Tag Archives: immigrant health

The Battle Isn’t Over: What’s Next for the SafeRx Campaign

Knowing how to take prescription medications safely is incredibly important—especially for people who are limited English proficient (LEP) or have other difficulties understanding prescription medication labels.  New York recently passed landmark SafeRx legislation that will greatly increase many New Yorkers’ access to prescription medication. Under SafeRx, prescription pads will have to reflect a patient’s language preference and medication labels will become more patient-friendly. Pharmacies will be required to provide translation and interpretation services to LEP consumers. But while the passage of SafeRx represents a huge victory, we still have more work to do.

The law will go into full effect in late March of 2013. The New York State Board of Pharmacy (SBOP) is currently in the process of drafting recommendations for the implementation of the legislation. Unfortunately, the SBOP has failed to include stakeholders—advocates and LEP consumers—in the process. The SBOP has yet to schedule even one formal public hearing at which advocates and consumers can provide input on how to best implement the new law. Only one informal meeting has been mentioned, but not scheduled—and it’s in Buffalo. Not exactly an easy trip to make for many people around the state.

In response to the limited opportunities for stakeholder engagement, members of the SafeRx Coalition have published a report which discusses several key recommendations for the implementation of SafeRx legislation. (You can also read the accompanying cover letter to the SBOP here.) Through our recommendations, we hope to balance the interests of consumers and the pharmacy industry alike, while still meeting the health needs of New Yorkers.

Here’s a quick rundown of our recommendations:

Determine Pharmacy Primary Languages Fairly
Rather than selecting languages based on whether or not 1% of the general population speaks a given language, SBOP should require translation services in the top seven languages spoken throughout the state. This approach ensures that a uniform standard is applied statewide.

Standardize Prescription Labels
Prescription labels should be patient-centered. Labels should have clear directions, written in simple and large fonts.

Notify Patients of Their Rights
A Patient Bill of Rights should be translated into the selected languages and shared with consumers on pharmacy websites, in stores, and through other outreach.

Include Mail Order Pharmacies
Those count, too! Resources should be dedicated to assessing the language access needs of consumers who use mail order pharmacies and the services that these pharmacies currently provide. In fact, many mail order pharmacies actually have already begun providing language services.

Eliminate the Waiver Option
As the legislation stands now, pharmacies have the ability to opt-out of the requirement to provide language assistance services. But the whole point of the SafeRx campaign is that pharmacies have a federal obligation to do so. Pharmacies shouldn’t be given the ability to dodge their legal responsibilities.

Promote Liability & Accountability
SBOP should implement a plan to monitor and assess pharmacies’ compliance with the law.

Modify Prescription Pads
The NYS prescription pad should be revised to reflect if a patient is LEP and, if so, what the primary language spoken is.

If implemented correctly, SafeRx could improve business for pharmacies by improving customer service and consumer loyalty. For the healthcare system as a whole, SafeRx could dramatically reduce the 700,000 emergency room visits and 100,000 hospitalizations that occur every year when patients misunderstand how to take prescription meds [i]—saving the healthcare system over 3 billion dollars per year overall. [ii]  

With millions of New Yorkers who stand to benefit and millions of dollars to be saved, there’s no reason for the SBOP not to get on board with our recommendations.  And with the clock ticking toward when the legislation will take effect, the time to do so is now.


[i] Daniel Budnitz, et al., National Surveillance of Emergency Department Visits for Outpatient Adverse Drug Events, Journal of the American Medical Association (JAMA), 2006; 296 (15):1858-1866.

[ii] William Shrank, et al., Educating Patients About Their Medications: The Potential and Limitations of Written Drug Information, Health Affairs, 2007; 26 (3):731-40.

