Struggling to find post-acute care for undocumented and uninsured immigrants

Patients without payers are challenging to place

When a Florida hospital transferred a seriously disabled, undocumented immigrant back to his native Guatemala for care and won a subsequent lawsuit filed by the man's American guardians, the case made national headlines.

And all over the country, the dilemma the hospital faced resonated with case managers who deal with the challenge of finding post-acute care for patients with no funding and no family in this country to care for them after discharge.

When patients no longer have acute care needs but cannot be safely discharged and have no means to pay for post-acute care, they often stay in hospitals for months or even years.

"Hospitals don't have unlimited resources and can't provide millions of dollars of care for one individual. For instance, quadriplegics ordinarily would go to a rehabilitation center after acute care, but if these patients are undocumented or uninsured, the hospital social worker rarely can identify a place that will take them. It's an ongoing problem," points out Deborah Cruze, JD, MA, program associate, health sciences and ethics at Emory University's Center for Ethics in Atlanta.

Before taking her current position, Cruze was a clinical ethicist at Grady Memorial Hospital, Atlanta's 953-bed public hospital, which houses the only Level 1 trauma center in the region.

Because of the Emergency Medical Treatment and Labor Act (EMTALA), hospitals have to take care of every patient who has an emergency and comes in the door. No other provider has to meet that requirement, Cruze points out.

"Every other provider — nursing homes, rehabilitation centers, and long-term care facilities — can say no. That leaves the care for those patients up to the hospital," she says.

In the Florida case, the patient was treated at the hospital for a traumatic brain injury he received in an automobile accident, but no post-acute facility would take him because he had no funding. After providing care for several years at a cost exceeding $1.5 million, the hospital chartered an air ambulance and transported the man to a Guatemalan hospital, which eventually discharged him to the care of his mother, who lives in a remote village.

When the man's cousin filed a lawsuit challenging the hospital's decision, a jury decided that the hospital did not act unreasonably when it transferred the patient back to his home country.

"Hospitals struggle with both undocumented and indigent patients with conditions that make them difficult to place in post-acute care. The laws concerning each are different; but when they need complex medical care after discharge, both groups are difficult to place," Cruze says.

It's not unusual for Lutheran Medical Center in New York City to have patients in the emergency department who require acute care beds that are being taken up by patients who could be in a nursing home if they had funding, says Fred Nenner, LCSW, director of social work.

Lutheran Medical Center is located in an urban setting in New York City in an area that traditionally has had a large immigrant population.

"We are a Level 1 trauma center and care for severely injured patients. Put that together with an immigrant population that is likely to be ineligible for post-hospital care, and we are at risk for treating patients who cannot be safely discharged to the community," he says.

The 479-bed hospital's mission statement says that its objective is to serve its neighbors.

"We try to serve that mission; but when the hospital treats those patients who need a skilled level of care in a nursing home facility and for whom we cannot access Medicaid coverage, we are basically stuck with those patients," Nenner says.

Only about 1% of the charity patients at Medical City Dallas Medical Center are undocumented, but the percentage is trending up, says Pat Wilson, RN, BSN, MBA, director of case management.

"Providing health care for undocumented immigrants is becoming more challenging every day, especially in Texas and California. When patients are unfunded, the chances of finding a post-acute facility to take them are slim," Wilson says.

Having patients who aren't in need of an acute care bed but can't be safely discharged poses more than just a financial problem, says Regina Hasan, LMSW, executive director of social services at WellStar Health System in Marietta, GA.

"Kennestone Hospital often runs an 80% to 90% census. If a patient who isn't in need of acute care is taking up a bed, and we have patients holding in the emergency department while waiting for a bed, that doesn't provide the best-quality care we can for our community," Hasan says.

The 633-bed Kennestone Hospital is the flagship facility for the five-hospital WellStar Health System.

"We're a not-for-profit public hospital, and we treat anybody who presents for treatment the same way, whether they have insurance or not. But when patients don't need acute care and have no place to go after discharge, we have no choice but to keep them," she says.

At Grady Memorial Hospital, at one time, nearly half of the beds in the step-down unit were occupied by people who no longer needed acute care but had no place to go, Cruze says.

"Hospitals have only so many ventilators and only so many providers to take care of all these patients," she adds.

"If you believe that all individuals have the right to access health care, that means that the health care system should take care of anyone who needs care for as long as he or she needs care," Cruze says.

On the other hand, when a hospital provides an intense level of care to one person for the rest of his or her life, an intensive care unit bed will be taken up for years, and the hospital may not be able to take someone who could recover and return to society as a contributing member, she adds.

"Hospitals don't have unlimited resources. If they have to continue to treat people without reimbursement, they may have to close their doors," Cruze points out.

When Cruze worked in Arizona, some hospitals there closed their emergency departments because they were providing long-term care for so many catastrophically ill patients who had no other place to go after discharge and for whom the hospitals received no reimbursement.

"When this happens, the rest of society has no access to emergency care," she says.

There are several different categories of undocumented workers, Cruze points out. One group comes to the United States to work and sends money back home. They may be the easiest to return to their country of origin because they have family there to care for them.

But there are other undocumented patients who may have immigrated with their families at an early age but never became citizens. They aren't eligible for Medicaid, and they may not know anyone in their native countries, so sending them back isn't a viable option.

"The problem becomes more difficult when you look at the facts of individual cases," Cruze says.

The 1996 federal welfare reform act (the Personal Responsibility and Work Opportunity Reconciliation Act) says people admitted to the United States after August 1996 cannot receive coverage except in emergencies until they have been residents for 10 years.

"If a patient has an entitlement benefit that we can access, we can usually see the light at the end of the tunnel," Nenner says.

In the case of patients who may have been in this country for five years or longer, Lutheran's social work staff work with them to establish residency so they can receive benefits.

However, they aren't always successful. Lutheran Medical Center has been caring for a Mexican quadriplegic who has lived in New York for more than 10 years but has used so many different names that the hospital can't establish his identify so he can get Medicaid. His elderly parents in Mexico don't want him to come back, leaving the hospital no choice but to keep him since he cannot be safely discharged.

Under current law, undocumented immigrants may not receive anything but emergency Medicaid; but under EMTALA, the hospital must provide emergency care for them.

"People protest that illegal immigrants should not get benefits, but if they go to the hospital, under current laws, they get care but the hospital doesn't get paid," Cruze points out.

Grady provided care for a patient in his 80s who came to Atlanta from another country. He was in the United States legally but he hadn't been here the five years necessary to qualify for Medicaid. He didn't qualify for Medicare because he hadn't paid into the system. The patient was on a ventilator and required too much care for his family to take care of him. Instead, he lived in the hospital for the rest of his life.

(For more information, contact: Regina Hasan, LMSW, executive director of social services at WellStar Health System, e-mail:; Fred Nenner, LCSW, director of social work, Lutheran Medical Center, e-mail:; Pat Wilson, RN, BSN, MBA, director of case management, Medical City Dallas Hospital, e-mail: