Whitney Palmer

Hospitals Choose Care Over Compensation When Treating Immigrants

Published in the February 2005 AAMC Reporter

David Pate, M.D., chief medical officer at St. Luke’s Episcopal Health System in Houston, faced an almost impossible decision several months ago. A 19-year-old woman, who was neither a U.S. citizen nor a legal immigrant, desperately needed a heart transplant but could not afford the operation or any required aftercare. He could deny the procedure, thus allowing the woman to die, or approve the surgery and absorb the charges.

Ultimately, Dr. Pate authorized the procedure, saving the woman’s life. The hospital’s uncompensated costs topped $1 million. The hospital, affiliated with Baylor College of Medicine and the University of Texas Medical School at Houston, always tries to do the right thing, he said, but sometimes weighing the financial considerations versus the medical and ethical issues is a complex situation, especially when the patient is in the country illegally.

“These are very complicated issues when you ask yourself if this money should have gone to care for people in our own community,” he said. “But I have daughters this age, and I wanted to help this woman who had her whole life ahead of her.”

St. Luke’s and other academic medical centers across the country encounter similar moral and financial dilemmas frequently. The burden of providing healthcare for undocumented immigrant patients who likely cannot pay for services is particularly acute in six states: Arizona, California, Florida, New Mexico, New York and Texas. Confronting the many pitfalls in this field is difficult, but teaching hospitals deal with them in a uniform way. They simply provide the care.

Under the Medicare Modernization Act, the federal government allotted $25 million over four years for the care of undocumented immigrant who enter hospitals through emergency rooms across the country. The money is divided among states, but additional money is available to the six states with the highest illegal immigrant populations. More specific instruction on how to allocate the funds have not yet been published.

Patient Overload

But hospitals in the affected states still face a laundry list of challenges when providing healthcare to illegal immigrants. Emergency rooms are often clogged with patients who cannot receive care elsewhere, and facilities rarely receive reimbursement for any emergency services or aftercare rendered to them. Some physicians shy away from working in these hospitals because they will not be compensated, and physicians who see patients must battle with the language barrier.

Undocumented immigrants receive the same type and quality of care in St. Luke’s emergency room as any other patient would, whether they come in themselves, transferred from another hospital or are brought in by a documented family member, Dr. Pate said. Despite the high financial loss, illegal immigrants only constitute a minority of the hospital’s patients.

Providing this initial care is simple. The difficulty arises when patients need extensive, costly follow-up care. Even though St. Luke’s is a tax-exempt facility and has a health amount of charity dollars, Dr. Pate said he is careful not to spend exorbitant amounts of money on uninsured patients who could receive adequate care elsewhere. Consequently, physicians transfer patients who need more long-term or chronic care to other hospitals in the area.

Patients with more complex cases occasionally find themselves in the same situation in Los Angeles, said Patrick Dowling, M.D., chair of the University of California-Los Angeles Family Medicine Center affiliated with the UCLA School of Medicine. A “safety net” system of county service clinics functions as the medical provider for the more than two million Los Angeles resident who lack health insurance. An overwhelming majority are undocumented immigrants.

Prohibitive Care

Consulting a physician for preliminary care is sometimes the easy part of an illegal immigrant’s travels through the U.S. healthcare system. If they need any additional care, such as medications, X-rays or CAT scans, seeing a specialist or a consultant is virtually impossible.

“Getting adequate services for these individuals is the hard part,” Dr. Dowling said. “The cost of care is just too high.”

But the majority of undocumented immigrants navigate life in America without using the healthcare system to a great degree. Young, healthy men in search of jobs constitute the largest portion of the illegal immigrant population in Los Angeles area, Dr. Dowling said, and they rarely visit the hospital for medical services.

In addition, young women of Latino heritage — the largest immigrant population in Los Angeles — do not require extensive medical care either. As young mothers, their babies tend to be some of the healthiest in the hospital, requiring little additional services, Dr. Dowling said. If they did require additional care, however, a California law mandates Medicaid coverage for any pregnant woman regardless of immigration status.