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Filed under immigrant health, immigrant rights, language access, legislation

Bridging Theory and Practice for Language Rights

Check out a newly published article in the Journal of Health Care for the Poor and Underserved, co-authored by Health Justice Director, Nisha Agarwal, on the importance of language access in the pharmacy setting. This is an area where the evidence about the importance of providing language concordant services for patients who are limited English proficient (LEP) keeps growing and, despite all the discussion in medical circles about “evidence-based” policymaking, we continue to face resistance at state agencies charged with protecting and advancing public health. Instead of collaborative discussions about how to improve access to prescription medications for immigrant communities and reducing health disparities, we hear complaints about how language assistance services might put huge chain pharmacies out of business – immigrant scape-goating at its worst.

We’re taking our fight to the pages of research journals, as well as to the corridors of power in Albany and to the streets until we win. Join us in this effort! Send us an email and let us know that you’d like to join the coalition to ensure Safe Access for Everyone to prescription medications (SafeRx): healthjustice[at]nylpi.org.

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Ready to Leave with No Place to Go

by Shena Elrington, Staff Attorney

Undocumented immigrants lack access to viable long-term care options. This is hardly surprising, given the surge in anti-immigrant sentiment, the serious budget crises facing federal, state and local governments and the piecemeal way in which we approach health care delivery. Although not surprising, the lack of long-term care options has very real consequences for both the lives of these immigrants and the overall well-being of the healthcare system.

A flurry of recent newspaper articles has brought the plight facing undocumented immigrants in need of long-term care into sharp focus. In the typical scenario, an undocumented immigrant suffers a catastrophic injury or illness, such as stroke, and is rushed to the emergency room, where she receives care, as required by federal law. The initial injury or illness may have been so severe that the patient becomes incapacitated, unable to feed or care for herself. The hospital then looks for appropriate long-term care facilities, such as nursing homes, to care for the patient. Finding such a facility, however, is nearly impossible because the patient cannot pay out of pocket and is ineligible for Medicaid because of her immigration status. The hospital, unable to find an appropriate facility to discharge the patient, chooses whether to continue to treat the patient, at a cost of several thousand dollars per day, for an indefinite period of time.

Some undocumented immigrants who find themselves in this precarious situation fare better than others. They all, however, live in a constant state of uncertainty, unsure of when the hospital will stop caring for them. And when the hospital terminates treatment, as it inevitably will, undocumented immigrants are faced with a truly terrifying range of “choices”, leading them closer and closer to death.

In September, a hospital in Atlanta refused to provide dialysis to nearly two dozen undocumented immigrants who had been receiving treatment for years. As deadly toxins built up in their systems, some immigrants sought care at various emergency departments, but were refused treatment because their conditions had not deteriorated significantly enough to trigger the hospital’s duty to provide emergency care under federal law. These immigrants were forced to wait until they were literally at death’s door to receive treatment. After much wrangling and public outrage, the hospital agreed to continue to provide dialysis for three more years.

But, what happens when that three-year period comes to an end?

Some hospitals, acting outside the federal immigration process, actually contract with private transport agencies to have these patients, with or without their consent, flown back to their home countries, without ensuring that there are any healthcare facilities in those countries able to support their needs. In essence, these immigrants are sent home to die. Based on our work with community partners and advocates, we know these “medical deportations” are not isolated events.

The perils undocumented immigrants in need of long-term care face are the direct result of failures in our immigration and health policies. Our current system mandates that hospitals provide care to undocumented immigrants when they are so ill that they require emergency treatment, at the most expensive point of access in the health care system – the emergency room – yet provides no real avenue for them to receive cheaper preventative care or be moved from more expensive acute care facilities to more appropriate, and less expensive, long term care facilities like nursing homes when necessary.

While health reform expanded the number of Americans eligible for Medicaid, it fell short of including undocumented immigrants – prohibiting them from even purchasing insurance within the exchanges. While the majority of undocumented immigrants are young and healthy, it is inevitable that tragedy will strike at one point or another and some immigrants will need long-term care. Our current policies make no provisions for this eventuality. Worst yet, there is virtually no oversight over hospitals that repatriate patients to their home countries, discharging them to family members or facilities abroad that often lack the means to properly care for them. And, there is little to no discussion of the legal and ethical breaches healthcare providers and hospitals may be committing by failing to discharge undocumented immigrants to appropriate healthcare facilities.

