Monthly Archives: February 2010

Balancing the Scales of Health Justice for Uninsured Immigrants

This post features Liane Aronchick, a volunteer attorney at New York Lawyers for the Public Interest.  She has coordinated the Working Group on Medical Repatriation at NYLPI since October 2009.

Less than a month after the devastating earthquake in Haiti, the U.S. military halted airlifts to treat seriously injured Haitians from Port-au-Prince to Florida hospitals.  The decision to halt came quickly after Florida Governor Charlie Christ requested that the U.S. Department of Health and Human Services reimburse the hospitals that were treating the injured Haitians, causing speculation that hospitals did not want to treat Haitian patients without some kind of compensation.

The hospitals vehemently denied refusing patients simply because they could not afford care, but the controversy nevertheless highlights the adversarial stance that hospitals take when required to provide health care to non-citizens. When a seriously injured and uninsured patient arrives for treatment at a hospital, the hospital’s priorities shift, placing financial compensation above treatment and care when that patient is a non-citizen. The hospital will stabilize the patient, but the caliber of long-term care and follow-up deteriorates based on the patient’s nationality.  Indeed, it has become a regular practice in hospitals to repatriate uninsured non-citizens in need of long-term and intensive care to hospitals in their home countries—where resources are often scarce and treatments are limited. This practice is known as “medical repatriation” or “medical deportation.” What’s more, transferring hospitals fail to sufficiently investigate whether the transferee hospitals are even capable of providing the care the patient needs. In effect, the American hospital dumps the patient on an ill-equipped and poorly stocked hospital, potentially condemning the patient to death, but somehow it is permissible because the patient is a non-citizen.

Advocates and service providers in New York are banding together to strike a balance to the inequitable treatment that uninsured immigrants receive in American hospitals. New York Lawyers for the Public Interest, the New York Immigration Coalition and the New York Academy of Medicine have collaborated to create a working group on medical repatriation.  The goals of the working group are to 1) determine to what extent medical repatriation is being practiced by hospitals in New York State, 2) research the causes of repatriation, and 3) to develop long and short-term strategies to counter the practice.

To determine the extent and scope of the medical repatriation in New York State, researchers conducted structured interviews with service providers, including social workers, attorneys, policy workers and advocates, who are on the front-lines of patient advocacy.  The research revealed that, on average, hospitals in the New York area face approximately four repatriation cases per year.  While the majority of hospitals maintain that they do not repatriate patients against their will, the voluntariness of the patient’s departure is often murky when she never intended to leave the country. The hospital does not want to continue to provide the patient with uncompensated treatment. The patient no longer needs hospitalization, but she has nowhere to go and no one to care for her in the United States due to her lack of insurance. Left with little alternatives, the patient “elects” to depart, but mostly because she has no other choice.

The decision to repatriate an immigrant patient stems from a variety of social and legal factors. From the legal end, hospitals are bound by both state and federal laws to treat patients arriving with emergency medical conditions, regardless of the patient’s ability to pay. Due to the patient’s lack of insurance, however, the hospital is often unable to discharge the patient once the need for hospital-level care has ended. Hospitals are then forced to make economic decisions that prioritize financial resources over patient care, causing the patient’s and the hospital’s interests to diverge.   When the relationship between a large private hospital and an undocumented and uninsured immigrant patient becomes adversarial, it is more often than not the patient who suffers.

Communication between the patient and the hospital is a key social factor contributing to the repatriation trend.  When patients are unable to communicate with and understand their health-care providers due to a language or other barrier, their decision to return to their home country is not fully informed.  They do not realize that their decision to return to their home country could impede legal re-entry into the United States in the future, or compromise the quality of health care that they receive after they have been transferred.  Even when the patients are aware of their rights, their inherently weakened position in relation to the hospital impedes communication further; they may fear contesting the decision to repatriate because, as an undocumented immigrant, they are already on unequal ground.

The working group on medical repatriation has emerged to level the playing field between hospitals and immigrant patients. To counter the social causes of repatriation, a team of pro-bono attorneys will mobilize and intervene when a patient is at risk of repatriation without her consent.  This “legal rapid response team” would screen the patient for public benefits eligibility, educate patients and their families, in their own language, on their rights to appropriate discharge and about the immigration implications of their decisions to repatriate, and would otherwise conduct the kind of bedside advocacy that hospitals do not do once the relationship has turned adversarial. The team could also engage with hospital administration to negotiate alternatives to the international discharge, or when all else fails, pursue litigation. To affect the legal causes of repatriation, the working group could advocate for policy changes that benefit both hospitals and patients, like increased state funding for charity care or stronger civil and criminal penalties for inadequate discharges.

Importantly, the goal is not to generate or perpetuate adversity between hospitals and patients, but rather, to “fill the gaps” in patient services that hospitals do not often have the resources or training to provide.  Undocumented, uninsured and severely injured immigrants are featherweights on the scales of health justice. We on the working group want to weigh in.

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Filed under immigrant health, immigrant rights, insurance, language access, medical deportation

Community Health Planning: Now As Important As Ever

This post features guest author and ally, Judy Wessler of the Commission on the Public’s Health System (CPHS), which has fought for years to preserve and expand New York’s health care safety net.  CPHS just released a new Report on Charity Care Payments to New York City Hospitals that readers of this blog are encouraged to look at.  In addition to the lack of community health planning, the method by which charity care dollars are distributed in New York State critically impacts which hospitals remain financially healthy and which ones — usually the ones providing care to the must vulnerable — do not.  If you are interested in getting a copy of the report, please contact Judy by clicking here.

