Biden administration says federal law preempts state abortion bans when emergency care is needed

[BumRushDaShow]

Last edited Mon Jul 11, 2022, 06:42 PM - Edit history (1)

Source: CNN

(CNN) In new clarifying guidance announced Monday, the Biden administration said that federal law preempts state abortion bans when emergency care is needed and that the federal government can penalize institutions or providers that fail to provide abortions as needed to treat medical emergencies. "Under the law, no matter where you live, women have the right to emergency care -- including abortion care," HHS Secretary Xavier Becerra said in a news release Monday. "Today, in no uncertain terms, we are reinforcing that we expect providers to continue offering these services, and that federal law preempts state abortion bans when needed for emergency care."

In more than a dozen states, legal fights are underway over abortion bans and other laws that strictly limit the procedure after the US Supreme Court overturned the Roe v. Wade decision June 24. In a letter to the nation's health care providers on Monday, Becerra said a federal statute called the Emergency Medical Treatment and Active Labor Act, also known as EMTALA, protects providers' clinical judgment and the actions they take to provide stabilizing treatment to pregnant patients who are under emergency medical conditions, regardless of restrictions in any given state.

The act has been on the books since 1986. It specifically requires all patients get appropriate medical screening, examination, stabilizing treatment and facility transfer. The administration said examples of emergency medical conditions include, but are not limited to, ectopic pregnancy -- when the fertilized egg grows outside a woman's uterus -- and complications of miscarriages. Stabilizing treatment could include abortion. ecerra said that if a state law bans abortion and does not include an exception for the life or health of the pregnant person, that law is preempted by the federal statute.

"We heard a lot from physicians that we needed to be clearer on these points because people were still too scared to treat people," a senior adviser with HHS said in a background briefing. The new guidance is "meant to try to provide that reassurance here on the clinical judgment of these physicians and hospitals." HS said it will do everything within its authority to ensure that patients get the care they need. The statute applies to emergency departments and other specific clinical settings. Providers also will not have to wait for a patient's condition to worsen to be protected.

Read more: https://www.cnn.com/2022/07/11/health/federal-abortion-law-preempts-state-law/index.html

---

Wow. Someone found a 1986 law!

Here is the letter from the HHS Secretary to healthcare providers (PDF) - https://www.hhs.gov/sites/default/files/emergency-medical-care-letter-to-health-care-providers.pdf

ETA - here is the HHS Press Release -

FOR IMMEDIATE RELEASE
Contact: HHS Press Office 202-690-6343
[e-mail]

July 11, 2022



Following President Biden’s Executive Order to Protect Access to Reproductive Health Care, HHS Announces Guidance to Clarify that Emergency Medical Care Includes Abortion Services

Today, the U.S. Department of Health and Human Services (HHS) announced new guidance and communication to ensure all patients — including pregnant women and others experiencing pregnancy loss — have access to the full rights and protections for emergency medical care afforded under the law. This announcement follows President Biden’s executive order on reproductive health issued Friday.

HHS, through the Centers for Medicare & Medicaid Services (CMS), issued clarifying guidance on the Emergency Medical Treatment and Active Labor Act (EMTALA) and reaffirmed that it protects providers when offering legally-mandated, life- or health-saving abortion services in emergency situations. In addition to the guidance, Secretary Xavier Becerra, in a letter to providers, made clear that this federal law preempts state law restricting access to abortion in emergency situations - PDF*.

“Under the law, no matter where you live, women have the right to emergency care — including abortion care,” said HHS Secretary Xavier Becerra. “Today, in no uncertain terms, we are reinforcing that we expect providers to continue offering these services, and that federal law preempts state abortion bans when needed for emergency care. Protecting both patients and providers is a top priority, particularly in this moment. Health care must be between a patient and their doctor, not a politician. We will continue to leverage all available resources at HHS to make sure women can access the life-saving care they need.”

“Everyone should have access to the health care they need — especially in an emergency,” said CMS Administrator Chiquita Brooks-LaSure. “Under federal law, providers in emergency situations are required to provide stabilizing care to someone with an emergency medical condition, including abortion care if necessary, regardless of the state where they live. CMS will do everything within our authority to ensure that patients get the care they need.”

The EMTALA statute requires that Medicare hospitals provide all patients an appropriate medical screening, examination, stabilizing treatment, and transfer, if necessary, irrespective of any state laws or mandates that apply to specific procedures. Stabilizing treatment could include medical and/or surgical interventions, including abortion. If a state law prohibits abortion and does not include an exception for the health or life of the pregnant person — or draws the exception more narrowly than EMTALA’s emergency medical condition definition — that state law is preempted.

Read the Secretary’s letter to health care providers - PDF*.
Read the EMTALA guidance issued.

Following the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, Secretary Becerra announced HHS’s action plan to protect access to reproductive health care, including abortion care, which includes five priorities:

1. increasing access to medication abortion;
2. protecting patients and providers from discrimination, and ensuring privacy for patients and providers;
3. protecting emergency abortion care;
4. ensuring providers have family planning training and resources; and
5. strengthening family planning care, including emergency contraception.

Since the plan was announced, HHS has taken the following actions:

Launched the ReproductiveRights.gov public awareness website, which includes a know-your-rights patient fact sheet;

Convened a meeting with health insurers, and sent them a letter, calling on the industry to commit to meeting their obligations to provide coverage for contraceptive services at no cost as required by the Affordable Care Act;

Issued guidance to patients and providers that addresses the extent to which federal law and regulations protect individuals’ private medical information when it comes to seeking abortion and other forms of reproductive health care, as well as when it comes to using health information apps on smartphones;

Announced nearly $3 million in new funding to bolster training and technical assistance for the nationwide network of Title X family planning providers; and

Met with Michigan Governor Gretchen Whitmer, Oregon Governor Kate Brown, and Maine Governor Janet Mills and state attorneys general to discuss state-specific concerns.

HHS will take additional actions in the coming days.

HHS is committed to providing accurate and up-to-date information about access to and coverage of reproductive health care and resources. The Department’s goal is to make sure patients and providers have appropriate information and support.

Visit ReproductiveRights.gov to learn more about the care available to patients, and their right to that care.