We need to discuss these issues, even if talking about them is difficult in a political climate where anti-immigrant sentiment runs rampant and budget cuts seem to always land on the backs of the poor, because some of our most fundamental values are at stake. Just a few weeks ago, we glimpsed the erosion of these values during a Republican presidential nominee debate, when the audience proudly affirmed their willingness to let a hypothetical 30 year old man who needed intensive care die because he opted out of health insurance. There is little doubt that this crowd would feel the same way about an undocumented immigrant in need of care, who had no access to insurance to begin with. Is this really the kind of world we want to live in?

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Do You Understand Your Prescription Labels?

We here in NYLPI’s Health Justice Program, along with our partners Make the Road New York, are getting ready to hold a press conference at 12:30pm on Tuesday, December 14 near City Hall at Broadway and Park Place (East side of Broadway).  We will use that opportunity to release our new report detailing our findings from a monitoring study of language access in pharmacies, and to join with consumers, advocates, and State Assemblyman Richard Gottfried, State Senator Jose Peralta, and Councilmember Julissa Ferraras in calling for the state legislature to pass a bill that would ensure standardized prescription drug labels and language assistance services in chain pharmacies all across New York State.

It may seem like  common sense, but prescription drug labels are only effective if patients are able to understand them.  That feeling of confusion upon returning home from the pharmacy and not understanding how to take the medication is universal.  With dozens of ways for a pharmacist to write “take once a day,” it is often challenging for patients to understand and act correctly on just one prescription instruction.  For those who take multiple medications, such as the elderly, and for the over 2.4 million people in the New York who speak English less than “very well” and are therefore considered limited English proficient (LEP), though, the lack of translation and prescription label standardization makes labels literally incomprehensible.

The consequences of patients’ misunderstanding prescription labels can be dire and costly.  Every year, unintended misuse of prescription medications causes over one million “adverse drug events,” resulting in expensive visits to the emergency room, hospitalization, and even death.

Everyone should be given the opportunity to understand their prescription medication labels.  Fortunately, solutions exist to this serious health problem that are simple, inexpensive, and efficient for pharmacies to implement.  Creating easy-to-understand, standardized prescription labels, and providing that information in a patient’s language in person or over the phone, can significantly improve health outcomes.

Since 2007, NYLPI and Make the Road have been championing the issue of safe access to prescription medications in New York State, particularly with regard to language access.  We worked with the New York State Office of the Attorney General to enforce existing laws relating to language access in pharmacies, which resulted in settlement agreements with seven chain pharmacies operating across the state.  We also worked with the New York City Council to pass the Language Access in Pharmacies Act, which requires chain pharmacies in the city to provide translation and interpretation services for LEP consumers filling prescriptions.

This past summer, Make the Road and NYLPI surveyed over 250 chain pharmacies across New York—including Rite Aid, Duane Reade, K Mart, CVS, Pathmark, Target and Walgreens—to determine the extent to which pharmacies were complying with the city law and Attorney General settlement agreements.  Chain pharmacies not bound by local law or the settlement agreements were also surveyed to determine whether additional regulation actually improves access to services for patients.

What we found encourages us that our efforts thus far are significantly improving the health and safety of all New Yorkers.  It also pushes us forward in our work toward making that goal a reality.  Among other findings, our results show that:

  • The settlement agreements and local law have led to significant improvements in the provision of language assistance services compared to when we began this work in 2007.
  • However, nearly 50% of pharmacies surveyed were still unable to state that they met the prescription label translation requirements of the laws.
  • Further, almost 30% of surveyed pharmacies could not state that they provided mandated interpretation services for medication counseling.
  • Pharmacies not subject to the settlement agreements or local law provide the poorest access to limited English proficient consumers.

