Tag Archives: immigrant health

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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Update: Immigrants and Health Reform

This update comes to us courtesy of our friends at the New York Immigration Coalition.

Congressional leaders and President Obama are back after taking a break for the holidays and passage on Christmas Eve of the Senate’s health reform bill, H.R. 3590, the “Patient Protection and Affordable Care Act.”  Now that both the House and the Senate have passed their respective bills, they must come together to negotiate a final bill.  Congressional leaders have decided to bypass the Conference Committee process for a more abbreviated negotiation process among Democratic leadership and committee chairs, including Senate Majority Leader Harry Reid; House Speaker Nancy Pelosi; House Majority Leader Steny Hoyer; Senate Majority Whip Dick Durbin; House Committee Chairs George Miller, Charles Rangel, and Henry Waxman; Senate Committee Chairs Max Baucus and Tom Harkin; as well as NY Senator Charles Schumer, Vice Chair of the Democratic Conference.

This negotiation process is the last chance to make the improvements that are of vital importance to immigrant workers and families.

By and large, the House bill better exemplifies the general goals of health reform – making health insurance more affordable for millions of people (including immigrants who are naturalized citizens and lawful residents), helping to contain the skyrocketing costs of the health care system in the United States, and including many provisions to reduce health disparities and improve health outcomes.  However, there are still grave inequities for immigrant community members, both lawfully residing and undocumented, that must be addressed in this final negotiation process.    While naturalized citizens and many lawfully residing immigrants would gain access to more affordable health insurance, the five-year waiting period in federal Medicaid for lawfully residing immigrants remains and undocumented immigrants are excluded from reforms.  Most appalling is a provision in the Senate bill, which will be used as the basis for negotiations, which prohibits undocumented immigrants from buying full-price insurance with their own money in the new Exchange insurance marketplace.  Below is a discussion of the major provisions in the bills and the impact on immigrants.

Undocumented Immigrants & the Exchange. The Senate bill contains a dangerous provision prohibiting undocumented immigrants from buying health insurance with their own money at full price in the Exchange, while the House bill does not.  The exclusion must not make it into the final bill.  This provision is completely counterproductive to the goals of health reform.  Health reform should allow opportunities for more people to pay into the health care system, not less.  It is costlier to the health care system and to tax payers to exclude people – without insurance people avoid care until it becomes more serious, and more costly.  Also, verifying the citizenship or immigration status of each person who wants to pay their own money in the Exchange would be very costly to do and to an inhuman end – to keep people who just want to keep themselves and their families healthy from buying insurance with their own money.  It is unfathomable to think that a provision of health reform would actually cause some people to lose the coverage they currently have.  Finally, creating an immigration status requirement for the purchase of private goods sets a dangerous and unacceptable precedent.

Undocumented Immigrants, Medicaid & Subsidies. Undocumented immigrants are already restricted from most public health insurance programs, including Medicaid and Family Health Plus in New York, and neither bill changes that policy.  Also, neither bill allows undocumented immigrants to be eligible for the affordability/tax credits or subsidies that would make insurance more affordable.

Lawfully Residing Immigrants & Medicaid. Tragically, neither bill restores federal Medicaid eligibility for lawful permanent residents within their first five years.   This means that the most recent, lowest income legal residents will still not have access to a critical safety net benefit that their own tax money supports.  Yet these same people will be required to buy insurance.  Importantly, as a result of a lawsuit in 2001, New York extends Medicaid and Family Health Plus coverage to all lawfully residing immigrants who meet the income guidelines regardless of how long they have been lawful residents, and must continue to do so with state-only money.

The NYIC acknowledges New York Senators Schumer and Gillibrand for cosponsoring an amendment filed by Senator Menendez giving states the option to restore Medicaid to lawfully residing immigrants within their first five years.  Although the amendment did not come to a vote before the Senate bill was passed, Senate Majority Leader Reid made a commitment to the Democratic caucus that this provision would be included in the Senate Conference Report.  We must hold him and Congress to that commitment.

Lawfully Residing Immigrants & Subsidies. Hundreds of thousands of lawfully residing immigrants in New York who currently make too much money for Medicaid or Family Health Plus, do not receive insurance through an employer, and cannot afford to buy insurance on their own are eligible in both bills for the affordability/tax credits that will make insurance more affordable.