Despite the fact that the majority of undocumented immigrants are young and healthy, it is estimated that the price tag associated with providing care costs billions of dollars each year. The exact amount of uncompensated care for undocumented immigrants at the national level is unknown.

The search for quality healthcare is not the primary motivation for individuals to come to the United States. The main draw is still employment, said Dan Griswold, director of the Center for Trade Policy at the Cato Institute. While immigrants seek work in the United States to support relatives in their native country, their own medical needs arise infrequently.

“When undocumented immigrants seek medical services, it is usually incidental,” Griswold said. “They generally come in because of an accident or an illness they’ve ignored for a while. And because they don’t have health insurance, they’re going to go too the emergency room.”

Fragile Ground

At this point, with no health insurance and low wages, illegal immigrants are no different from under- and uninsured American citizens living below the poverty line, Griswold said. High medical bills could make life in America frightening for some illegal immigrants, but a recently stalled government proposal could have made seeking much-needed healthcare an even riskier activity.

Last year, the Centers for Medicare and Medicaid Services (CMS) published a requirement that all hospitals ask patients directly about their immigration status when providing care. In a letter to CMS, the AAMC expressed its strong opposition to the requirement, arguing that it would cause fewer undocumented immigrants to seek treatment. The proposal raised numerous concerns, and the agency received so many letters in protest that it was eventually dropped.

Forcing immigrants to divulge their legal or illegal status could erupt into a public health problem in the future, said UCLA’s Dr. Dowling. The fear of deportation could be so strong that undocumented immigrants would forego medical treatment until they become a danger to the public. By then, they will require more expensive services than they would have if they went to the emergency room initially.

Dr. Pate at St. Luke’s said undocumented immigrants could also stop seeking healthcare if they left a particularly bad situation in their native country.

“I suspect there would be a chilling effect for many individuals,” Dr. Pate said. “If the scenario of going home is so bad, many may decide that it is better to be sick in the United States than risk returning to their country.”

Unfounded Fears

But Greg Pivirotto, president and chief executive officer of University Medical Center in Tucson, Ariz., said any concerns about scaring undocumented immigrants away from healthcare simply by asking them whether they are in the country legally are unfounded.

University Medical Center, which is affiliated with the University of Arizona, has tracked patients’ immigration

status for 20 years with no deleterious effects, he said.

“All of this ‘to do’ about scaring immigrants away is a lot of baloney,” he said. “It’s not illegal to ask, and you don’t even have to do it directly. We do it, and we’re still delivering care.”

In fact, a year ago, the Tucson facility implemented a policy that requires patients, including undocumented immigrants, to provide an address to start a payment plan before leaving the hospital. If illegal immigrants do not give the hospital this information, the administration waits seven days and then sends their name and available contact information to immigration services, Pivirotto said.

Immigration officials do not depart the individuals, but they do put an “unpaid medical bills” marker on the immigrant’s file that will show up in case he or she ever applies for documents in the future.

The threat of having their names in a file with the immigration authorities has not stopped undocumented immigrants from seeking healthcare at University Medical Center, however. In the 12 months since enacting the payment policy, the facility has doubled the amount of care it provides for illegal immigrants, and the total uncompensated care cost jumped from $6 million in 2003 to $12 million in 2004.

“Everything comes back to finances, and some doctors don’t want to come in the middle of the night if they won’t get paid,” Pivirotto said. “Fortunately because we’re in a university environment, many doctors still work here because they believe in what they’re doing and are less drive by the bottom line.

March 23, 2010 - Posted by wjpalmer | Healthcare, Politics | academic medical center policies for treating illegal immigrants, cost of treating undocumented immigrants, illegal immigrants healthcare, illegal immigrants receive healthcare in emergency rooms, uncompensated care