While the oversight and additional regulation by state and local authorities have had a positive impact on patient access to pharmacies, more needs to be done.  The city law only covers New York City chain pharmacies and the settlement agreement expires in 2013.  In addition to the ongoing language barriers, the fact remains that many consumers, regardless of the language that they speak, continue to have a difficult time understanding the instructions and labels that accompany their medication, and there is little in existing law to help them.

The state bill, championed by Assembly Member Gottfried and State Senator Tom Duane, contains provisions that would ensure that all patients can better understand their prescription medications.  The bill, which would apply to all chain pharmacies across New York, would authorize the State Board of Pharmacy to create a framework for standardized prescription labels that are easier for consumers to understand.  It would also expand upon the legal requirements already contained in the local law and would codify many of the translation and interpretation requirements of the settlement agreements.

We hope you will join us at the press conference, and will sign on to show your support for New York Assembly bill A11627 (Gottfried) and Senate bill 8365 (Duane) and to call on members of the Assembly and Senate to sponsor and support the legislation.

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The Hypocrite’s Oath: Latino Immigrants and Health Access in the Hamptons

This post, by Health Justice Director Nisha Agarwal, first appeared on the Race-Talk.org blog and is also available on Huffington Post.

Like many New Yorkers did this summer, I boarded a Hampton Jitney from the east side of Manhattan in late August and made my way to the finger tips of Long Island.  Instead of landing on the beach, however, I found myself in the crowded office of a small community-based organization bursting with children and parents, canned goods and clothing swaps, and the bilingual chatter of Latino immigrants seeking help for any number of different problems.  I was with a colleague, and we were there to meet a client.  Here is her story:

In late July, Laura was rushed to the emergency room of a local Hamptons hospital due to severe stomach pains.  She is only a teenager, undocumented, uninsured, and uncomfortable speaking anything but Spanish to discuss complicated health matters.  After some ten hours spent unattended on a hospital gurney, Laura was finally seen by a surgeon the following morning.  No one explained to her, in a language she could understand, why her stomach was on fire or why she was about to receive an operation.  Turns out it was appendicitis.

Laura was admitted to the hospital for 24 hours after her surgery and then summarily discharged, even though she was still in pain.  No one talked to her about a discharge plan or explained self-care strategies to use in the wake of her operation.  All she knew, through the help of family members advocating on her behalf, was that there was still a drainage tube in her body, and she would have to go to her surgeon’s private office to have it removed.

At this private office, Laura was told that she would have to pay $1500 upfront to extricate the tube, and if she didn’t pay it they couldn’t do the procedure for her.  The emergency room of the hospital where she was originally treated, and to which she returned after this extortionate demand, also refused to remove the tube, insisting again that she go to the surgeon’s private office.  Her fear mounting, Laura turned to her primary care physician and the local community group for help.  Together they advocated with the hospital and the surgeon to have the fee for the tube removal reduced to $300.

Sitting in the surgeon’s waiting for the second time, Laura and her family were subjected to a verbal assault by the physician who initially treated her.  She was the reason he and his assistant had to get up in the middle of the night to come to the ER and operate, he shouted.  She was ungrateful for the fact that he wasn’t getting paid for the services he was providing to her.  Oh, and he also wanted to know—in front of all of the other patients in the waiting room—was she in the country legally or illegally? Only after his anger was vented did the surgeon remove the drainage tube from Laura’s body, but as a parting gift, he also reneged on their payment arrangement and billed her $5000.

As a civil rights-oriented health care lawyer in New York City, I thought I knew what racial and ethnic disparities in health care looked like, and how they manifested themselves.  But Laura’s case surprised even me.  Here we had potential violations of federal and state discharge planning laws, language access regulations, patient dumping statutes and financial assistance laws, not to mention flagrant disregard for the medical profession’s codes of conduct and a whiff of fraud and consumer protection violations.

