Arrington v. WongArrington v. Wong
Magali V. Sunderland and Hilary Benson Ganges, Trecker & Fritz, Honolulu, Hawai‘i, for the plaintiff-appellants.
Peter C.-P. Char and Deborah A. de Quevedo, Char, Hamilton Campbell & Thom, Honolulu, Hawai‘i, for defendants appellees Norbert B. Wong, M.D. and the Emergency Group, Inc.
William S. Hunt, Ellen Godbey Carson, and Jason H. Kim, Alston Hunt Floyd & Ing, Honolulu, Hawai‘i, for defendant appellee The Queen‘s Medical Center.
Thomas E. Cook, Lyons, Brandt, Cook & Hiramatsu, Honolulu, Hawai‘i, for defendants-appellees City and County of Honolulu, Clarence Uyema, EMT, and Jerry Ho, EMT.
Appeal from the United States District Court for the District of Hawai‘i David A. Ezra, District Judge, Presiding. D.C. No.CV-98-00357-DAE
Before: William C. Canby, Jr., Stephen Reinhardt, and Ferdinand F. Fernandez, Circuit Judges.
Opinion by Judge Reinhardt; Dissent by Judge Fernandez
REINHARDT, Circuit Judge:
We are required on this appeal to construe the language of the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA),
I. Background1
On May 5, 1996, at approximately 11:30 p.m., Harold Arrington (Arrington) was driving to his job as a security guard when he experienced difficulty breathing. One of his co-workers called for an ambulance; it arrived shortly after midnight. The ambulance left the scene at 12:24 a.m. to take Arrington to the closest medical facility, the Queen‘s Medical Center (Queen‘s hospital).
On May 18, 1998 plaintiffs filed an amended complaint in federal district court against three sets of defendants: (1) Dr. Wong and his employers, the Emergency Group., Inc.; (2) the emergency personnel, Clarence Uyema and Jerry Ho, and their employers, the City and County of Honolulu; and (3) The Queen‘s Medical Center. The amended complaint alleged, among other things, a violation of the Emergency Medical Treatment and Active Labor Act of 1986(EMTALA). Subsequently, Queens filed a Rule 12(b)(1) motion to dismiss (lack of subject-matter jurisdiction), Wong and The Emergency Group filed a Rule 12(b)(6) motion to dismiss (failure to state a claim), and the City and County of Honolulu, Clarence Uyema and Jerry Ho filed a motion for judgment on the pleadings under Rule 12(c). The district court heard all three motions on September 21, 1998, and two days later filed its order. It granted the defendants’ motions and dismissed the plaintiffs’ complaint on the ground that, for the purposes of EMTALA, Arrington had never “come to” Queens emergency department. The court concluded that EMTALA applied only in the case of a patient‘s “physical presence” in the emergency room. See Arrington v. Wong, 19 F. Supp. 2d 1151, 1156 (D.C. Haw. 1998). This appeal ensued.
II. Standard of Review
We review de novo a district court‘s dismissal of a complaint: for failure to state a claim pursuant to
III. Analysis
To provide emergency treatment to indigent and uninsured patients, Congress enacted the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA), commonly known as the Patient Anti-Dumping Act,
Under EMTALA, for those hospitals with an emergency department: “if any individual . . . 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.”
In the instant case, appellees urge in their briefs that the phrase “comes to the emergency department” in
Our reading of the statute as a whole leaves it uncertain precisely what
Administrative agency regulations interpreting the rule “will often suffice to clarify a standard with an otherwise uncertain scope.” Village of Hoffman Estates v. Flipside, Hoffman Estates, Inc., 455 U.S. 489, 504 (1982).“Administrative interpretation and implementation of a regulation are . . . highly relevant to our analysis . . . [and ] a federal court must . . . consider any limiting construction that a[n] . . . enforcement agency has proffered.’ ” City of Chicago v. Morales, 527 U.S. 41, 92 n.10 (1999) (quoting Ward v. Rock Against Racism, 491 U.S. 781, 795-96 (1989)).