The Politics of Reform. The Obama administration will be especially influential in this final bill negotiation process.  The President must hear from you that the exclusion of undocumented immigrants in the Exchange is unacceptable and that the five-year waiting period in Medicaid for legal immigrants must be removed.  Allowing undocumented immigrants to use their own money to buy unsubsidized insurance in the Exchange is consistent with the goal of achieving just and humane immigration reform this year, and not a bargaining point.

As we look to the Senate/House negotiations, we have these priorities:

1) Everyone, regardless of immigration status, should be able to buy insurance with their own money in the Exchange.   Adopt the House policy.

2) Lawfully residing immigrants must be treated fairly.

a. Include Senate amendment 2991 enabling states to restore Medicaid to legal immigrants in their first five years.

b. For legal immigrants who live in states that retain the five-year waiting period, make sure that subsidies for those lowest income legal immigrants are fair.

c. Allow all lawful residents, including non-immigrant visa holders to be eligible for subsidies.

3) Adopt House provisions for verification of citizenship and immigration status, which are more established, streamlined, and protective of individual rights.

4) Protect the safety net health care system so that the millions of people who remain uninsured after reform passes still have access to health care.

Contact:  Jenny Rejeske, Health Advocacy Coordinator, 212-627-2227 x223, jrejeske@thenyic.org.

For more information and talking points, please visit the website of the New York Immigration Coalition www.thenyic.org or the website of the National Immigration Law Center:  www.nilc.org.

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Hospital Mismanagement and the Perpetuation of Racial and Ethnic Disparities

This post, by the Director of NYLPI’s Health Justice Program, originally appeared on the blog of the Committee of Interns & Residents, which is fighting for the right to unionize at St. Barnabas Hospital.  You can read more about CIR’s efforts here.

Last summer, on her wedding night, Juana R. arrived at the St. Barnabas Hospital emergency department with severe abdominal pain.  A Spanish-speaker, Ms. R. needed an interpreter to communicate effectively with her providers, but she was never given one.  Instead, from the moment of her arrival at the ED, to her transfer to the ICU, to her eventual discharge a month later, she was systematically silenced by the hospital.  Invasive tests and procedures were performed without obtaining Ms. R.’s consent (she signed a litany of documents in English only).  Various medication regimens were attempted, many of which caused extreme pain and nausea, but Ms. R had no way of properly communicating these problems to her providers.  Only after legal intervention did this patient receive the communication assistance services she needed in order to understand her diagnosis and the reason for her admission.  Now, over a year after her discharge from Barnabas, Ms. R. remains emphatic that she will never again return to the hospital for care. She describes what she endured as a nightmare. [1]

As previously reported on this blog, Ms. R.’s case resulted in St. Barnabas Hospital being cited by the State Department of Health for failure to comply with public health regulations.  More broadly, her experience speaks to the ways in which poor hospital administration can compromise patient care and exacerbate racial and ethnic disparities in health care.

Well-known studies about the relationship between race and health care have focused on the individual patient-provider interaction – on how inter-personal biases and prejudices can sway treatment decisions.  However, in my experience as a civil rights lawyer in this field, I have found that institutional racism is a more salient factor than individual animus in explaining my clients’ negative encounters with the health care system.  Patients like Ms. R. are denied the interpretation services to which they are entitled not because of the ill will of particular caregivers, but because, more typically, hospitals like Barnabas are not managed well enough to have the policies and practices in place to ensure timely access to important support services – a systems failure that hurts patients and providers.

My office has also found that, across the city, health care institutions will steer Medicaid and uninsured patients, who are disproportionately people of color, into poorly equipped and under-staffed clinic settings while “better” patients (i.e. white, privately insured patients) are sent to the faculty practices.  At the broadest level, this upward redistribution of health care resources has meant that hospitals located in New York City’s low-income communities of color have closed down over the past decade, while facilities located in more affluent white communities have thrived.  In some cases, the hospitals that shut their doors had patient populations that were over 90% African-American, Latino and Asian.

Viewed in this way, the primary way to eliminate racial and ethnic disparities in health care is to overhaul the institutions that create and perpetuate racial and economic disparities within medicine.  This means more people like Ms. R. stepping forward and demanding investigations of unlawful practices at hospitals like St. Barnabas.  It also means more communities raising their voices against hospital policies that enrich some while impoverishing others.  Ultimately, it means more of us—all of us—speaking out against health care institutions designed to promote private gain over the public’s health.


