Emergency Care for the Undocumented: Who Bears the Burden and Where to Draw the Line?
Article Outline
- Who Pays?
- How Big is the Problem?
- The Problems Wax and Wane
- A Lifeline, But not a Solution
- The Tragedy Among the Statistics
When Paula Gomez, executive director of a community clinic in Brownsville, TX, saw a 12-year-old girl with failing kidneys recently, she and the clinic doctors found they could not arrange a transplant. Because the girl’s parents had brought her to this country illegally as a toddler, she’s not eligible, though she certainly will die without it.
The girl’s case illustrates the politics and compromise that have characterized the issue of medical care for the undocumented. The federal government has moved toward paying for emergency care, an unfunded mandate for 20 years, but defining what constitutes an emergency can have tragic consequences. Hospitals are supposed to provide emergency care to all patients who come in the door, regardless of their ability to pay or their immigration status. The requirement is in line with the Hippocratic Oath and enshrined in federal law, specifically the 1986 Emergency Medical Treatment and Labor Act (EMTALA).
“We don’t turn people away at the door. We’re morally and legally bound to treat people,” said Carla Luggiero, a director for federal relations at the American Hospital Association.
But once a patient is stabilized, the obligation ends. In the case of the 12-year-old in Brownsville, that meant she’d be eligible for emergency dialysis when her potassium levels got high enough to pose a risk of killing her immediately, but not for a transplant or even for regularly scheduled dialysis.
“She’s not bleeding, she’s not having a heart attack, she’s not having a baby,” said Gomez. Because she was undocumented, the girl didn’t qualify for any coverage that would have enabled treatment.
Who Pays?
Historically, Medicare has only covered legal residents, meaning hospitals must absorb most of the cost of treating undocumented immigrants who cannot pay. Recently, that has begun to change. A few years ago, Congress authorized partial reimbursement for the cost of providing this care under Section 1011 of the Medicare Modernization Act of 2003. Hospital groups and local officials applaud the act, but it has yet to prove a panacea. The program’s launch was slowed by debates over requirements, and when it did launch, hospitals were slow to enroll, in part claiming the administrative burden was too high. (The Center for Medicare and Medicaid Services contracted Trailblazer to set up and manage the program.)
The funding is allocated by region, in an attempt to steer money to border states, whose hospitals are believed to treat the largest share of undocumented immigrants, but there is no way to reallocate funds if one region doesn’t claim its total. Groups such as the American Hospital Association and the Border Counties Coalition are still doing outreach and education to ramp up participation.
“I think the first thing we appreciated about 1011 was that this was recognition by the Congress, by the President that this was a burden that we were seeing in border hospitals,” noted Steven Escoboza, president and CEO of the Hospital Association of San Diego and Imperial County. “In terms of funding, it doesn’t cover costs yet.” Escaboza didn’t have an exact ratio of how much of San Diego hospital’s expenses were reimbursed, but continued, “I can tell you clearly, it does not cover the total cost for services rendered.”
Others echo that concern, including David Austin, who, working with a group called the US/Mexico Border Counties Coalition, lobbied for the Section 1011 funding, and also Luggiero, the director for federal relations at the American Hospital Association.
For the 2005 fiscal year, when states were first able to seek reimbursement, $58 million out of $250 million allotted was applied for. For 2006, $170 million was applied for. Some hospitals complained about the enrollment process, especially given the limited reimbursement. “It was a very burdensome program. It has gotten less burdensome,” said Luggiero. “The trend lines I’ve seen show that an increasing number of hospitals are participating in the program.”
Escaboza agrees. “I think it took a while for hospitals to understand what’s required for claiming reimbursement,” he said. “In the last year or so, we have seen here in San Diego and throughout California … hospitals earnestly and appropriately submitting claims.”
Right now, the unclaimed funds from 2005 and 2006 are still available, as the money rolls over from year to year. So far, the AHA has already had to lobby against one Congressional attempt to redirect unused Section 1011 funds (the attempt was dropped), and Luggiero remains cautious about the future.