The remaining problem -the problem presented by Arrington‘s case -is whether hospitals must admit emergency patients who are being transported to the hospital in non-hospital owned ambulances. Specifically, may the hospital‘s emergency room personnel refuse to treat such patients and divert them to other hospitals when the emergency room is called by paramedics or other ambulance attendants and notified that the patient is en route to the hospital. The regulation answers this question as well. It provides that if ambulance personnel contact the hospital to “inform[ ] the hospital that they want to transport the individual to the hospital for examination and treatment,” the hospital may not deny the individual access unless it “is in ‘diversionary status,’ that is, it does not have the staff or facilities to accept any additional emergency patients.”
The Department of Health and Human Services clearly recognized that hospitals could abuse the Act simply by diverting all persons in emergency straits, before they arrive on hospital property. Under
In the instant case, Arrington was in a non-hospital owned ambulance that was en route to Queen‘s hospital, and the ambulance personnel contacted the hospital‘s emergency room on his behalf and requested treatment. By the plain language of the agency‘s rules, the hospital was obliged to treat Arrington unless the hospital was in “diversionary status,” or, in other words, lacked “the staff or facilities to accept any additional emergency patients at th[e] time ” it was contacted.
Nor is our decision inconsistent with the Fifth Circuit‘s decision in Miller v. Medical Ctr., 22 F.3d 626 (5th Cir. 1994). Miller held that where the patient was in bed at another medical facility, and a doctor at that facility had, by telephone, requested the hospital to accept his patient for medical treatment, 1395dd did not apply. See id. at 628-629. Arrington, by contrast, was not resting in bed at another facility. He was traveling towards (i.e., coming to) Queen‘s hospital by ambulance when the ambulance personnel contacted the hospital‘s emergency department to make arrangements for prompt treatment upon his arrival.
Whichever standard of review we were to apply, the agency‘s interpretation passes muster. Examining the agency‘s interpretation under the less deferential “reasonableness” standard, see Chevron, 467 U.S. at 843, it is apparent that this rule is consistent with the language of the statute and effectuate sits intent. The “overarching purpose of [EMTALA is to ] ensur[e] that patients, particularly the indigent and underinsured, receive adequate emergency medical care.” Vargas v. Del Puerto Hosp., 98 F.3d 1202, 1205 (9th Cir. 1996) (citing Eberhardt, 62 F.3d at 1255). The agency‘s interpretation achieves this purpose, ensuring that emergency patients may be diverted to other hospitals only when the diverting hospital has a valid, treatment-related reason for doing so. The agency‘s interpretation works no hardship on the hospital. As the Department‘s regulations note,
IV. CONCLUSION
The effects of patient dumping on the availability and quality of emergency services for indigent and uninsured patients are well documented. See Karen I. Treiger, Note: Preventing Patient Dumping: Sharpening the COBRA‘s Fangs, 61 N.Y.U. L. Rev. 1186, 1190 (1986) (cited by appellants).10 Congress has legislated to prevent patient dumping, and the Department of Health has promulgated a regulation applying that legislation to a broad range of cases. We follow the Department of Health‘s regulation and hold that a hospital may divert an ambulance that has contacted its emergency room and is on its way to that hospital only if the hospital is in diversionary status. The judgment of the district court is hereby REVERSED. The case is REMANDED to the district court for further proceedings consistent with this opinion.
