Owens v. Nacogdoches County Hosp. Dist.

• Citation: 741 F. Supp. 1269
• Decision Date: 26 June 1990
• Docket Number: Civ. A. No. L-87-97-CA.
• Parties: Betty OWENS and Rebecca Owens by her next friend Betty Owens, Plaintiffs, v. NACOGDOCHES COUNTY HOSPITAL DISTRICT, d/b/a Memorial Hospital, et al., Defendants.
• Court: U.S. District Court — Eastern District of Texas

741 F. Supp. 1269

Betty OWENS and Rebecca Owens by her next friend Betty Owens, Plaintiffs, v. NACOGDOCHES COUNTY HOSPITAL DISTRICT, d/b/a Memorial Hospital, et al., Defendants.

Civ. A. No. L-87-97-CA.

United States District Court, E.D. Texas, Lufkin Division.

June 26, 1990.

COPYRIGHT MATERIAL OMITTED

Brenda Willett (Beverly Luna, of counsel), East Texas Legal Services, Nacogdoches, Tex., for plaintiffs.

David L. Allen, Zeleskey, Cornelius, Rogers, Hallmark & Borgfeld, Lufkin, Tex., for defendants.

MEMORANDUM OPINION

JUSTICE, District Judge.

On August 3, 1987, Rebecca Owens, a sixteen year old indigent resident of Nacogdoches County whose pregnancy was full term, began to experience labor pains. She went to the emergency room at Memorial Hospital in Nacogdoches at approximately 3:00 p.m. After initial processing, she was taken to the Labor and Delivery room, where she was examined by Dr. Bruce Thompson, who was under contract with Memorial Hospital to provide obstetric and gynecological care to indigent pregnant women. After approximately one-half hour, Dr. Thompson discharged Ms. Owens with instructions that she go to John Sealy Hospital in Galveston, Texas — a facility approximately two hundred miles and four hours driving time away — to deliver her baby. On the night of August 3, this court, upon the petition of Rebecca Owen's mother and next friend Betty Owens, issued a temporary restraining order enjoining Memorial Hospital from refusing to admit Rebecca Owens for the purpose of delivering her baby. On August 7, 1987, four days after the issuance of the temporary restraining order, Rebecca Owens was admitted to Memorial Hospital, where Dr. Bruce Thompson delivered her baby. Plaintiff has brought suit against the hospital and its board of directors in their official capacities, seeking damages, and declaratory and injunctive relief pursuant to 42 U.S.C. § 1395dd, the Emergency Medical Treatment and Active Labor Act, which forms part of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA).

It is clear beyond peradventure first, that no attempt was made by defendant hospital to comply with the transfer requirements of § 1395dd; second, that the sole reason for the instruction to Rebecca Owens to go to John Sealy Hospital was that she was without funds; third, that this action constituted "dumping," the very evil which § 1395dd was designed to prevent; fourth, that this incident was not an isolated one, but part of a pattern of dumpings of indigent patients that continued virtually until the time of trial in this civil action — a pattern caused by the unwillingness of defendant hospital to take the steps requisite for adequate performance of its statutory responsibilities for the care of indigent patients under both federal and state law; and finally, that what occurred to Rebecca Owens is capable of repetition, yet might evade review. Accordingly, judgment in this civil action will be entered for plaintiff, damages and attorney's fees in accordance with the stipulation of the parties will be awarded to her, and defendant hospital will be permanently enjoined from refusing her delivery in any future pregnancy in violation of 42 U.S.C. § 1395dd.

I. Background—42 U.S.C. § 1395dd

The Emergency Medical Treatment and Active Labor Act, sometimes referred to as the Anti-Dumping Act, was enacted by Congress as part of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA), and codified at 42 U.S.C. § 1395dd. The Act was a response to a national epidemic of "dumping," the practice by hospitals of refusing emergency care to indigent patients outright or of transferring such patients, without regard to the necessity for stabilizing their condition, to other — typically public — hospitals. See generally McClurg, Your Money Or Your Life: Interpreting the Federal Act against Patient Dumping, 24 Wake Forest L.Rev. 173 (1989); Note, Preventing Patient Dumping: Sharpening the COBRA's Fangs, 61 N.Y.U.L. Rev. 1186 (1986).

The extent and severity of patient dumping has been increasing in recent years, and the act is the latest governmental attempt to deal with the phenomenon. Other attempts have been made both by Congress —notably in the Hill-Burton Act, which requires hospitals which have received certain Federal funds to provide necessary emergency care to all residents of the community served by the hospitals — and by various state legislatures, including that of the State of Texas.

