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March 17, 1993

Substandard Care, Antidumping, and George Orwell

JAMA. 1993;269(11):1384. doi:10.1001/jama.1993.03500110052023

To the Editor.  —The article "Socioeconomic Status and Risk for Substandard Medical Care"1 highlighted an important concern about the provision of medical care to the medically indigent and concluded that "the uninsured are at greater risk for suffering medical injury due to substandard medical care."The authors analyzed over 30000 hospital records from 1984 and properly cited a number of limitations of their study. Unfortunately, they did not discuss that federal "antidumping" statutes (commonly referred to as COBRA [Consolidated Omnibus Reconciliation Act] legislation) were not enacted until 1986. This legislation carries significant civil penalties for noncompliance. The absence of such legislation in 1984 makes generalization of conclusions to the current time problematic at best because a significant number of injuries were judged to be due to negligent care.Furthermore, that negligent injuries were highly likely to occur in the emergency department deserves comment. Though the authors properly cited the