Monthly Archives: July 2010

Leaving Undocumented Immigrants Behind

This post is by Shena Elrington, Staff Attorney and Simpson Thacher & Bartlett Public Interest Fellow in the Health Justice Program at NYLPI.

On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act into law.  The legislation represents the most sweeping reform of the American health care system since the New Deal.  Although the legislation calls for nearly universal health coverage – reducing the number of the uninsured by 32 million by 2019,  it fails to extend such coverage to undocumented immigrants, creating a large coverage gap that will inevitably strain the burgeoning health care system.

The new legislation prohibits undocumented immigrants from purchasing private health insurance in newly formed state exchanges at full costs and receiving premium tax credits or cost-sharing reductions to help purchase insurance.  Notwithstanding the new legislation, undocumented immigrants may still receive emergency care under the Emergency Medical Treatment and Active Labor Act (EMTALA) and Emergency Medicaid.  Neither EMTALA nor Emergency Medicaid, however, provides undocumented immigrants with adequate care.  EMTALA, for instance, requires only that hospitals screen individuals for emergency medical conditions and stabilize (or appropriately transfer) individuals with such conditions.  Beyond screening and stabilizing individuals, EMTALA imposes no additional obligations on hospitals to provide care.  Emergency Medicaid is only available to individuals – regardless of immigration status – who are so acutely ill that the failure to receive medical attention would place their health in serious jeopardy.  Health care providers are often unfamiliar with Emergency Medicaid’s eligibility requirements and deny coverage to undocumented immigrants based on their immigration status.  Both EMTALA and Emergency Medicaid focus on providing care only when individuals are at their sickest and when the cost of treatment is at its highest.  From both a health and financial standpoint, it makes little sense for undocumented immigrants to initially engage the health care system at this point.

There are some 7 million undocumented immigrants in the United States, with an estimated 700,000 living in New York State. Sooner or later these individuals will need health care and will likely receive this care at the emergency stage.  The Affordable Care Act offers some hope for folding this population into the health care system in the form of $11 billion support for the creation of community health centers in underserved communities.  Absent federal immigration reform – an issue as divisive as health reform itself, individual states will need to ensure that undocumented immigrants are not left entirely out of the fold.  Failing to do so will only end up being more costly in the future.

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Filed under federal, immigrant health, immigrant rights, legislation

They Had Plenty of Time: Monitoring Pharmacy Compliance with Language Access Laws

This post is by Rylee Sommers-Flanagan, a summer intern with the Health Justice Program and a student at Emory University in Atlanta, GA.

According to the US Census of 2000, ten years ago over 35% of the then 8 million residents of New York City were foreign born, and 47.6% spoke a language other than English at home. Since then, these numbers have only grown.

Given those demographics, it’s fitting for federal, state and local law to require pharmacies (as well as hospitals, other health care facilities, and all city agencies providing direct public services) to provide language assistance services to limited English proficient (LEP) customers or patients. Language assistance services entail translation (of written documents) and interpretation (of the spoken word). Because New York also requires that pharmacists counsel customers with regard to their prescriptions, both types of service are indispensable.

Even so, when activist organization Make the Road New York teamed up with us to file a civil rights complaint with the New York State Office of the Attorney General (OAG) in July of 2007, the results of the ensuing investigation were predictably disappointing. The OAG found seven chain pharmacies with names you’ll recognize – A&P, Costco, CVS, Duane Reade, Rite-Aid, Target, and Wal-Mart – in violation of the law and came away with seven settlement agreements, requiring newly specific and official translation and interpretation services.

In all cases, the deadline for implementing the required improvements was at latest May 15, 2010. They had plenty of time.  We’re now trying to figure out whether pharmacies have used that time to get in line with their legal obligations.

Unfortunately, verifying compliance may not be so simple. On a recent visit to a CVS/Pharmacy and then a Rite-Aid, I asked which languages they could print on their labels and was promptly informed that no pharmacy employees could answer my questions unless I was a customer. The cold shoulder response makes monitoring pharmacies significantly more challenging, and it seems unlikely to be an accidental roadblock. We’ve heard through our contacts in the industry that many of the pharmacies are trying only to comply with the letter of existing laws and not their spirit.  And we also know they’re resisting language access requirements in other states.  Our allies in California report that pharmacy lobbyists–many from the same companies that signed settlement agreements in New York–are telling regulators on the left coast that it is not possible, difficult or too expensive to provide language assistance services.