The rationale behind the bill is plainly explained in the legislative history by the Report of the House Committee on the Judiciary:

In recent years there has been a growing concern about the provision of adequate emergency room medical services to individuals who seek care, particularly as to the indigent and uninsured. Although at least 22 states have enacted statutes or issued regulations requiring the provision of limited medical services whenever an emergency situation exists, and despite the fact that many state court rulings impose a common law duty on doctors and hospitals to provide necessary emergency care, some are convinced that the problem needs to be addressed by federal sanctions.

1986 U.S.Code Cong.Admin.News Vol. 3, p. 728.

To address these problems, 42 U.S.C. § 1395dd requires that any hospital with an emergency room must provide a medical screening examination to any patient who appears complaining of an emergency medical condition. It further provides that such patients cannot be transferred to another facility in an unstable condition, and requires that such a transfer be "appropriate." The guidelines for an appropriate transfer are that the physician certify in writing that the benefits of such transfer outweigh the risk, that the transferring hospital provide the medical treatment necessary to minimize the risk to the health of the patient (which includes, in the case of a woman in labor, the health of the child as well as the mother), that the transferring hospital send the relevant records in its possession with the patient, that the transferring hospital obtain the assurance of the receiving hospital that the receiving hospital has space and facilities for the patient and has accepted the transfer, and that the transfer "is effected through qualified personnel and transportation equipment, as required including the use of necessary and medically appropriate life support measures."

In order to make clear what the responsibilities of the physician and the transferring hospital are, the act includes definitional sections which establish what is meant by an "emergency medical condition" and "active labor." For the purpose of this civil action, the relevant section is 42 U.S.C. § 1395dd(e)(2),¹ and particularly 42 U.S.C. § 1395dd(e)(2)(C):

(2) The term "active labor" means labor at a time at which —

(A) delivery is imminent,

(B) there is inadequate time to effect safe transfer to another hospital prior to delivery, or

(C) a transfer may pose a threat to the health or safety of the patient or the unborn child.

The definitional section of the act clearly establishes the basis for judging the acts of the physician and hospital. That is, the physician cannot, by a mere assertion that in his judgment neither an emergency medical situation nor active labor exists, evade or negate the plain intent of the statute. To hold otherwise would render the statutory scheme merely precatory, which, as the above citation of the history of the act makes clear, is not what Congress intended.

The act provides for a variety of sanctions to enforce its provisions, including termination or suspension of the defendant hospital's medicare provider agreement, civil monetary penalties, and the establishment of causes of action for both patients who are dumped and hospitals which receive dumped patients. The basis for this civil action is the first of the civil enforcement sections, § 1395dd(d)(3)(A):

(A) Personal harm. Any individual who suffers personal harm as a direct result of a participating hospital's violation of a requirement of this section may, in a civil action against the participating hospital, obtain those damages available for personal injury under the law of the State in which the hospital is located, and such equitable relief as is appropriate.

The cause of action established by this section is plainly a Federal one, cognizable in a United States District Court. Bryant v. Riddle Memorial Hospital, 689 F.Supp. 490 (E.D.Pa.1988); Stewart v. Myrick, 731 F.Supp. 433 (Kansas 1990). The statute permits a patient injured by dumping to recover for her own injuries, and essentially to vindicate the purpose of the statute, which as it was described by Judge Newcomer in his scholarly discussion of Congressional intent, is to "establish ... a series of federal guidelines which medicare hospitals having emergency medical care must follow to prevent the problem of patient dumping." Bryant v. Riddle Memorial Hospital, 689 F.Supp. 490, 493 (E.D. Pa.1988). Accordingly, this court has federal question jurisdiction over this civil action, and Rebecca Owens has standing to maintain it.

II. Narrative of Events

Rebecca Owens, a sixteen year old indigent female resident of Nacogdoches County, was pregnant with her first child in 1987. During the course of her pregnancy she received pre-natal care and counseling from the East Texas Health Services Clinic in Lufkin, Texas, under the auspices of the Maternal and Infant Health Improvement Act (M.I.H.I.A.) program, a program established by the State of Texas to provide such services for indigent, and especially adolescent, expectant mothers.

All pertinent records concerning Rebecca's pre-natal care were turned over to the Owens family by the clinic at the end of July, 1987. Further, the East Texas Health Services clinic advised the Owenses "from day one that Rebecca could go to any county hospital," to deliver her child. Testimony of Betty Owens.

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