*This content is in the process of Section 508 review. If you need immediate assistance accessing this content, please submit a request to [e-mail]. Content will be updated pending the outcome of the Section 508 review.
###

https://www.hhs.gov/about/news/2022/07/11/following-president-bidens-executive-order-protect-access-reproductive-health-care-hhs-announces-guidance-clarify-that-emergency-medical-care-includes-abortion-services.html

[LonePirate]

1. More of this sort of action, please!

[JohnSJ]

2. This is a good, but I have no doubt that someone will challenge this all the way up to the SC, and

who knows what they will do

[ShazzieB]

16. Came here to say the same thing!

But this will at least help for a while.

The problem with the deviant, err, devout Catholics on the SCOTUS is that they probably subscribe to the belief that a woman should be allowed to die if terminating her pregnancy is the only thing that will save her life. Never mind if the fetus is doomed anyway (see ectopic pregnancy, incomplete miscarriage, etc).

It might be mildly entertaining to watch them turn themselves into pretzels trying to come up with a legal justification for striking down that law, but that is the sort of entertainment I could do without.

[JohnSJ]

19. Yes

[CTyankee]

24. "You want medical personnel to stand by and watch a woman die before their eyes?"

THAT is the question I would like asked in candidate debates on this issue. Let the right to lifers have to DEFEND this atrocious behavior.

[localroger]

3. This is an executive order, not legislation, I don't think the SC gets to weigh in

This is one of those checks and balances. It's basically the executive saying "you can pass whatever laws you want, but only the ones I agree on will get enforced." It would be a pissing match between the Congress and White House, except Congress hasn't weighed in yet so it's between the Feds and the states. And there's that supremacy clause thingy which, if they go after it too hard, would free up those states that want to pass restrictive gun laws to do whatever they want. Really a clever move within the bounds of what is immediately possible.

[BumRushDaShow]

4. The E.O. is doing what?

Citing a 1986 law.

That is what Executive Orders do - direct Federal agencies with guidance on how to implement existing laws.

(I am a retired fed who worked under 30+ years of whiplash E.O.s )

[localroger]

28. Thanks for the clarification /nt

[Willis88]

11. Executive orders can absolutely be challenged in court

I really like Biden's move on this one and will probably hold under judicial review, but you never know these days at the SC...

[Piratedog]

20. EMTALA is a statute, not an EO.

[localroger]

27. EMTALA is guidance though. EO says it will be enforced per new guidelines /nt.

[BumRushDaShow]

32. "EMTALA is guidance"

"EMTALA" = Emergency Medical Treatment and Active Labor Act = a law that was included as a rider in the -

H.R.5300 - Omnibus Budget Reconciliation Act of 1986

(the appropriations legislation sponsored by my former congressman as a note and inclusion of this was similar to how the Assault Weapon Ban was added to an appropriations bill). The law encoded into statute that include penalties for non-compliance.

The law came about due to hospitals refusing to treat indigent patients who needed emergency care due to lack of insurance and/or money, including throwing them out of the hospital or clinic, often left to die on the street.

Specifically the statue applicable to the law is in 42 USC - 42 U.S. Code § 1395dd -

42 U.S. Code § 1395dd - Examination and treatment for emergency medical conditions and women in labor

U.S. Code


(a) Medical screening requirement

In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (within the meaning of subsection (e)(1)) exists.

(b) Necessary stabilizing treatment for emergency medical conditions and labor

(1) In general

If any individual (whether or not eligible for benefits under this subchapter) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either—

(A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or

(B) for transfer of the individual to another medical facility in accordance with subsection (c).

(snip)

(d) Enforcement

(1) Civil money penalties

(A) A participating hospital that negligently violates a requirement of this section is subject to a civil money penalty of not more than $50,000 (or not more than $25,000 in the case of a hospital with less than 100 beds) for each such violation. The provisions of section 1320a–7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under this subparagraph in the same manner as such provisions apply with respect to a penalty or proceeding under section 1320a–7a(a) of this title.

(B) Subject to subparagraph (C), any physician who is responsible for the examination, treatment, or transfer of an individual in a participating hospital, including a physician on-call for the care of such an individual, and who negligently violates a requirement of this section, including a physician who—

(i) signs a certification under subsection (c)(1)(A) that the medical benefits reasonably to be expected from a transfer to another facility outweigh the risks associated with the transfer, if the physician knew or should have known that the benefits did not outweigh the risks, or

(ii) misrepresents an individual’s condition or other information, including a hospital’s obligations under this section,
is subject to a civil money penalty of not more than $50,000 for each such violation and, if the violation is gross and flagrant or is repeated, to exclusion from participation in this subchapter and State health care programs. The provisions of section 1320a–7a of this title (other than the first and second sentences of subsection (a) and subsection (b)) shall apply to a civil money penalty and exclusion under this subparagraph in the same manner as such provisions apply with respect to a penalty, exclusion, or proceeding under section 1320a–7a(a) of this title.

(snip)

https://www.law.cornell.edu/uscode/text/42/1395dd

[LeftInTX]

29. Executive Orders are frequently shot down by the SC

[Cha]

5. Kick for PJB.. Kick for DEMS!! TY!

Please Fight to Save Our Democracy💙 in 2022 & 2024!

[50 Shades Of Blue]

6. K & R!

[Hugh_Lebowski]

7. While on the one hand I love this, it's necessary and good to remind providers of Federal Law

At the same time I'm concerned with ceding ground like we've been doing, centering efforts around emergency care, and rape/incest when it comes to abortion rights.

Feel like we really need to fight for ALL choice (at least within previously established time limits when it comes to elective abortions), and not get suckered into accepting a shitty compromise on the other side's terms.

Where once I was perhaps willing to consider a X-week limit on elective abortions, I feel like I'm being forced into accepting 'life of the mother' in all cases, and 'rape' if we're really lucky ... and nothing on elective procedures.

And this backsliding feeling is fucking horrible, and I'm not even female. Can't imagine how it feels for my DU sisters, esp. those of child-bearing age

[Novara]

13. This is not ceding ground at all.

This means states can't write laws with no exceptions. This is actually a huge fucking deal and opens the door for more legislation to protect women's rights. This tells the asinine backwards states to suck it.

[Hugh_Lebowski]

61. It's not a 'huge fucking deal' because it's just a reminder that the laws for this already exist

Nothing new has been accomplished here, it's not the 'BFD' of the ACA, which was something just passed at the time Biden called it that.