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State Cites St. Barnabas for Failure to Provide Language Services

This post, about our successful efforts to secure and enforce rights to language services for a client at St. Barnabas Hospital in the Bronx, originally appeared on the blog of the Committee of Interns & Residents, which is fighting for the right to unionize at St. Barnabas Hospital.

The NY State Department of Health recently issued a citation to St. Barnabas finding that the hospital has violated state laws mandating that non-English speaking patients receive translation services so that they can understand diagnoses, treatment plans, and other essential healthcare information.

According to the attorney who prepared the complaint, a Spanish-speaking patient admitted to St. Barnabas Hospital filed a complaint with the State after spending more than a week in the hospital without receiving translation services that would allow her to understand her diagnosis and medical documents she was asked to sign. Only after the patient’s attorney intervened did St. Barnabas provide a telephone-based translation service to the patient.

The Department of Health’s investigation finds the following violations of state law:

  • St. Barnabas failed to document the patient’s language preference.
  • St. Barnabas failed to document whether the patient was provided with a qualified translator.
  • After the patient was diagnosed with tuberculosis, St. Barnabas failed to document that the diagnoses and treatment plan were explained to the patient in a language she could understand.

In diverse communities like the Bronx, where it is estimated that more than 50% of families speak a  language other than English at home, timely access to effective translation services is essential to delivering quality healthcare.

Research compiled by the Agency for Healthcare Research and Quality finds that “Language barriers in the health care setting can lead to problems such as delay or denial of services, issues with medication management, and underutilization of preventive services.”  Local stories compiled by New York Lawyers for the Public Interest also illustrate the severe consequences of inadequate communication in healthcare settings.

Given these high stakes, let’s hope that this Bronx patient’s complaint has spurred St. Barnabas Hospital to make real improvements in the language services it provides to the communities it serves.

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Why Language Access Matters

This post, by NYLPI’s Health Justice Director, originally appeared on the blog of the National Campaign to Restore Civil Rights.

Every person who reads this likely speaks English, and speaks it well.  Whether we are people of color, people with physical disabilities, members of a religious minority, women, gay, working class or poor, we stand with the vast majority of America in that we enjoy “English privilege.”  Practically speaking, English privilege means this: For over 24 million people in the United States, it is difficult and sometimes impossible to get jobs, hold jobs, feed their families, vote in an election, be on a jury, make doctors’ appointments, take medication, use the courts, receive an education, get a home, keep a home—basically, participate in all of the ordinary and extraordinary features of American life—because they do not speak English.

Consider the experience of María Angela C., a Spanish-speaking woman from New York City who is in the process of learning English but hasn’t mastered it well enough to understand complicated health information.  One day, her 5-year-old son broke out in hives due to an allergic reaction.  She rushed him to the doctor, who wrote her a prescription but did not explain how to take the medication.  When María Angela went to the pharmacy to fill the prescription, the pharmacist also failed to explain how to take the medication and handed her a bottle with instructions in English only.  María Angela took the bottle home, opened it and saw a pink liquid that resembled “pepto,” so she surmised that the medication should be administered orally.  After her son took a spoonful, however, he reacted with extreme disgust, and María Angela became nervous.  She asked a neighbor to translate the label and learned that the medication actually had to be applied topically.  María Angela was devastated.  Her son risked another allergic reaction, or worse, due to the fact that the health care delivery system that she encountered operated in English only, and she did not (yet) have the English-speaking ability to navigate it safely.

María Angela and her son faced a barrier to equal health access, to a basic human need, that the rest of us take for granted.  Though many Americans have felt powerless and overwhelmed in the U.S. health care system, most of us have probably not felt silenced – quite literally unable to ask for or receive help because of the language we speak.  Fortunately, civil rights laws are in place to break this silence.  Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of national origin, which includes language.  In the health care context, this means that hospitals and pharmacies must provide interpretation services and translated medication labels to ensure that individuals such as María Angela can access health services with the same hope as the rest of us: that it will improve well-being, not further compromise it.  Unfortunately, the Supreme Court has, in recent years, begun to interpret the law in such a way that this right to equal access does not have an adequate remedy.  In the 2001 decision of Alexander v. Sandoval, a case about an English-only amendment to the Alabama state constitution, the Court held that private individuals cannot sue in federal court for violations of Title VI unless they can show that they were the victims of intentional discrimination – that is, if they can point to something like a “Whites Only” sign on the front door of the pharmacy.

