MDs in “ethically untenable” position with undocumented patients

Bioethicists can start conversation

If an undocumented patient presents to an emergency department, the hospital will likely meet its obligations to stabilize the patient as required by the Emergency Medical Treatment and Labor Act, but what happens after that?

“The problem is what happens after somebody is stabilized. Undocumented patients are far more likely than other populations to lack health insurance, and they don’t have access to Medicaid,” says Wendy E. Parmet, JD, associate dean for academic affairs and Matthews Distinguished University Professor of Law at Northeastern University School of Law in Boston, MA. One problem is that hospitals are often unable to find rehabilitation and skilled nursing facilities that will treat undocumented immigrants who are not eligible for Medicaid. In some cases, patients with long-term injuries requiring significant amounts of care have been subject to medical deportation. “We have seen hospitals arrange for the transport of some of these people back to their country of origin, which raises significant ethical dilemmas,” says Parmet. “Hospitals are hiring air ambulances to send them back. It’s clearly ‘dumping,’ but they are not on the street, and that’s why we are not getting the uproar.”

John Henning Schumann, MD, associate professor of medicine and director of the internal medicine residency program at the University of Oklahoma School of Community Medicine in Tulsa, once cared for a Chinese immigrant who came to the hospital paralyzed from a stroke and had no family or friends to help. “There was no ability to discharge him to anywhere safe. The hospital contracted with a company to medically evacuate him to China at a cost of over $50,000, paid for by the hospital.”

Schumann says that patients invariably wish to stay in the United States, but without a follow-up care plan in place, “the hospitals are doing what they see as their ethical best — and have the expensive receipts to ‘prove’ that what they’re doing is ‘ethical’ — providing expensive transport to facilitate safe aftercare of such patients.”

In some cases, nephrologists cannot dialyze immigrants without coverage until they are much sicker and require emergent dialysis, so patients can’t do the maintenance required to keep them from returning to the emergency department in an acutely ill state. “It’s really a very strong ethical dilemma for providers. They are unable to provide what they know is appropriate care,” says Parmet. “From a fiscal point of view, it is pennywise and pound foolish.”

“Need to speak up”

The Patient Protection and Affordable Care Act (PPACA) does not directly address ways of caring for undocumented individuals, who are excluded from the mandate to buy insurance on exchanges unless they file tax returns and can thus be penalized, and are also excluded from the upcoming Medicaid expansion in most states. Parmet notes that the PPACA reduces payment to hospitals for uncompensated care on the assumption that a greater percentage of the population will be insured.

“There is certainly strong reason to believe that immigrants will be a larger share of the uninsured after the PPACA is fully implemented, especially in those states where Medicaid is expanded,” she adds. “But for the hospitals having less resources for providing care for the uninsured, it could actually exacerbate the problem.”

There is more money in the PPACA for community health centers, which often provide care regardless of an individual’s immigration status, notes Parmet, but some individuals may require a higher level of care than the centers can provide.

“Some of these issues also apply to documented immigrants. Under our federal laws, many categories of immigrants aren’t eligible for Medicaid, so they can’t get coverage for long-term care. They might even be insured for short-term care, but it’s not a really robust policy,” adds Parmet. “Suddenly they’re in a car crash and need months in a rehab facility, and their insurance doesn’t cover it.”

The ethical considerations are straightforward, says Schumann. “We are oath-bound to care for all patients, regardless of color, creed, nation of origin, financial status, language skill, or immigration status,” he says. “We should aspire to this ideal. We often fall very short.” Parmet says that current policies put providers in an “ethically untenable” situation. “Providers need to speak up,” she urges. “The ethical principles need to be absolutely clear so hospital administrators and public policy makers understand that it’s a violation of medical practice to ask providers to act in ways beneath the standard of care.”

Bioethicists can play a role in communicating the ethical responsibilities of providers across the continuum of care, suggests Parmet. “The responsibility for treating a patient population should not be left to the hospital alone, and certainly not to emergency departments alone,” she says. “As we move toward Accountable Care Organizations, we should be thinking of this less as the ethical obligation of the hospital and more about groups of providers having responsibility for patients across the spectrum of need.” (See related story, p. 54, on how bioethicists can address care of undocumented patients.)

Sources

• Thomas Foreman, DHCE, MA, MPIA, Director, Department of Clinical and Organizational Ethics, The Ottawa Hospital, Ontario, Canada. Phone: (613) 737-8899 ext. 19967. E-mail: tforeman@toh.on.ca.

• Wendy E. Parmet, JD, Associate Dean for Academic Affairs/Matthews Distinguished University Professor of Law, Northeastern University School of Law, Boston, MA. Phone: (617) 373-2019. E-mail: w.parmet@neu.edu.

John Henning Schumann, MD, Associate Professor of Medicine/Program Director, Internal Medicine Residency, University of Oklahoma School of Community Medicine, Tulsa. Phone: (918) 579-1217. E-mail: john-schumann@ouhsc.edu.