How Big is the Problem?
No one knows exactly how much hospitals spend on emergency care for undocumented immigrants. Shelton Brown, an assistant professor at the University of Texas School of Public Health in Brownsville, notes that researchers in border regions can’t outright ask if a patient is a US citizen. If they do, the interview ends. Similarly, most hospitals don’t attempt to document citizenship. In fact, when Congress debated adding language to Medicare Modernization Act of 2003 that would have required doctors to document a patient’s immigration status, and, if the person was not in the country legally, contact the Department of Homeland Security, hospitals groups lobbied to get the language removed. In addition to fearing the rule would prevent some patients from seeking needed emergency care, doctors argued that already overburdened ED staff shouldn’t be asked to take on the responsibility of border control agents.
So, while just about everyone seems to agree that it costs a lot of money to treat undocumented immigrants without insurance, hard numbers are hard to come by.
One of the most cited studies was done in 2000, when a group of 24 counties in Texas, Arizona, New Mexico and California came together to form the US/Mexico Border Counties Coalition. Officials in those counties wanted the federal government to address the costs of federally mandated care for undocumented immigrants, and Arizona Senator Jon Kyl secured funding for a study to try to assess the magnitude of the problem. The Border Counties Coalitions contracted MGT of America, a consulting and research firm, to conduct it.
The final report from that study, called “Medical Emergency: Costs of Uncompensated Care in Southwest Border Counties,” used a variety of statistical techniques to estimate that in 2000, in the border counties, hospitals incurred costs of $190 million caring for undocumented immigrants, about 25% of $832 million total spent on uncompensated care in the region.
The Border Counties Coalition used the study to successfully lobby Congress for the Section 1011 funding, which provided $250 million a year for the years of 2005-2008, divided between all 50 states. Two-thirds of the appropriation was based on the estimated number of undocumented immigrants in each state. The other third was set aside for the 6 states with the highest numbers of arrests of undocumented immigrants (Arizona, Texas, California, New Mexico, Florida, and New York).
And the issue has gained national attention. “Where 10 or 15 years ago, this wasn’t much of an issue, over the years, I’ve been hearing more and more frequently from hospitals even in other parts of the country [away from the border] that have large numbers of documented and undocumented immigrants,” said Luggiero.
However, spending in border states still seems to outpace the rest of the country. In North Carolina, a state that’s had a recent influx of immigrants, Annette DuBard at the University of North Carolina at Chapel Hill and Mark Wayne Massing of the Carolinas Center for Medical Excellence decided to look at the issue. Federal guidelines do allow states to use Medicaid funds to provide some emergency medical services to undocumented patients that fall in a Medicaid-eligible category such as children, pregnant women, elderly or disabled individuals. DuBard and Massing analyzed all North Carolina Emergency Medicaid claims between 2001 and 2004. A total of 48,389 patients received care reimbursed under the program during those 4 years; most patients were eligible due to pregnancy, and more than 99% were undocumented immigrants. However, total Emergency Medicaid spending was still less than one percent of North Carolina’s total Medicaid expenditures during the period studied.
“There tends to be a lot of rhetoric around the burden placed by undocumented immigrants on medical expenditures,” said DuBard. “And it’s less than one percent.”
The Problems Wax and Wane
In addition to the Border Counties Coalition survey, less formal measures indicate that costs are likely higher in border regions. San Diego County has increased its own efforts to understand use of emergency care in recent years. Hospitals do not collect data on a patient’s immigration status but use proxy measures, such as an inability to provide an address, that indicate likely undocumented status. In recent years, it looks like approximately 10 to 12% of ED visits were by undocumented immigrants, Escaboza said, a drop from several years ago, when the numbers were closer to 25 percent. He cited increased border enforcement as the most likely cause.
“I’ve seen things go from bad to worse and then improve, but that could change again,” he said. He noted that anecdotally, it appears that illegal migration routes have moved to Arizona as enforcement has increased along the southern California border.