At the same time, I didn't mean to imply that this notice is directly responsible for my apprehension ... just that I worried to see our side so focused on the much more extreme/rare scenarios of 'life of the mother' and 'rape', generally. I feel like we're being 'set up', collectively, to accept the idea that we should 'settle' for non-elective procedures ... by the other side, not by Biden in this particular instance.

I just really don't like the spot we're collectively in, where we are being forced to accept the proverbial crumbs.

Not saying I have an answer to the SCOTUS being friggin dicks, I'm just saying it worries me, the focus on 'danger to the life of the mother' alone.

I will continue fighting for abortion for whatever reason the woman deems it necessary, within reasonable time limits, as was the case before.

Hope this makes it clear where I stand on this, and sorry for any confusion

[BumRushDaShow]

18. "Feel like we really need to fight for ALL choice"

Until Democrats have 51 Senators willing to kill the filibuster and pass -

H.R.3755 - Women's Health Protection Act of 2021

which passed the House 9/24/21 but was unable to get enough votes to invoke cloture and proceed to regular debate and a vote on 2/28/22, then there is nothing else that can be done but to VOTE the GOP the hell out of office.

The text of that removes the limitations.

A new version was just introduced in the House, post-Roe, on 7/7/22 (from the House - Energy and Commerce Committee) -

H.R.8296 - Women’s Health Protection Act of 2022

[FBaggins]

8. What states does this preempt?

Don't they all have exceptions for life-threatening medical conditions?

[Willis88]

12. No certain or doctors may be afraid to try due to possible prosecution from the state

[Novara]

14. Some asshole wrote a law that would make doctors re-implant ectopic pregnancies

Something that isn't even medically possible. I don't think it was voted on yet.

I don't know which states, but several of them have passed "no exception" bans.

[ecstatic]

63. You have to be kidding. This is sick

They want to run experiments on us now???

[Novara]

64. I am not kidding

I wish I was. They know nothing about women's bodies.

There oughta be a law that lawmakers can't write medical legislation without consulting a panel of doctors first.

[BumRushDaShow]

15. Here is the problem

Post-Roe, exceptions to state abortion bans won’t be easy to acquire

June 24, 2022, 1:24 PM EDT
By Elizabeth Chuck

(snip)

Like the exception in the case of rape and incest, proving that the health of a mother is in danger can be tricky. This too varies state by state, with some focusing on protecting the life of a pregnant person. Other exceptions broaden it out to health as a whole and whether continuing a pregnancy could jeopardize, for example, an organ function.

Arizona’s 15-week abortion ban provides exceptions for emergencies when continuing the pregnancy will “create serious risk of substantial and irreversible impairment of a major bodily function” for the mother. Oklahoma’s recent ban, the most restrictive in the country, is focused on life-threatening situations.

Mental health is almost never seen as enough of a reason to justify an abortion under the laws, said Carol Sanger, professor of law at Columbia University and the author of “About Abortion: Terminating Pregnancy in 21st-Century America.” “Most of the new statutes say that her death has to be a physical death, meaning that she has to be physically ill, not that she’s going to kill herself,” she said.

Even dire situations may give some abortion providers pause in their consideration of the health exception to the ban. With threats of being put in jail for not following the law to the letter or threats that their clinic may get shut down, steering clear of exceptions may feel preferable, even if it leads to dangerous outcomes, Howard said.

(snip)

https://www.nbcnews.com/news/us-news/post-roe-exceptions-state-abortion-bans-wont-easy-acquire-rcna34986

[summer_in_TX]

17. They do...

The problem is that while some conditions are immediately life-threatening, others may not be initially but can go south very quickly.

The big concern is doctors will hesitate, feel like they need to check with their hospitals' lawyers, and in some cases wait for approval and waste time that costs women their lives or leads to permanent health impairments.

This federal directive is excellent, particularly since it cites established law.

[stage left]

45. SC does for the time being

But has a bill in committee with no exceptions.

[FBaggins]

47. I believe the SC "no exceptions" bill is really "no exceptions for rape/incest"

The only change I see to existing law protecting the life of the mother is a documentation requirement to show that the procedure was necessary.

But yes, that still seems like a good fit for this clarification. HHS is making sure that ER doctors don't worry that they'll get burned by an overzealous application of that sort of language.

[DemocraticPatriot]

9. Kick & R

A little good news, for a change!

[flying_wahini]

10. Wonderful news for women with incomplete miscarriages. In Texas women have to wait for deadly

sepsis before the Dr.s would do anything. Once sepsis sets in the woman loses 8% chance of survival every HOUR. Very dangerous to “go home and just wait it out”. I’ve been telling women
to call in with high fever and tell them you took some Tylenol for the fever.
MOST Dr.s just need an excuse to do a D&C.

Just Lie before you die.

[yaesu]

21. well, at least until the 6 fascist kings and queen say different. nt

[OneCrazyDiamond]

22. I didn't think guidance docs were binding.

By definition, guidance documents “do not have the force and effect of law.” Perez v. Mortgage Bankers Ass’n, 575 U.S. 92, 97 (2015) (quoting Shalala v. Guernsey Mem’l Hosp., 514 U.S. 87, 99 (1995)). Unlike rules promulgated through the notice and comment process, therefore, guidance documents do not bind the public and are not treated as binding by the courts.

https://www.justice.gov/jm/1-19000-limitation-issuance-guidance-documents-1


Isn't that what HHS just did?

[BumRushDaShow]

23. HHS is sending a letter to healthcare providers

that reiterates the requirements and statutes found in the Emergency Medical Treatment and Active Labor Act, which requires that healthcare providers treat ANY emergency - including any that may come about due to a pregnancy.

The letter, with examples of medical conditions, including those that are impacting reproductive organs that can constitute the need for "emergency" intervention, with references to this law, can now be used by hospitals, clinics, and practices should state authorities attempt to sue.

[OneCrazyDiamond]

31. I hope it works.

It sure does help tying it to a federal law.