Sandoval
put the kibosh on virtually all federal litigation under Title VI in the health care arena, among many others.  Advocates have sometimes been able to work around the problem.  For example, our Health Justice Program (HJP) represents Make the Road New York, a Latino community-based organization in New York City, and has successfully approached  government agencies such as the state Attorney General’s office to compel investigations of and settlement agreements with national chain pharmacies that do not provide interpretation services and translated medication labels for their non-English speaking customers.  We have also drafted and lobbied for the passage of language rights laws that would compensate for the erosion of civil rights protections at the federal level.  In fact, this morning, New York City’s Mayor Bloomberg signed the Language Access in Pharmacies Act, which will ensure that, in the future, María Angela and her son can use pharmacies in the five boroughs and have their rights to language assistance services respected.

But what about people living in areas where government agencies are not as receptive to the claims of linguistic minorities, and where local elected representatives do not have the same numbers of immigrant constituents holding them accountable?  What about people like Baltazar Cruz, who went to a hospital in Mississippi to give birth and ended up having her child taken away from her because she didn’t speak English?   In these cases, re-opening the doors of the federal courthouse is crucial.  Language rights are, fundamentally, civil rights, which should have a remedy in every part of our country.  And leaving your health care provider with an understanding of how to care for your child, with that child still in your arms, is a basic right; it should not be a privilege.

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A First for NYC and the Nation

Yesterday, the New York City Council passed the Language Access in Pharmacies Act by a vote of 36 to 7, making it the first jurisdiction in the country to enact legislation ensuring that limited English proficient (LEP) individuals have equal and safe access to prescription medications.  We worked closely with Make the Road New York and the bill’s sponsor, Public Advocate Betsy Gotbaum, to draft the bill, negotiate its provisions and lobby for passage.  You can read/view articles about this in the Gotham Gazette, Channel 7 News, El Diario and the Daily News Blog.

The bill builds upon the agreements reached by the New York State Attorney General with major chain pharmacies in New York State in that it expands the number of pharmacies subject to stricter language access requirements (any pharmacy with 4+ stores), provides for fines and penalties in case of violation and does not expire after 2013, as the agreements do, among other things.

This is a huge victory for immigrant New Yorkers and for anyone concerned with public health, but we’re not quite ready to hang up our hats and call an end to the campaign.  There are a lot of things that the state regulates in terms of pharmacies (and that the city has no power over) that should be improved to ensure that LEP New Yorkers statewide are guaranteed equal access to prescription medications.  So, we plan to take our show on the road: from City Hall to Albany.  Stay tuned for more on these efforts and how you can get involved!

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Hate and the Politics of Health Reform

Raucous right-wing outbursts against health reform have been garnering a lot of attention lately, including within community organizing fora such as comm-org, whose editor recently asked: “Are right wing groups really building grass roots organizations and engaging in strategic actions? Or is this just right-wing-media-generated frenzy without any real organizing going on?”  According to one thoughtful response:

“People misunderstand Alinsky’s tactics and what community organizing is about. It is NOT about being disruptive; it is about helping poor people and disenfranchised people find their voice and carve out their own platform for expression. It IS about helping people empower themselves; bringing the oppressed together to stop oppressing each other and to identify the real oppressors; and taking collective action to make a positive difference.”

Indeed, community organizing is not about hate — not about the kind of unrighteous indignation that prompted one anti-health reform protester in New Hampshire to bellow: “We don’t need illegals. Send ‘em all back. Send ‘em back with a bullet in the head the second time.”  And hate there is in abundance at these town hall meetings, carefully crafted hate designed to shore up political fear and laziness.  It is notable, for instance, that even the inclusion of legal immigrants in health care reform is considered too hot to touch by most federal legislators, though there are plenty of reasons to believe that doing so will only help everyone.