Some people still laugh when some of us talk about the need for community-based health planning.  But the way things are going in this city, particularly with the threat of St. Vincent’s Hospital in Manhattan closing, we should be doing something.  St. Vincent’s is the only hospital on the West Side of Manhattan until 59th Street and it has a very active Emergency Room which is very much needed, along with other special programs.  One wishes that many voices now heard for St. V’s would have been heard when the St. Vincent Catholic Medical Center was off-shedding their other hospitals, most located in medically underserved communities of color.  Many communities that need services were stripped of those services – in Central Brooklyn, Southeast Queens, the North Shore of Staten Island.  Intervention is important – and oversight is even more important.  It was well-known that there were serious questions about the competence of the people and the companies that ran the St. Vincent Catholic Medical Center.  One wonders if there was ever a tally of what was spent by these hospitals in the bankruptcy court – millions upon millions of dollars.

This brings us back to the need for health planning.  If services are going to be increased or reduced, it is critical for communities and health care workers to know about this and have a say in what happens.  But this is not what is happening.  The state had an opportunity to fund some community-based planning with HEAL/FSHRP state/federal dollars.   An RFP was released to set up pilot projects to demonstrate what could be done with planning efforts.  Unfortunately, at least in New York City, the State Health Department chose the winners, and almost all of them are health care providers.  Does anyone know what is happening in these demonstrations?  Is any information available to the public?  Has anyone been invited to join in these efforts?  Surely it is time to go back to the drawing boards and come up with better solutions.  We need involvement of communities to ensure that there is not another St. Vincent’s problem.  We also need the State Health Department to be more involved in the monitoring of hospitals and their continuing viability.  The department needs to step in and act.  There are other hospitals that are financially SHAKY right now.  Some of them may be needed where they are located.  We should not have to wait for an announcement that XXXX hospital is going to close or go into bankruptcy.

More soon on what else could, and should be done.  We would welcome your ideas as well – and circulate those ideas that could work.

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Immigrants Are Largely Left Out of Health Reform

From our friends at the New York Immigration Coalition, a new report on immigrants in health reform and the barriers that immigrants face to getting insurance in general.

Immigrants, both those residing lawfully in the United States and those who are undocumented, will continue to face major barriers to health coverage even if federal health care reform is enacted, according to a new study released today by New Yorkers for Accessible Health Coverage (NYFAHC) and the New York Immigration Coalition (NYIC).  Currently, noncitizens comprise 12 percent of New York State’s population but 29% of its uninsured population.

“Two million New Yorkers are noncitizens, and they lack health insurance to a much greater extent than citizens,” said Jenny Rejeske, study co-author. “The substantial majority of these noncitizens are here legally, and they pay the same taxes as citizens do.  There is no justification for impeding their access to insurance and the care that they and their families need. It is time for policy makers to remove the barriers that prevent immigrants from getting the health care they need.”

The New York State Health Foundation-funded report, Health Insurance and Immigrants: Obstacles to Enrollment and Recommendations, documents numerous factors contributing to high uninsurance rates among noncitizens:

  • Immigrants work in lower paying jobs and for smaller firms that tend not to provide health insurance;
  • Undocumented immigrants are barred from public health insurance programs like Medicaid and Medicare that are available to citizens;
  • Even lawful permanent residents are barred from Medicaid and Medicare for five years,
  • Legal immigrants fear that enrolling in public coverage will classify them as “public charges” who may be denied permanent residence status;
  • Legal immigrants fear that receiving public coverage will expose their sponsors to claims for reimbursement;
  • Immigrants face cultural and language barriers; and
  • Immigrants are sometimes arbitrarily denied benefits even when they are entitled to them.

“The health reform bills currently being debated in Congress fail to address most of these barriers. Even more ominous, some proposals, such as one to exclude undocumented immigrants from using their own money to purchase full-price coverage in health insurance exchanges, would make it even harder for immigrants to enroll in coverage,” said study co-author Mark Scherzer.

“Immigrants make up a large proportion of the uninsured but are conspicuously absent from plans to expand coverage,” said David Sandman, Senior Vice President of the New York State Health Foundation. “If immigrants are left behind, we must ensure a strong safety net of health care services is in place to address their needs and fulfill the promise of opportunities to lead healthy and productive lives.”

The report’s key recommendations include:

  • Develop subsidy systems that allow low-income workers to enroll in affordable health insurance through their employers or independently;
  • Repeal the federal government’s “five-year bar” on Medicare and Medicaid enrollment;
  • Make public coverage available to all New York State residents, regardless of immigration status;
  • Develop a public education campaign to eradicate the notion that enrolling in public coverage would endanger immigration status;
  • Carefully monitor and control immigration officers who improperly exclude immigrants from adjusting their legal status;
  • Change federal and state laws to remove covered health expenses from the categories that can be recovered from immigrant sponsors;
  • Address cultural, linguistic and navigational barriers confronting immigrants by enforcing existing language access rules and improving support of community-based outreach, education, and navigation programs; and
  • Ensure the preservation and strengthening of robust hospitals and community health clinics, where the majority of low-income uninsured residents seek care.

Health Insurance and Immigrants: Obstacles to Enrollment and Recommendations is the third in a series of reports that analyze how health coverage among immigrants can be increased. The complete report is available upon request or at www.NYShealth.org; www.thenyic.org or www.cidny.org.

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