[BumRushDaShow]

34. See here where a portion of the statue was included in the post

https://www.democraticunderground.com/?com=view_post&forum=1014&pid=2941753

Another part of it would be this -

42 U.S. Code § 1395dd - Examination and treatment for emergency medical conditions and women in labor

U.S. Code

(snip)

(e) Definitions

In this section:

(1) The term “emergency medical condition” means—

(A) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in—

(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,

(ii) serious impairment to bodily functions, or

(iii) serious dysfunction of any bodily organ or part; or

(B) with respect to a pregnant woman who is having contractions—

(i) that there is inadequate time to effect a safe transfer to another hospital before delivery, or

(ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.

(snip)

https://www.law.cornell.edu/uscode/text/42/1395dd

The letter underscores to healthcare providers that there ARE laws that require treatment of women who are experiencing reproductive emergencies. The letter linked in the OP notes this -

THE SECRETARY OF HEALTH AND HUMAN SERVICES

WASHINGTON, D.C. 20201

July 11, 2022


VIA ELECTRONIC MAIL

Dear Health Care Providers:

In light of the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, I
am writing regarding the Department of Health and Human Services (HHS) enforcement of the
Emergency Medical Treatment and Active Labor Act (EMTALA). As frontline health care
providers, the federal EMTALA statute protects your clinical judgment and the action that you
take to provide stabilizing medical treatment to your pregnant patients, regardless of the
restrictions in the state where you practice.

(snip)

Emergency medical conditions involving pregnant patients may include, but are not limited to, ectopic
pregnancy, complications of pregnancy loss, or emergent hypertensive disorders, such as
preeclampsia with severe features. Any state laws or mandates that employ a more restrictive
definition of an emergency medical condition are preempted by the EMTALA statute.

The course of treatment necessary to stabilize such emergency medical conditions is also under
the purview of the physician or other qualified medical personnel. Stabilizing treatment could
include medical and/or surgical interventions (e.g., abortion, removal of one or both fallopian
tubes, anti-hypertensive therapy, methotrexate therapy etc.), irrespective of any state laws or
mandates that apply to specific procedures.

Thus, if a physician believes that a pregnant patient presenting at an emergency department,
including certain labor and delivery departments, is experiencing an emergency medical
condition as defined by EMTALA, and that abortion is the stabilizing treatment necessary to
resolve that condition, the physician must provide that treatment. And when a state law prohibits
abortion and does not include an exception for the life and health of the pregnant person — or
draws the exception more narrowly than EMTALA’s emergency medical condition definition —
that state law is preempted.

The enforcement of EMTALA is a complaint driven process. The investigation of a hospital’s
policies/procedures and processes, or the actions of medical personnel, and any subsequent
sanctions are initiated by a complaint. If the results of a complaint investigation indicate that a
hospital violated one or more of the provisions of EMTALA, a hospital may be subject to
termination of its Medicare provider agreement and/or the imposition of civil monetary penalties.
Civil monetary penalties may also be imposed against individual physicians for EMTALA
violations. Additionally, physicians may also be subject to exclusion from the Medicare and
State health care programs. To file an EMTALA complaint, please contact the appropriate state
survey agency2.

(snip)

https://www.hhs.gov/sites/default/files/emergency-medical-care-letter-to-health-care-providers.pdf (PDF)

[OneCrazyDiamond]

50. I think it is the right thing to do

Given the circumstances.

I just think, yeah but the extreme court won't let the EPA regulate CO2, and they they ones who put us in this mess. I could totally see them get offended by the HHS guidance and block it too. There are certainly enough people willing to fight this up to their domain, and they are emboldened now.

[BumRushDaShow]

52. Well in the case of the EPA & CO2

EPA was acting based on what has happened to the environment with what was originally dubbed "global warning" and later "climate change", since passage of the Clean Air Act of 1970. And in that case, that Act will really need to be updated (which is a struggle) so that their authority is more codified. The last update to that happened in 1990 and I *know* stuff has changed since then! Hell, Al Gore had a book and film on that in 2006 ( "An Inconvenient Truth:...." )!

In the case of what HHS is doing - they are referencing an existing law that was designed to keep hospitals from throwing people out into the streets without stabilizing them or getting them someplace to stabilize them or lose their Medicare reimbursement.

The "guidance" defining certain examples of medical emergencies that would apply based on the law, is to assuage the affected medical staff who night opt to withhold obstetric-gynecological care if they fear being prosecuted by their state.

[FBaggins]

37. Not "clinics and practices"

EMTALA applies to hospitals with emergency rooms that accept Medicare. Not all medical practices.

[BumRushDaShow]

39. Yes - any entity that accepts federal funding - notably Medicare

It's in the OP text of the Press Release -

The EMTALA statute requires that Medicare hospitals provide all patients an appropriate medical screening, examination, stabilizing treatment, and transfer, if necessary, irrespective of any state laws or mandates that apply to specific procedures.

HOWEVER the statute also says this and indicates options for "other medical facility", not specifying 'hospital" -

(b) Necessary stabilizing treatment for emergency medical conditions and labor

(1) In general

If any individual (whether or not eligible for benefits under this subchapter) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either—

(A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or

(B) for transfer of the individual to another medical facility in accordance with subsection (c).

(snip)

(c) Restricting transfers until individual stabilized

(1) Rule

If an individual at a hospital has an emergency medical condition which has not been stabilized (within the meaning of subsection (e)(3)(B)), the hospital may not transfer the individual unless—

(A)

(i) the individual (or a legally responsible person acting on the individual’s behalf) after being informed of the hospital’s obligations under this section and of the risk of transfer, in writing requests transfer to another medical facility,

(ii) a physician (within the meaning of section 1395x (r)(1) of this title) has signed a certification that [1] based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual and, in the case of labor, to the unborn child from effecting the transfer, or

(iii) if a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as defined by the Secretary in regulations) has signed a certification described in clause (ii) after a physician (as defined in section 1395x (r)(1) of this title), in consultation with the person, has made the determination described in such clause, and subsequently countersigns the certification; and

(B) the transfer is an appropriate transfer (within the meaning of paragraph (2)) to that facility.

A certification described in clause (ii) or (iii) of subparagraph (A) shall include a summary of the risks and benefits upon which the certification is based.

(snip)

https://www.law.cornell.edu/uscode/text/42/1395dd

I.e., you have hospitals that don't have "emergency rooms/departments" and they would be a case of still making an attempt to "stabilize" and then TRANSFER the patient to some "other facility" to receive care.