In Texas, health economist Shelton Brown kept running into the question of whether undocumented immigrants put a strain on border hospitals. The question isn’t directly related to his academic research, which looks at how distance migrated correlates to insurance status, but he decided to see what he could determine from the Texas Health Care Information Collection Center, a division of the state Department of Health Services. That data notes whether care was covered by private insurance or a government program. Patients without any coverage, including Medicare or Medicaid, are likely to be undocumented. He found that both the percentages of hospital admission through the emergency department and patients listed as self-pay were comparable in the hospitals in border counties and hospitals in the rest of the state. In fact, the rates were a smidge lower near the border.
As with all proxy measures, the status as a self-pay patient is an imperfect indicator of immigration status.
“I’m assuming that if the hospital could have signed them up for Medicare or Medicaid they would have done that. But I’m not sure of that,” said Brown.
A Lifeline, But not a Solution
Advocates argue that Section 1011 funding still isn’t enough to offset the true cost of providing health care to undocumented immigrants.
“It’s far from sufficient in terms of the dollar impact. And we are concerned about getting it reauthorized. We want to make sure that we get it reauthorized and hopefully at a higher level,” said Austin. “What we’d like to see is an expansion of the program.
… A good next step would be to get it expanded to include community health clinics.”
Politically, this is a less clear cut issue. However, some states are taking the initiative to expand coverage to undocumented immigrants. In California, for example, Governor Schwarzenegger has proposed health care reform that would provide coverage to all children, regardless of immigration status. And in a piece written for the Los Angeles Times Web site, Daniel Zingale, a senior advisor to Governor Schwarzenegger and chief of staff for Maria Shriver, wrote “In the case of undocumented immigrants, the governor is trying to move them out of costly emergency rooms and into clinics.… The governor’s plans would redirect funds towards prevention and primary—rather than emergency—care.”
In North Carolina, a state just learning to deal with immigration issues, DuBard agrees with the value of preventative care, noting that treating a communicable disease in its early stage could avoid more costly emergency care and also prevent transmission to others. Similarly, it’s more expensive to treat complications of pregnancy than it is to provide birth control and prenatal care. Pregnancy complications accounted for 83% of the emergency care spending documented by DuBard’s study.
“I think these data suggest that an investment in primary and preventative care might pay off even from a strictly financial standpoint,” she said.
DuBard also sees the issue as a doctor, not just a number cruncher. About half of the patients in her practice are recent immigrants. “What I see in my own patient population is hard working families who don’t have a chance against our health care system,” she notes. “They’re working for employers who don’t provide health care, and because of their immigration status they’re not eligible for our public system.”
Paula Gomez, of the Brownsville Community Health Center, agrees.
“We have a serious problem with drug resistant TB on the border and nobody seems to care.… We have issues with dengue, we have issues with typhoid,” she said.
The Tragedy Among the Statistics
Then there are patients like the 12-year-old who needed, but couldn’t get, a kidney transplant. It’s a heartbreaking situation. No one wants to tell a 12-year-old she can’t get life saving treatment. Yet, a kidney transplant is an expensive procedure. And kidneys themselves are a scarce commodity; not even all legal residents are able to obtain needed organs. According to the Web site of the National Kidney Foundation, patients listed for kidney transplants in 1999 faced an average wait of more than 3 years.
Gomez recalls explaining to the girl that she couldn’t arrange the treatment.
“She looked at her mom and said, ‘Why don’t we just go back to where my aunts and uncles are in Mexico City, and if I have to die, at least I’ll die with people who care,’” said Gomez. Eventually, the girl’s parents agreed and took her back to be near family. “She’s probably dead by now. There’s no way she could get the kidney transplant. It’s hard enough to get over here, let alone over there.”
“We can sit hear and argue what’s legal and not legal,” she continued. “When you’re in the health profession that’s not what you’re taught, you’re not taught to be a policeman.”
PII: S0196-0644(07)01444-8
doi:10.1016/j.annemergmed.2007.08.015
