (Largely) Unconstitutional and Why it Matters, 15 Minn. J.L. Sci. & Tech. 211 (2014). 

[100] See Tristan Dollinger, America’s Unraveling Safety Net: EMTALA’s Effect on Emergency Departments, Problems and Solutions, 98 Marq. L. Rev. 1759, 1761, 1771–72 (2015). 

[101] See infra Part I.

[102] Civil Monetary Penalties (Annual Adjustments)supra note 75. 

[103] See, e.g., Victoria K. Perez, EMTALA: Protecting Patients First by not Deferring to the Final Regulations, 4 Seton Hall Circuit Rev. 149, 160 (2007); George P. Smith, II, The Elderly and Patient Dumping, 73 Fla. B.J. 85–86 (1999); Frank supra note 46, at 218.

[104] Nadia Zuabi et al., Emergency Medical Treatment and Labor Act (EMTALA) 2002-15: Review of Office of Inspector General Patient Dumping Settlements, 17 West J. Emerg. Med. 245, 247 (2016).

[105] See infra Part I. 

[106] Whitmore & Anderson, supra note 49, at 14. 

[107] Hermer, supra note 43; see also David A. Hyman, Patient Dumping and EMTALA: Past Imperfect/Future Shock, 8 Health Matrix: J. of Law-Medicine 29, 50–52 (1998); Singer, supra note 30, at 57.