As the majority indicates, the Estate of Harold E. Arrington and a number of family members (collectively “the Estate“) brought this action against the Queen‘s Medical Center, Dr. Norbert Wong, the City and County of Honolulu, Clarence Uyema, and Jerry Ho. The district court dismissed the portion of the action against Queen‘s which was based on the Emergency Medical Treatment and Active Labor Act (EMTALA). See
If Queen‘s violated the substantive provisions of EMTALA, any person harmed thereby could sue it for damages for personal injuries. See
Congress could have used many different locutions and drawn many different lines when it enacted EMTALA. It could have, for example, said that a hospital could be liable when a request for services was made and somebody was willing and able to bring the person in distress to the hospital. It could have declared that if the person making the request was operating an ambulance heading toward the hospital, the hospital must accept the patient. Congress did not do so. Rather, it said that in addition to a request for services, the person must come to the hospital‘s emergency department. The plain meaning of that requirement is that a person must be at the hospital physically. It will not do for him to be in contact through electronic connection, or for him or someone else to hold a hope that he can get there. It surely does not mean “move toward;” it clearly means to arrive at the place in question.2-1
As the Supreme Court recently reiterated: ” ‘[as] in any case of statutory construction, our analysis begins with the language of the statute . . . . And where the statutory language provides a clear answer, it ends there as well.’ ” Harris Trust & Savings Bank v. Salomon Smith Barney Inc., 530 U.S. 238, 120 S. Ct. 2180, 2191, 147 L. Ed. 2d 187, (2000) (citation omitted); see also Pavelic & LeFlore v. Marvel Entm‘t Group, 493 U.S. 120, 123, 110 S. Ct. 456, 458, 107 L. Ed. 2d 438 (1989). Certainly that is entirely true when we do not encounter some ” ‘rare and exceptional circumstance’ ” that would, for example, make the plain reading absurd or demonstratively at odds with the statute‘s purpose. Rubin v. United States, 449 U.S. 424, 430, 101 S. Ct. 698, 701, 66 L. Ed. 2d 633 (1981) (citation omitted). We have held the same. See Oregon Natural Res. Council, Inc. v. Kantor, 99 F.3d. 334, 339 (9th Cir. 1996); Tang v. Reno, 77 F.3d 1194, 1196-97 (9th Cir. 1996); Farr v. United States, 990 F.2d 451, 455 (9th Cir. 1993). The statute at hand is just that plain. In fact, if a request without actual arrival is enough, the “comes to” language is read out of the statute for all practical purposes.3-1 That, itself, violates the ” ‘elementary canon of construction that a statute should be interpreted so as not to render one part inoperative.’ ” Mountain States Tel. & Tel. Co. v. Pueblo of Santa Ana, 472 U.S. 237, 249, 105 S. Ct. 2587, 2594, 86 L. Ed. 2d 168 (1985) (citation omitted). In other words, the plain reading of the “comes to” provision is neither absurd nor demonstratively at odds with the purpose of the statute, which is to prevent the dumping of patients who arrive at the hospital. Again, had Congress wished to do so, it could have drawn the line at some point other than the time when a person comes to an emergency department.
The Estate argues that two courts have, indeed, expanded the “comes to” language. I disagree. In both of those cases, the courts were focusing on the treatment portion of the statute. See
The final string to the Estate‘s bow is a regulation issued by the Department of Health and Human Services, which rather than adding clarity adds an ambiguity. The regulation first states that a person has “come to” an emergency department if he is on hospital property, including an ambulance “owned and operated by the hospital.”
At any rate, if the regulation does constitute an attempt to make a mere request for services unaccompanied by an actual arrival at the hospital sufficient to bring the hospital within the strictures of EMTALA, I would find the regulation itself to be invalid. Where, as here, the intent of Congress is clear “that is the end of the matter; for the court, as well as the agency, must give effect to the unambiguously expressed intent of Congress.” Chevron, U.S.A., Inc. v. Natural Res. Def. Council, Inc., 467 U.S. 837, 842-843, 104 S. Ct. 2778, 2781, 81 L. Ed. 2d 694 (1984); see also Lujan-Armendariz v. INS, 222 F.3d 728, 749 (9th Cir. 2000). Of course, in that respect, “[t]he judiciary is the final authority on issues of statutory construction and must reject administrative constructions which are contrary to clear congressional intent.” Id. at 843 n.9, 104 S. Ct. at 2781 n.9. So it is here. The agency simply does not have the authority to extend the statute beyond the plain limits set by Congress. Nor does this court, by the way.
Congress does not always express itself with great lucidity. But there is nothing lutaceous about the language that we are called upon to construe here. It takes no great conning of the phrase “comes to” as used in this statute to discover that it means to physically arrive at the hospital. That being so, the Estate has no cause of action under EMTALA because Harold Arrington never did come to Queen‘s. If the Estate is to recover damages for what it sees as improper conduct, it must seek those in state court based upon state causes of action.6-1
Therefore, I respectfully dissent.
Notes
An individual in a nonhospital-owned ambulance off hospital property is not considered to have come to the hospital‘s emergency department, even if a member of the ambulance staff contacts the hospital by telephone or telemetry communications and informs the hospital that they want to transport the individual to the hospital for examination and treatment. In such situations, the hospital may deny access if it is in “diversionary status,” that is, it does not have the staff or facilities to accept any additional emergency patients.
(emphasis added).