[FBaggins]

40. Abortion clinics can't receive federal funding

My point is that there can't be an abortion clinic in some state using this guidance to preempt state law and remain in business.

A covered hospital without the ability to provide the specific care needed could transfer a patient to one that otherwise wouldn't be covered by EMTALA, but I can't imagine a hospital ER that can't provide that care nor a situation where a specialist could remain in business in a state that otherwise bans abortion to receive such transfers.

The guidance is really quite narrow. I'm having trouble thinking of cases that would result in an abortion that wouldn't already be allowed under the laws of the state with abortion restrictions.

[BumRushDaShow]

41. Nowhere do I say "abortion clinics"

because obviously states with laws banning abortion, have effectively closed those facilities down.

This does NOT preclude facilities that handle OB-GYN services.

And again, you have some small/rural hospitals that HAVE NO ER and they have to transfer - and that ends up being a huge cost for the patient - on average $10,000 by medivac as an example. We saw that happen with COVID-19 where rural red counties were shunting their emergency patients into the city hospitals and even sending them to other states.

Just stop.

[FBaggins]

42. OB-GYNs transfer emergency patients to hospital ERs, not the other way around

I'm having a tough time imagining a scenario where an abortion is required by a medical emergency and a hospital with an ER is less equipped to deal with it than an ob-gyn outside the hospital.

But either way - the law doesn't refer to other facilities except those that receive transfers from a covered hospital. It doesn't give a non-ER doctor cover to say "I had to perform the procedure under EMTALA".

And again, you have some small/rural hospitals that HAVE NO ER and they have to transfer

They aren't covered by EMTALA. b.1.B doesn't refer to "hospitals that have no ER" because hospitals without an ER aren't covered by EMTALA at all.

What you have yet to point to is a scenario that begins with something other than a patient presenting at a hospital with an ER that has an existing agreement with HHS.

[BumRushDaShow]

43. You are again missing the full depth and breadth of what can happen to a woman

And again, you have some small/rural hospitals that HAVE NO ER and they have to transfer

They aren't covered by EMTALA.

If that hospital can't treat them, then they are required to transfer to someplace that CAN. That was my point (including giving the COVID-19 example).

And if that EMTALA hospital has no one on staff to handle the gynecological emergency, there are provisions to again TRANSFER. As a sad note, I know a number of hospitals with emergency departments, don't have maternity wards (including the hospital close to me although they do have an associated "Women's Center" that does diagnostic tests like mammograms, dexa scans, biopsies, and certain gynecological surgical procedures).

The whole point is not to "dump" patients out into the streets.

I don't know if you are a woman or not but there are certain procedures that can be and are routinely done outside of emergency rooms including what women-in-the-know had before ROE - D & Cs - Dilation and Curettage -

A dilation and curettage procedure, also called a D&C, is a surgical procedure in which the cervix (lower, narrow part of the uterus) is dilated (expanded) so that the uterine lining (endometrium) can be scraped with a curette (spoon-shaped instrument) to remove abnormal tissues.

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/dilation-and-curettage-d-and-c

During the procedure

A D&C may be performed in a doctor’s office, on an outpatient basis, or as part of your stay in a hospital. Procedures may vary depending on your condition and your doctor’s practices.

The type of anesthesia will depend on the specific procedure being performed. Some D&C procedures may be performed while you are asleep under general anesthesia, or while you are awake under spinal or epidural anesthesia. If spinal or epidural anesthesia is used, you will have no feeling from your waist down. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/dilation-and-curettage-d-and-c

My own mother was plagued with fibroids in her uterus and breasts and had to have multiple D&Cs during her child-bearing days. These procedures were OUTPATIENT. Finally, her gynecologist recommended that she go on and have a hysterectomy, which she did in 1972 at age 42 but since that was BEFORE ROE, she had to FUCKING HAVE MY FATHER CONSENT TO IT.

And 14 years ago, I experienced sudden sharp pains near my bladder, got the dildo cam (trans-vagnial ultrasound), and was diagnosed with a 2+" cyst on one of my ovaries. The young resident (who was an D.O., NOT a GYN) was freaking and wanted to immediately transfer me from my local hospital that DID have an emergency room, to a different one (she was fearing ovarian cancer). I wasn't biting and eventually talked to an OB-GYN surgeon (who was head of the department) and we went over the options. A week later I got EVERYTHING removed, what they call a hysterectomy with bilateral salpingo oophorectomy, and with the cervix removed. Thankfully no cancer.

I am sick of fucking loon men getting into my reproductive decisions. If men bled one a month for a week or more, over a course of upwards of 50 years of their lives, the entire situation, including the work environment and medical leave, would be different.

[FBaggins]

51. I don't disagree with the vast majority of what you're saying

I'm certainly not going to argue that men should get to make your reproductive decisions.

Nor am I arguing that there aren't lots of medical procedures that are routinely done outside of emergency rooms.

What I am saying is that those aren't covered by this law. No "clinics and practices" or "other entities" will be able to ignore state law on the basis of a claim that EMTALA requires the care to be provided.

As the guidance itself says:

The Emergency Medical Treatment and Labor Act (EMTALA) provides rights to any individual who comes to a hospital emergency department and requests examination or treatment.

https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/reinforcement-emtala-obligations-specific-patients-who-are-pregnant-or-are-experiencing-pregnancy-0

If you can think of a hypothetical where such an ER can't perform some specific procedure but it would nevertheless count as an emergency that's fine, but such would be exceedingly rare if they exist at all. The fact that some other facility can perform the procedure doesn't change the fact that EMTALA only applies if a woman shows up at a covered ER with an emergency. It can't provide other doctors with cover to perform procedures banned by state law.

If that hospital can't treat them, then they are required to transfer to someplace that CAN

That's incorrect. EMTALA does not require a rural hospital lacking ER facilities to transfer patients to other hospitals that do have ERs. If the hospital doesn't have an ER (or even one that does but doesn't accept Medicare), then they aren't covered by the law at all. The law creates an obligation that a hospital ER can't turn away emergencies for lack of an ability to pay... but it does not create a right that any doctor must treat any emergency case.


On edit - I note the following from the guidance:

If an emergency medical condition is found to exist, the hospital must provide available stabilizing treatment or an appropriate transfer to another hospital that has the capabilities to provide stabilizing treatment

This does not appear to include any outside clinics or other providers. Just another hospital.