Those of us in New York may be tempted to hear-no-evil and see-no-evil when it comes to the place of immigrants in health care reform because  legal immigrants, at least, are eligible for public health insurance and other benefits under our state law, so the decisions regarding immigrant inclusion made at the federal level may have little practical relevance for folks living here.  (This is due to a lawsuit that was filed by several public interest legal organizations in New York City in the late-1990s, which resulted in the state’s highest court declaring that “care for the needy is not a matter of legislative grace; it is a constitutional mandate.”)  But the kind of hate-mongering that has infected the public conversation on health policy is an affront to the low-income communities of color and immigrant communities that we represent, and to the kind of authentic and inclusive grassroots organizing for health justice that we embrace.  We have a responsibility to offer an alternative frame to the debates, one centered on concepts of fairness, commitment, common sense and public welfare.  (Click here for a set of resources from our friends at the National Immigration Law Center.)  And we have the duty to inform others–our friends, family and neighbors–that true community organizing is not what they are seeing and reading about in these town hall meetings . Real organizing is about solidarity and social justice, not about divisiveness and disruption. Real organizing is what we can all do in response to the angry few.

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Carrots and Sticks

Check out this post from our friends at the Empire Justice Center about some legislation we’ve been trying to push to try and get New York State Medicaid to reimburse health care providers for language assistance services.  In other words: when a Medicaid patient who is limited English proficient (“LEP,” for those of us in the biz) goes to a hospital or community health center, she should be provided with an interpreter so she can actually understand what her doctor is telling her and, reciprocally, the provider should get reimbursed through Medicaid for the cost of that interpreter.

You may be wondering, why would a consumer advocacy organization like ours spend time pushing for legislation that would put more money in health care providers’ pockets?  Simple: sometimes carrots work better than sticks.  We’ve worked closely with the sponsors of the bills to make sure that the Medicaid reimbursement is structured in an accountable way: providers will only get money if they actually provide language access services.  Also, they will only get reimbursed if they provide competent language assistance services — not if they pull someone in from the waiting room to interpret, or if they use a staff member who doesn’t have the requisite training.

Should health care providers be making these services available under the law, regardless?  Yes.  Will we be watching to enforce the law, funding or not?  Absolutely. But we’ve also dangled a carrot at the end of our stick in the hopes that, together, we can ensure equal access to high-quality health care for all.

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International Patient Dumping

A little before 1am on December 1, 1985, a pregnant woman who was about to give birth was taken by a friend to a hospital in San Pablo, California. Upon arrival, hospital staff refused to admit the woman because the hospital did not accept her insurance plan. The woman was told to go to another hospital in Oakland instead. Approximately three hours later, the woman arrived at the second hospital, where doctors detected an irregular heartbeat in the fetus. Nevertheless, the woman was once again denied service because hospital staff could not find any record of the woman being enrolled in an insurance plan. She was eventually taken to the local county hospital, which accepted patients regardless of their insurance status. By the time the woman arrived at the county hospital, however, the fetus had a barely detectable heartbeat. At 4:26am, the woman’s baby was pronounced dead. This outcome could have been avoided if the two hospitals she went to first did not refuse to treat her.

In 1986, in response to dramatic news accounts of cases such as the one described above, Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA). The purpose of EMTALA was to “send a clear signal to the hospital community, public and private alike, that all Americans, regardless of wealth or status, should know that a hospital will provide what services it can when they are truly in physical distress.” The purpose was, in other words, to prevent the practice of “patient dumping.”

These days, patient dumping continues, and it has gone international. In a process known as “medical deportation,” uninsured patients, generally undocumented immigrants, in need of tertiary or long-term care are transferred by private hospitals back to their home countries, where they are not guaranteed a sufficient level of health care to survive. It is tempting to think–and it is often suggested–that medical deportation is a new, thorny, perhaps intractable problem in health care policy arising out of the growth in the undocumented immigrant population in the United States. However, we see it as just another iteration of how health care services are often denied to low-income communities of color unless adequate protections are put in place. Earlier forms of patient dumping tended to disproportionately impact low-income, African-American patients living in major urban areas. Meanwhile, medical deportation disproportionately impacts low-income immigrant communities, including those living in major urban areas like New York City. Both offer rather breathtaking examples of how financial and bureaucratic imperatives cause health care providers to forget that they work in the service and support of human life.

This past week, we co-hosted, along with the New York Immigration Coalition and the New York Academy of Medicine, a meeting of health, immigrant, and disability rights advocates from across New York State to start strategizing about ways to address the problem of medical deportation in the short- and long-term. The meeting was very well attended–approximately 40 people participated–and it covered a lot of ground, but one message came through clearly: that there is an urgent need to, once again,” send a clear signal to the hospital community… that all Americans, regardless of wealth or [immigration] status, should know that a hospital will provide what services it can when they are truly in physical distress.”

We will keep you as the work of the medical deportation workgroup progresses.

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