Where Healthcare and Policing Converge: How Georgia Law Promotes Evasion of Financial Responsibility for Indigent Arrestees' and Municipal Inmates' Medical Care
L. Taylor Hamrick
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When a law enforcement officer arrests an injured or visibly sick person, the officer typically transports the arrestee directly to a hospital for treatment prior to formal booking in a jail or detention facility.1 Indeed, convicted inmates, pretrial detainees, and arrestees have a constitutional right to receive necessary medical care while in police custody.2 However, the United States Supreme Court has distinguished a government's constitutional obligation to provide necessary medical
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care from a duty to pay for such care.3 Instead, the Supreme Court has held that a governmental entity must pay for medical treatment of a person in its custody only if the person cannot receive treatment without payment.4 Thus, while a government entity must ensure an injured person in its custody receives care, the government may lawfully defer the costs of such care if alternate sources of funding are available.5 States therefore have substantial discretion in determining precisely how to uphold this constitutional responsibility in practice.6
In Georgia, the state legislature enacted section 42-5-2 of the Official Code of Georgia Annotated (O.C.G.A.),7 which allocates how state and local governments will pay for the medical expenses of "inmates."8 The statute, however, does not define "inmate," leaving open the question of whether the statute applies to arrestees in law enforcement custody who require medical attention prior to a formal booking in a detention facility.
To further complicate matters, because the Georgia Code elsewhere defines "inmate" in terms of a person's confinement in a detention facility,9 arresting law enforcement agencies that do not operate their own jails—most often, municipal police departments—enjoy a statutory loophole that allows them to legally deny financial responsibility for arrestee medical care prior to a formal jail booking. This statutory ambiguity has sparked protracted litigation among Georgia's cities, counties, and hospitals about who pays for inmate care before formal booking.10 Unfortunately, such litigation has led to neither binding precedent on the substantive issue from the state appellate courts nor legislative action to clarify the statutory provision.11 Consequently,
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lingering uncertainty surrounding this and other related legal questions emboldens municipal law enforcement agencies to shirk their responsibilities to pay for indigent arrestees' medical care. While the statute aims to ensure that all persons in government custody have access to medical care and streamline the means of providing such care, the uncompensated hospitals are victims of the statute's shortcomings.
Indeed, because the Emergency Medical Treatment and Active Labor Act (EMTALA)12 requires hospitals that accept federal Medicare funding to treat injured persons presented to its emergency rooms regardless of the patients' ability to pay for the services rendered,13 hospitals suffer financially—not only from the lack of reimbursement, but also from the expense of often protracted litigation sparked by an unclear area of law. This Comment explores the legal history of providing and paying for medical care of persons in custody of Georgia's law enforcement agencies and the practical implications of failing to allocate a clear duty to pay for indigent arrestee medical care.
Ultimately, this Comment does not propose a radical, cure-all alternative to Georgia's current "non-approach" to allocating financial responsibility for arrestee medical care before booking or municipal inmate medical care. Rather, it merely attempts to elucidate a muddled and often overlooked area of law where Georgia's systems of healthcare and policing directly converge. That is not to say, however, that the current state of the law is sustainable or desirable; quite the contrary. As the statutory and judicial construction of the law surrounding inmate medical care presently stands, often fact specific, legal formalism gives virtually unlimited discretion to self-interested parties: both the hospitals and state and local law enforcement agencies. That is, the current state of the law emboldens law enforcement to hide handcuffs from the hospital, deny custody, and avoid financial responsibility. Conversely, though hospitals cannot lawfully turn patients away, the law also incentivizes emergency room employees to stabilize and release indigent arrestees as quickly as possible—perhaps through a back door, unbeknownst to the officer—in the interest of minimizing their expenses.
By refusing to state clearly and concisely who pays for arrestee medical care before booking, the Georgia legislature has afforded—and Georgia Courts have sanctioned—immense discretion to hospitals and law enforcement agencies to alter facts in their favor and manipulate legal loopholes to their benefit. The unsettled nature of this area of law, coupled with significant discretion afforded to self-interested parties, ultimately harms the public interest. While indigent, accused criminals
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are not necessarily a sympathetic class when it comes to convincing politicians and courts to fund their care, the present alternative—of unfunded uncertainty that makes predictive financial planning by all parties a near impossibility—harms patients, taxpayers, government entities, and hospitals alike. Indeed, it is time for the law—either the state legislature or judiciary—to pick a payor: to clarify who should pay for arrestee and municipal inmate medical care and save the public from the current vacuum of unlimited, unpredictable discretion among the involved parties.
This Comment begins by mapping the legal history of providing and paying for the medical care of persons in custody of law enforcement. This piece explores the Supreme Court's recognition of an incarcerated person's constitutional right to receive adequate medical care, as well as the Court's interpretation of how that constitutional right can impose—or fail to impose—financial responsibility for inmate and detainee medical care. The focus then narrows to Georgia's statutory scheme for allocating a duty to pay for inmate medical care: specifically, ambiguities in the statutory language about when and to whom the duty applies and interpretations of the language by Georgia courts. Two Georgia Court of Appeals opinions provide particularly rich case studies, illustrating the uncertainty and protracted litigation bred by the current statutory scheme and the interpretive gaps therein. Next, this Comment examines how EMTALA interacts with Georgia law to the detriment of hospitals, followed by a comparative analysis of a neighboring jurisdiction's alternative approach to payment for indigent arrestees' medical care. Finally, this Comment ruminates upon the practical implications of Georgia's uncertain system for allocating financial responsibility for indigent arrestee and municipal inmate medical care.
While the United States Supreme Court has held that states may not expressly restrict access to medical care,14 a state is only responsible for providing medical care to an individual where it has significantly infringed upon that individual's liberty.15 Incarcerated persons' rights to adequate medical care derive from the Eighth Amendment16 prohibition of cruel and unusual punishment, and the Due Process Clauses of the Fifth17 and Fourteenth Amendments.18 In Estelle v. Gamble,19
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the Supreme Court held that refusing to provide necessary medical care for convicted inmates is incompatible with contemporary standards of decency, and causes unnecessary and wanton infliction of pain in violation of the Eighth Amendment.20 The Court reasoned that, because inmates have been deprived of their liberty and cannot seek care for themselves, it is fair to require the government to provide care.21 As explained below, the Eighth Amendment prohibition against cruel and unusual punishment only protects a person following a conviction.22 The rights of pretrial detainees and arrestees arise instead from the due process guarantees of the Fifth and Fourteenth Amendments.23 However, before City of Revere v. Massachusetts General Hospital,24 the Court considered a state's duty to provide medical care only in terms of receipt and adequacy of the care.25 That is, until City of Revere, the Court had not contemplated whether the Constitution requires the state to pay the treating hospital for the care provided.
A. A Substantive Due Process Right to Receive Medical Care
City of Revere v. Massachusetts General Hospital26 presented the Supreme Court with its first opportunity to consider whether a state or municipality has a constitutional duty to pay for medical treatment received by an individual in police custody.27 In this seminal case, the Supreme Court held that injured arrestees, like pretrial detainees and convicted prisoners, have a substantive due process right to receive necessary medical care.28 However, the Court held that the duty to provide medical care includes no corresponding duty to pay.29 Indeed, the Court rejected that the Eighth Amendment prohibition against cruel
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and unusual punishment attaches a duty to governmental entities to pay for the medical care of indigent arrestees in custody in order to ensure the receipt of medical care.30 Rather, the Court held that Eighth Amendment rights and duties are not implicated prior to conviction.31
In City of Revere, city police responded to a call about a breaking and entering in progress. On the scene, police pursued a suspect, Patrick Kivlin...