[BumRushDaShow]

53. Regarding this

If you can think of a hypothetical where such an ER can't perform some specific procedure but it would nevertheless count as an emergency that's fine,

Then why do you keep arguing this? What HHS is doing is providing OPTIONS for those in states that have hauled off and willy nilly attempted to remove exceptions or that have fuzzy exceptions.

NONE OF THIS IS AN ISSUE in states that have not tried to ban abortions or other potential reproductive services that some fucking loon might think "is an abortion".

but such would be exceedingly rare if they exist at all.

WTF? With COVID-19 running rampant in some parts of the country and emergency rooms filling up, what the hell happens to a woman who goes to a hospital with COVID patients lining the hallways and there's no one to handle her ectopic pregnancy or excessive bleeding from endometriosis in her uterus and around abdomen (that happened to me in addition to the ovarian cycst) where she is bleeding continually?

You say FUCK YOU and let her bleed all over the floor?

The fact that some other facility can perform the procedure doesn't change the fact that EMTALA only applies if a woman shows up at a covered ER with an emergency. It can't provide other doctors with cover to perform procedures banned by state law.

Again - if there is a need to TRANSFER - there is the option to do so.

(b) Necessary stabilizing treatment for emergency medical conditions and labor

(1) In general

If any individual (whether or not eligible for benefits under this subchapter) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either—

(A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or

(B) for transfer of the individual to another medical facility in accordance with subsection (c).

(snip)

(c) Restricting transfers until individual stabilized

(1) Rule

If an individual at a hospital has an emergency medical condition which has not been stabilized (within the meaning of subsection (e)(3)(B)), the hospital may not transfer the individual unless—

(A)

(i) the individual (or a legally responsible person acting on the individual’s behalf) after being informed of the hospital’s obligations under this section and of the risk of transfer, in writing requests transfer to another medical facility,

(ii) a physician (within the meaning of section 1395x (r)(1) of this title) has signed a certification that [1] based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual and, in the case of labor, to the unborn child from effecting the transfer, or

(iii) if a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as defined by the Secretary in regulations) has signed a certification described in clause (ii) after a physician (as defined in section 1395x (r)(1) of this title), in consultation with the person, has made the determination described in such clause, and subsequently countersigns the certification; and

(B) the transfer is an appropriate transfer (within the meaning of paragraph (2)) to that facility.

A certification described in clause (ii) or (iii) of subparagraph (A) shall include a summary of the risks and benefits upon which the certification is based.

(snip)

https://www.law.cornell.edu/uscode/text/42/1395dd

[FBaggins]

54. You may have started your reply before my "on edit"

The transfer has to be to another hospital ER. There isn't an option for a COVID-overloaded ER to transfer the patient to a local gynecologist.

If an emergency medical condition is found to exist, the hospital must provide available stabilizing treatment or an appropriate transfer to another hospital that has the capabilities to provide stabilizing treatment

Just as clearly - that gynecologist wouldn't be "covered" even if they could receive the transfer. There is no obligation that doctors in general must provide emergency services. The law created an obligation to serve emergency patients and not dump them elsewhere. The exception to that "no dumping" provision does not create a federal right to receive care somewhere else that preempts state laws.

[BumRushDaShow]

55. It does not say "ER".

It ticks off stipulations on approval of the transfer "to another facility" and who can authorize it. I.e., a reference to certifications to move "by a physician (within the meaning of section 1395x (r)(1)".

42 U.S. Code § 1395x - Definitions

(r) Physician

The term “physician”, when used in connection with the performance of any function or action, means (1) a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he performs such function or action (including a physician within the meaning of section 1301(a)(7) of this title), (2) a doctor of dental surgery or of dental medicine who is legally authorized to practice dentistry by the State in which he performs such function and who is acting within the scope of his license when he performs such functions, (3) a doctor of podiatric medicine for the purposes of subsections (k), (m), (p)(1), and (s) of this section and sections 1395f(a), 1395k(a)(2)(F)(ii), and 1395n of this title but only with respect to functions which he is legally authorized to perform as such by the State in which he performs them, (4) a doctor of optometry, but only for purposes of subsection (p)(1) and with respect to the provision of items or services described in subsection (s) which he is legally authorized to perform as a doctor of optometry by the State in which he performs them, or (5) a chiropractor who is licensed as such by the State (or in a State which does not license chiropractors as such, is legally authorized to perform the services of a chiropractor in the jurisdiction in which he performs such services), and who meets uniform minimum standards promulgated by the Secretary, but only for the purpose of subsections (s)(1) and (s)(2)(A) and only with respect to treatment by means of manual manipulation of the spine (to correct a subluxation) which he is legally authorized to perform by the State or jurisdiction in which such treatment is provided. For the purposes of section 1395y(a)(4) of this title and subject to the limitations and conditions provided in the previous sentence, such term includes a doctor of one of the arts, specified in such previous sentence, legally authorized to practice such art in the country in which the inpatient hospital services (referred to in such section 1395y(a)(4) of this title) are furnished.

https://www.law.cornell.edu/uscode/text/42/1395x

Again, the whole point is to provide stabilizing treatment and if they can't, then they have to transfer to someone who can provide that, and as far as we know, it could be out-of-state as well.

that gynecologist wouldn't be "covered"

Why wouldn't a gynecologist be covered?

It's obvious you are going in circles and are unfamiliar with medical issues that women go through. One of the leading causes of maternal death among black women is preeclampsia, which is an extreme condition of high blood pressure -

Preeclampsia is one of the leading causes of maternal deaths worldwide, with Black women three to four times more likely to die from pregnancy-related causes than white women, according to the U.S. Centers for Disease Control and Prevention. Preeclampsia affects approximately 1 in 25 pregnancies in the U.S, and those who experience it have an increased risk of developing chronic hypertension and cardiovascular disease later in life.

https://www.hopkinsmedicine.org/news/newsroom/news-releases/us-born-black-women-at-higher-risk-of-preeclampsia-than-foreign-born-counterparts-race-alone-does-not-explain-disparity

So you may have situations where the closest facility is an URGENT CARE (not a hospital ER) and they have facilities that actually are Medicare-eligible facilities.