What is more, hers is potentially not the only story of its kind.  In our interview, Laura’s sister mentioned another family member who had been turned away from the emergency room of the same Hamptons-area hospital.  The director of the community-based group where we were conducting the interview also knew of a similar case.  To her, the mistreatment was targeted toward a specific patient population.  As an Irish-Catholic nun, she noted, she had little problem accessing high-quality, respectful care from the same surgeon who treated Laura.  However, the same was not true for the low-income Latino/a residents of the community whom she served.

Since meeting with Laura, I have wondered how cases like her come into being.  What are the factors that allow doctors—people who have pledged to do no harm—to exhibit openly hate and bias, to take actions that actually threaten the lives and well-being of some category of their patients?  What are the dynamics that make it acceptable for immigrant patients seeking relief from pain and illness to be turned away from their local houses of healing?  How does this happen in a place known to be the summer playground of New York’s financial and cultural elite?  Do the Haves not have enough?

As has been mentioned previously on this blog, this has been a long, hot summer of hate and injustice against Latinos and immigrants, and I can’t help but think that the vitriol spewed into our airwaves is creating a space—a social sanction—for overt acts of harm.  After all, Long Island is the place that anti-immigrant provocateur Steve Levy calls home, and whose blistering comments against the undocumented are only the most public example of the kind of anger that led to Marcelo Lucero’s brutal murder two years ago this fall.  Levy and others like him have also complained that Mexican “anchor babies” are the reasons hospitals on Long Island are in financial distress.  It should come as little surprise to us, then, that some physicians at these very hospitals have adopted a hostile attitude toward those patients that they see as a threat.

As a health care advocate, I have to be attuned to these broader dynamics around race and immigration, for they are directly impacting the clients I serve.  And, as racial justice activists, we all have to be vigilant of the many manifestations of hate – not only in the extreme examples of violent crimes and assaults, but also the quiet, painful attacks that take place in our schools, workplaces and hospitals.

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(Not) Born in the USA

This post is by Macharia Edmonds, a summer intern with the Health Justice Program and a law student at Northwestern University School of Law in Chicago, IL.

Too often in this country, the treatment of those not born in America differs from those born within our borders.  Some New York hospitals have done the unthinkable and are discharging some non-citizen patients to their death.  These hospitals are practicing what is called medical deportation.  This occurs when a hospital discharges a severely injured, sometimes disabled, non-citizen patient who is in need of long term care to a medical facility in their home country.  Unfortunately these facilities are usually not equipped to adequately treat the patient’s medical needs and the patient often suffers considerable pain and sometimes death from this lack of treatment.

Under New York state law, a patient is required to sign off on a discharge plan which details any health care arrangements needed after the discharge.  These patients are sometimes incapacitated or can have a limited English proficiency which makes understanding the choices they are dealt with difficult if not impossible.  In situations where the patient does not speak English the hospital can and should provide an interpreter.  In situations where the patient may be incapacitated, things become more complex.  If the patient is not able to consent to a discharge then the hospital should look to either an appointed surrogate or a family member.  If there is no one from these groups available to decide, there is often confusion as to who has the right to make this decision.

The New York State Legislature has attempted to address this issue by introducing S7429 and A8647C, a bill that creates a three person panel which would be in charge of making these decisions in the absence of other family or appointed representatives.  This panel would presumably be able to protect patients from being denied adequate medical treatment.  This bill is well intentioned but has a number of issues.  Some of these issues include who is allowed to serve on this panel, the lack of information given to the patient and family during the decision making process, and the lack of restrictions and regulations on discharges to foreign medical facilities.  NYLPI has offered and will continue to offer to the Senate and Assembly suggestions for this bill so that it ensures these patients who are incapacitated and not able to advocate for themselves receive the proper medical care.  No matter what country you are a citizen of, simply being a human being should require a certain level of care.

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Filed under immigrant health, immigrant rights, legislation, medical deportation

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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