Challenges emerge when dealing with uninsured
Challenges emerge when dealing with uninsured
Florida case of Guatemalan man is example
Two events made hospital discharges of uninsured, illegal immigrants a politically charged issue this past summer:
One, the backlash against proposed health care reform used the prospect of taxpayers contributing to the health care costs of illegal immigrants as a political wedge issue; and, two, a Stuart, FL, hospital became a national example of the public relations nightmare that ensues when discharge planning fails to find a solution that satisfies all parties.
Although national health care critics claimed proposed Congressional bills would cover illegal immigrants, these bills purposely omitted any discussion about care for this population and would not be of any financial help to hospitals treating illegal immigrants. However, health care systems are mandated to provide care and make an appropriate discharge to everyone who arrives through the emergency room, experts say.
Hospitals typically assume the costs of medical care for uninsured patients in the form of a bad debt write-off, and the amount of bed debt varies according to a hospital's population and location, says Susmita Pati, MD, MPH, senior co-director of PolicyLab and director of research programs for FOCUS at The Children's Hospital of Philadelphia. Pati also is an assistant professor of pediatrics at the Children's Hospital and the University of Pennsylvania in Philadelphia.
"In New York, California, and Texas, there are a lot of uninsured people, so hospitals in those states will have a larger proportion of bad debt than hospitals in other places," Pati says.
"Discharge planning is always a challenge for children, whether you have insurance or you don't because of issues with coordination of care," Pati says.
The public rarely considers how hospitals cover the medical costs of the uninsured until there is a high-profile case like the one in Stuart, where an undocumented worker, named Luis Alberto Jimenez, was injured and needed emergency medical care that was not reimbursed by any governmental or private insurer.
The Emergency Medical Treatment and Active Labor Act (EMTALA), passed by the U.S. Congress in 1986, requires all hospitals receiving Medicare or Medicaid funding to provide an appropriate medical screening and stabilizing medical treatment to anyone who comes through their doors needing emergency treatment, says Eve Green Koopersmith, Esq, a partner and chair of the discharge planning, patient rights, and elder law practice group at Garfunkel, Wild & Travis in Great Neck, NY.
Hospitals must provide emergency medical care and, if necessary to stabilize an emergency medical condition, admission to the hospital, regardless of patients' ability to pay, and this includes care to undocumented workers, who are not eligible for federally funded medical reimbursement, she adds.
However, if uninsured, undocumented patients require nursing or therapy treatment in a post-acute setting, there is no funding or mandate for that to occur.
"So, there's the conundrum," Koopersmith says. "If you have a patient who requires skilled services, it's difficult to establish a discharge plan for that person if there is no funding."
The U.S. is not alone in mandating emergency care.
"Almost every country is like the United States and provides emergency care to everyone, because you can't just let people die," says James Dwyer, PhD, an associate professor in the Center for Bioethics and Humanities at SUNY Upstate Medical University in Syracuse, NY.
"We're different from other countries, because for immigrants - both legal and illegal - we haven't been as good at providing primary care and rehabilitation after they leave the hospital," Dwyer says. "I think other societies have done more."
The debate is over what, if anything, this society owes to people who are in this country illegally, he adds.
"That's the hard issue," Dwyer says. "I believe that as a society we owe people who are working here - even if we have a right to keep them out - primary care and a reasonable amount of rehabilitation."
However, it's a different debate when the question is whether a particular hospital owes an uninsured, illegal immigrant post-acute, post-emergency care.
"We're sort of stuck here where hospitals can't do it all, and there has to be more community solutions to this problem," Dwyer says. "But hospitals do have a role to play in this, and it's not just in caring for patients, but also in being proactive and trying to get community and national solutions in place."
The Jimenez civil lawsuit against Martin Memorial Medical Center of Stuart highlighted this dilemma.
Officials from Martin Memorial Medical Center declined to be interviewed for this story due to the possibility of a legal appeal in the case.
The issue raises ethical and health care payer questions for the United States, but it also suggests that hospitals need to have a plan for how to effectively and safely discharge patients when there are no volunteers to take them in.
"Hospitals and emergency rooms have no alternative but to treat patients who have no ability to pay in emergency situations, but there is no requirement for long-term care service providers," says Linda S. Quick, president of the South Florida Hospital & Healthcare Association of Hollywood, FL.
"And hospitals are ill-suited to become residential facilities, and that's how we get into these problems in the first place," Quick says. "One thing institutions are going to have to do a better job of is having communications with patients and families, literally from day one, about what is realistic in the way of expectations they can have."
U.S. hospitals, particularly Florida health systems and hospitals bordering Mexico, have dealt with the ethical and financial consequences of providing emergency care to uninsured illegal immigrants for years, Dwyer says.
"It's hard to get good data, but there are reports suggesting that [discharging illegal immigrant patients to other countries] is a pretty widespread practice," Dwyer says. "Consulates get phone calls from hospitals trying to arrange these deportations, and some hospitals have admitted to deporting between seven and 100 patients a year."
About 85% to 90% of the patients and families accept the transfer, he notes.
U.S. hospitals commonly make arrangements with immigrants' families, both in the U.S. and outside this country, Koopersmith says.
"When I'm consulted on these issues, it's always a discharge arranged with consent with the patient or, if the patient doesn't have the mental capacity to make decisions, with the patient's family," she explains.
"Hospitals are coming up with discharge plans and trying to be creative in providing ongoing services for patients," Koopersmith says.
For uninsured, undocumented immigrants who need long-term nursing care, there are few options in the United States, because Medicaid does not cover these patients, and few facilities will care for these patients as charity cases, experts say.
The state of New York provides more funding options by expanding Medicaid coverage to some noncitizens, and some cities might have immigrant groups who will offer some form of assistance, Koopersmith notes.
Even American citizens who have no insurance and who have lived in the United States for less than five years could face this problem, because public assistance isn't available to them, Dwyer says.1
"The problem is the health care system doesn't have long-term care services for unfunded patients," Quick says. "I don't envy discharge planners their efforts to find alternatives."
1. Dwyer J. When the discharge plan is deportation. Hospitals, immigrants, and social responsibility. Bioethics. 2009;23(3):ii-iv.Two events made hospital discharges of uninsured, illegal immigrants a politically charged issue this past summer:
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