[FBaggins]

56. I gave you the text from the current HHS notice

Last edited Tue Jul 12, 2022, 11:38 AM - Edit history (2)

It clearly says "to another hospital". The communication is also addressed to hospital staff for covered hospitals... not all medical providers in the state.

If you want to call HHS and tell them that they don't understand the law... feel free. I suspect you'll find that you're cherry-picking text defined in sections you aren't citing.

I've found several additional sourced on this point:

EMTALA governs how patients are transferred from one hospital to another. Under the law, a patient is considered stable for transfer if the treating physician determines that no material deterioration will occur during the transfer between facilities.

https://www.acep.org/life-as-a-physician/ethics--legal/emtala/emtala-fact-sheet/#:~:text=EMTALA%20governs%20how%20patients%20are,during%20the%20transfer%20between%20facilities.

The second legal requirement of EMTALA is regarding patient stabilization and treatment. If the patient has been found to have an emergency medical condition, they must stabilize the patient. The hospital can alternatively transfer the patient to another hospital.

https://www.ncbi.nlm.nih.gov/books/NBK557812/

Why wouldn't a gynecologist be covered?

Because the law does not apply to gynecologists who are not part of a hospital ER. The law doesn't currently apply to other doctors. If you imagine a broken leg coming in to a busy hospital ER and they know that the GP across the street can set a broken bone... that wouldn't mean that said GP has to provide the service (and thus couldn't use the law as "cover" for providing the service if some state outlawed it.)

Remember that the point here is to be able to say federal law requires certain treatment options in an emergency so state law is preempted in those circumstances. It is therefore critical to understand when federal law requires emergency treatment and on whom those requirements rest. Other medical providers who could provide the service aren't helped in this regard if it can't be shown that the law requires them to do so. EMTALA only places that burden on hospital ERs that accept Medicare. Even if we can imagine a circumstance where someone might otherwise be transferred to a different type of facility - that (non ER) doctor couldn't claim that they were required by federal law to provide the emergency service.


It's obvious you are going in circles and are unfamiliar with medical issues that women go through.

And that's the thing. I don't need to be familiar with women's medical issues to read the law.

[BumRushDaShow]

57. And I gave you the text to the statute that they are referencing

If you want to call HHS and tell them that they don't understand the law... feel free. I suspect you'll find that you're cherry-picking text defined in sections you aren't citing.

And as a note, I used to work under HHS for 3 decades before retiring, but nice try.

Much of this is being done because doctors and other healthcare providers are terrified of being sued for providing medical care for women undergoing emergencies that are impacting their reproductive system, including if that treatment might require removal of an embryo or fetus.

The point of that HHS document was to underscore that doctors treat/stabilize or transfer women who are undergoing a medical emergency - including one that involves her reproductive system or transfer them to someplace that can, and this applies if the state law has a "narrower definition" than the current federal statute.

This was also a warning shot across the bow of extremist legislators who are cooking up even more extreme prohibitions of specific procedures, to suggest they think twice. For example, some nonsense was introduced a few years ago in OH where one bill was drafted to "re-implant an ectopic fetus or face murder charges.

Why wouldn't a gynecologist be covered?

Because the law does not apply to gynecologists who are not part of a hospital ER.

You outright claimed earlier that gynecologists weren't eligible at all. Now you have walked that back.

Remember that the point here is to be able to say federal law requires certain treatment options in an emergency so state law is preempted in those circumstances

And THAT is what I have been saying all along.

And that's the thing. I don't need to be familiar with women's medical issues to read the law.

And THAT has been the problem in this country when it comes to women and their healthcare needs.

[FBaggins]

58. No you didn't. You gave me your own *interpretation* of a piece of the text.

You can now see that how HHS interprets it contradicts your own reading (backed up by multiple citations).

in OH where one bill was drafted to "re-implant an ectopic fetus or face murder charges.

Which is ridiculous on its face (I doubt that it's even possible).

You outright claimed earlier that gynecologists weren't eligible at all. Now you have walked that back.

That's not even a plausible claim. The clear context was that of hospital ER's transferring to someone else. All gynecologists that meet that description are outside the bounds of the law in question. If there's an ob-gyn who also works in a covered hospital's ER, then she is covered by the law while she's in the ER. But it doesn't help her at all in her private practice.

And THAT is what I have been saying all along.

And I haven't seen anyone disagree with you on that point. But you said (in #22) that the letter was being sent to "healthcare providers" and that it "can now be used by hospitals, clinics, and practices". I corrected you (in #37) that it actually wasn't sent to (and didn't apply to) "clinics and practices" - just hospitals with ERs that accept Medicare. You replied that it was instead "any entity that accepts federal funding"

That simply isn't true.

Just as importantly - even if you were correct that the transfer could be to somewhere other than another covered hospital. It still doesn't help your position. Because receiving such a patient doesn't mean that the receiving facility is now required by EMTALA to provide emergency care. They might choose to provide it, but state law is only preempted when federal law requires the treatment. And EMTALA only arguably provides such a requirement to covered hospitals.

There there's this:

(f)Preemption The provisions of this section do not preempt any State or local law requirement, except to the extent that the requirement directly conflicts with a requirement of this section.

"Directly conflicts" could be a tough standard to get by an unsympathetic court.

[BumRushDaShow]

59. And my last reply before the hearing starts since I'm hosting the live threads

No you didn't. You gave me your own *interpretation* of a piece of the text.

I actually posted the statute portions multiple times in this thread.

You can now see that how HHS interprets it contradicts your own reading (backed up by multiple citations).

And once again, the Secretary's point is to notify healthcare providers of their duties under that statute when it comes to determining their state law applicability and how to act appropriately. And this is because for the hundredth time, these medical practitioners are having issues with what happens if they receive a patient undergoing a reproductive emergency.

in OH where one bill was drafted to "re-implant an ectopic fetus or face murder charges.

Which is ridiculous on its face (I doubt that it's even possible).

Regardless of whether something is "possible or not", when you have extremists elected to office, they can and have passed bills into law that are crap. A case in point are the so-called "heat beat laws" that insist that elecctrical activity in an embryonic circulatory system, is somehow a "heart" that is "beating". Myriads of physcians have and continuet to protest this, but these states pass this stuff into law anyway.

You outright claimed earlier that gynecologists weren't eligible at all. Now you have walked that back.

That's not even a plausible claim. The clear context was that of hospital ER's transferring to someone else. All gynecologists that meet that description are outside the bounds of the law in question.

This is what you posted -

Just as clearly - that gynecologist wouldn't be "covered" even if they could receive the transfer.

And THAT is what I have been saying all along.

And I haven't seen anyone disagree with you on that point. But you said (in #22) that the letter was being sent to "healthcare providers" and that it "can now be used by hospitals, clinics, and practices". I corrected you (in #37) that it actually wasn't sent to (and didn't apply to) "clinics and practices" - just hospitals with ERs that accept Medicare. You replied that it was instead "any entity that accepts federal funding"

That simply isn't true.

You apparently haven't been in hospitals that have affiliates with "group practices" - whether LITERALLY inside the main buildings or on the campus of the hospital and/or as part of "health systems", that include all the pieces and parts that go along with providing "emergency care". That includes anesthesiologists, surgeons, and others who are on the staff of those hospitals and maintain offices within them.

[FBaggins]

60. Ok. Hope the hosting goes well. I'll try to drop in.

I actually posted the statute portions multiple times in this thread.

Did you post a portion of the statute defining "another medical facility" as something other than "another hospital" (or at all)? Did you provide any language saying that this other facility was also required to provide emergency care?

You did neither. And without both, your argument falls.

In all of the CMS guidance that I've found so far. the "other facility" is universally described as the "receiving hospital"

once again, the Secretary's point is to notify healthcare providers of their duties

Yes - and you portrayed that notification as covering all healthcare providers rather than just those working in a hospital that has an ER and participates in Medicare. The secretary's letter tries really hard to leave people with that impression. But the actual EMTALA guidance makes clear which medical providers actually have that duty.

This is what you posted -

Just as clearly - that gynecologist wouldn't be "covered" even if they could receive the transfer.

And THAT is what I have been saying all along.

??? Perhaps you read that as "would be covered"? The point is that nothing in EMTALA creates an obligation on a receiving facility even if we imagine that a transfer could be to anywhere. The obligation is on the covered hospitals. Nothing in the law would provide cover for a gynecologist across town to say "I'm required to provide emergency care by federal law"... because she isn't so required unless she's working in a covered hospital with an ER.


whether LITERALLY inside the main buildings or on the campus of the hospital

I haven't challenged what might count as part of the hospital. I clearly said that hospitals with ERs that receive medicare are covered by EMTALA. But we can't say "she's a gynecologist with a practice across town but she has admitting privileges at the hospital, so she has to provide emergency services in her own practice".

[Bayard]

25. BIG K&R!

[iluvtennis]

26. *2. n/t

[betsuni]

30. K&R

[AZLD4Candidate]

33. Tell me we're going to go through another nullification crisis!

[BumRushDaShow]

35. They will be playing with fire if that happens...

[Skittles]

36. healthcare folk should not fear being sued

Biden needs to do what has to be done to ensure women receive the care they need.

[BumRushDaShow]

38. Per what I posted above from the statute associated with the "EMTALA" that is referenced

https://www.democraticunderground.com/?com=view_post&forum=1014&pid=2941753

hospitals/clinics/providers will be fined if they DON'T provide the care and the state law will be preempted.

42 U.S. Code § 1395dd - Examination and treatment for emergency medical conditions and women in labor

U.S. Code


(a) Medical screening requirement

In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter) comes to the emergency department and a request is made on the individual’s behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (within the meaning of subsection (e)(1)) exists.

(b) Necessary stabilizing treatment for emergency medical conditions and labor

(1) In general

If any individual (whether or not eligible for benefits under this subchapter) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either—

(A) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or

(B) for transfer of the individual to another medical facility in accordance with subsection (c).

(snip)

(d) Enforcement

(1) Civil money penalties

(A) A participating hospital that negligently violates a requirement of this section is subject to a civil money penalty of not more than $50,000 (or not more than $25,000 in the case of a hospital with less than 100 beds) for each such violation. The provisions of section 1320a–7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under this subparagraph in the same manner as such provisions apply with respect to a penalty or proceeding under section 1320a–7a(a) of this title.

(B) Subject to subparagraph (C), any physician who is responsible for the examination, treatment, or transfer of an individual in a participating hospital, including a physician on-call for the care of such an individual, and who negligently violates a requirement of this section, including a physician who—

(i) signs a certification under subsection (c)(1)(A) that the medical benefits reasonably to be expected from a transfer to another facility outweigh the risks associated with the transfer, if the physician knew or should have known that the benefits did not outweigh the risks, or

(ii) misrepresents an individual’s condition or other information, including a hospital’s obligations under this section,
is subject to a civil money penalty of not more than $50,000 for each such violation and, if the violation is gross and flagrant or is repeated, to exclusion from participation in this subchapter and State health care programs. The provisions of section 1320a–7a of this title (other than the first and second sentences of subsection (a) and subsection (b)) shall apply to a civil money penalty and exclusion under this subparagraph in the same manner as such provisions apply with respect to a penalty, exclusion, or proceeding under section 1320a–7a(a) of this title.

(snip)

https://www.law.cornell.edu/uscode/text/42/1395dd

[ancianita]

44. A thousand thanks for all the links, B!

[BumRushDaShow]

46. LOL

YW given that I have been using my convertible laptop for about a week since my main one needs a hard drive swap (finally got the new one in and will need to disassemble, clone, and reassemble - actually did that before with my main laptop after the original drive started failing after the 1st year, although my replacement gave me 4 more years).

My convertible is mounted on a clamp and I had a small bluetooth chiclet type keyboard that I paired with it, but that was a PITA to type on for long periods (it was really because I mainly use this to stream or if I go outside to web surf), so I got a foldable bigger one last week that I am getting used to in the interim (also finally got an ergonomic mouse too).

Ironically, my convertible has the same CPU and has more RAM than the main one, plus has a SSD hard drive, but that drive is only about 1/2 the size and the screen is a couple inches smaller.

[ancianita]

48. RIGHT?!

You could do this with one hand tied behind your back! You make it all make total sense! I get it!

And am so grateful!

[BumRushDaShow]

49. HA!

( *pulls out the tube of Aspercreme* )

[ecstatic]

62. Assuming doctors with that skillset will even hang around the Gilead states

What good is emergency care protection if none of the doctors know how to do it?