This is troubling, to say the least, and patently untrue.  Recently, for example, we spoke with representatives from a an international firm called RxTran that is well-equipped to create a database of translated warnings and instructions for easy use by pharmacists as an integrated part of their work routine. In fact, RxTran designed such an economically feasible and work convenient product—it typically costs less than $2 per day—that even some small, independent pharmacies have purchased database access.

It may be that the chain pharmacies are lazy or greedy and near-sighted (imagine trying to attract customers to whom you are incomprehensible). But for either possibility, we need to remember their pattern of negligence and, now call for the follow up.

Failing to provide accurate translation and interpretation has proven devastating on many occasions. Examples range from the children who vomit endlessly until they arrive in an emergency room (only to discover parents have been administering topical medications orally), to the little old ladies who take eleven times the amount of prescribed medicine (due to faulty translation of the word ‘once’). The United States, for better or worse, has not declared English a national language – can the illness and death ultimately associated with simple language errors really be declared an acceptable side effect of pharmacy arrogance?

Enforcing language access laws may be as difficult as passing them but we, who deserve to comprehend what makes us well or sick, must hold the Rite Aids, Duane Reades and CVSs accountable for that information, in all the languages we speak.

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Filed under immigrant health, immigrant rights, language access

Policy Is About Priority: Where Do Moms Fit In?

This post is by Rylee Sommers-Flanagan, a summer intern with the Health Justice Program and a student at Emory University in Atlanta, GA.

Recently, news sources and blog sites released a flurry of commentary and news articles on the results of a study by the New York State Health Department that indicate unusually high mortality rates for pregnant women in New York, particularly New York City. While the report declined to make a causal link, the article published in the New York Times mentioned not only that “death rates were highest in the Bronx and Brooklyn,” but that black women were “seven times as likely to die in pregnancy as white women.”

Unfortunately, these numbers don’t surprise us. Due to entrenched racial inequalities, health disparities between whites and people of color are visible in both treatment and outcomes. Care is often segregated and sometimes it is simply nonexistent.

Take, for example, Central Brooklyn, where 92% of the population is of color. Since 2003, three major medical providers – Caledonia Hospital, St. Mary’s Hospital and the Lyndon B. Johnson Health Center – have all closed. Also in the last seven years, Central Brooklyn has lost OB/GYN and NICU services at the Interfaith Medical Center, prenatal services at the Kingsbrook Jewish Medical Center, as well as two WIC centers and four primary clinics, all now closed.

Losing these services won’t improve the disparate health fates of residents in Central Brooklyn. Predictably, the most dramatically medically underserved are also victims of the highest rates of maternal mortality and similarly elevated infant mortality rates – in Central Brooklyn, 8.75 infants die per 1000 live births compared to 2.1 deaths per 1000 in the Upper East Side.

Maternal and infant mortality are enough cause for concern, but decreased medical services have many more consequences. Another telling example is the remarkable gap in both rates and results of diabetes in Central Brooklyn as compared with the same in New York City as a whole. In 2008, 68% more people died from diabetes in Central Brooklyn than did in the rest of New York City. The story repeats itself to the tune of a variety of medical conditions. Hope seems foolhardy in this climate of hospital bankruptcies, pared budgets, and continuously diminished access to care.

But improvement is not impossible. One approach, embodied in the Infant Mortality Reduction Initiative (IMRI) has been successful in reducing infant mortality and increasing the number of women who receive pre- and post-natal care. By networking with existing programs and creating community partnerships, IMRI is generating progress. Yet, even as the report on maternal mortality illuminated the distance stretching ahead, the city has moved to severely reduce funding for IMRI and consequently participating organization like the Brooklyn Perinatal Network. There are few groups currently filling the gaping fissure left by multiple hospital closures and decreased services in the medically underserved regions of New York City. We need them all to be secure.

New York City is not the only player to blame in this game. According to The Lancet, 23 countries are on course for reducing maternal mortality as outlined in Millennium Development Goal 5, that’s 75% by 2015. The United States is not among them. A surprising set of countries – China, Egypt, Ecuador and Bolivia – are ahead of schedule.

Ultimately, policy is about priority; why aren’t mothers, infants and health a priority? Well, that’s our question for the City of New York, as well as the rest of these United States.

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Filed under health disparities, people of color