Hello readers, we are pleased to announce that the peer-reviewed journal, Progress in Community Health Partnerships, has published a piece about our campaign with Bronx Health REACH to end segregation in the delivery of health care services by teaching hospitals in New York. You can download a copy of the piece here. Feedback welcome! We are using every avenue at our disposal to get the word out about this urgent issue, including the very types of publications that health care providers and policy decision-makers are likely to peruse.
Tag Archives: New York City
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?
The federal Medicaid program has become something of a policy piñata in the national discourse. Over the course of the past year conservatives have been asking, “is Medicaid real health insurance?” The public insurance program for low-income individuals has been criticized for not providing sufficient access to physicians, long wait times to see a physician when one can be accessed, and poorer quality of care once patients get in the door – all of which conservatives argue are reasons to dismantle the program altogether. If being on Medicaid isn’t much better than being uninsured, why bother spending tax dollars on it?
Meanwhile, a recent editorial in the New York Times offered unequivocal praise for the Medicaid program, pointing to a study conducted in Oregon that allowed researchers to compare the experiences of people who received Medicaid coverage to those who did not. According to the study, Medicaid recipients reported better health than the uninsured recipients and were less likely to have medical bills sent to collection agencies or forgo other obligations in order to pay for their medical care. Supporters of the public health insurance plan were therefore able to hit back against conservative naysayers and argue that Medicaid truly is a program worth preserving and expanding.
While the national debate lurches back and forth, we find a more complicated reality on the ground, in the low-income communities of color where we work to eliminate race- and class-based biases in the health care system. The uncomfortable truth is that Medicaid beneficiaries do often receive poorer quality of health care, particularly when it comes to accessing specialists. But to see this you have to look at how Medicaid beneficiaries fare vis-à-vis privately insured individuals, not the uninsured, which has been the focus of current debates.
For example, in our work with Bronx Health REACH, a faith-based community coalition in the Bronx, we have seen how Medicaid patients seeking specialty services at major New York City hospitals are seen in separate—effectively segregated—facilities from their privately-insured peers, with longer wait times, less experienced doctors, and much less continuity and coordination of care. (You can read more about these problems in this monograph published by the Bronx Health REACH coalition and in this complaint we filed with the New York State Attorney General.)
Working with low-income parents, we have also seen how children with Medicaid have to wait for grotesquely long periods of time before they can get mental health treatment and special education evaluations, if they are able to access these services at all, and how elite institutions providing such services refuse to serve publicly insured populations despite the significant shortage of pediatric mental health providers in New York City.
Our experience thus seems to support conservative arguments to some extent: Medicaid beneficiaries do not have sufficient access to physicians, experience long wait times to see a physician when one can be accessed, and suffer from poor quality of care once they get in the doctor’s door, at least when compared with those patients who are privately insured.
Undoubtedly the current climate surrounding Medicaid makes it difficult for advocates to point out the lower quality of care Medicaid beneficiaries receive, for fear that any criticism of the program will serve as powerful ammunition for the other side to use. But acknowledging certain aspects of the conservative argument need not mean that advocates have to accept the entirety of their conclusions. Something else we’ve learned through our work is that Medicaid isn’t “bad” insurance per se. Rather, healthcare providers and institutions choose to treat Medicaid beneficiaries badly by discriminating against them with respect to the quality of care provided. Consider the Bronx example. Hospitals in New York City (and elsewhere) are not only reimbursed by Medicaid for providing patient care, they also receive over $1 billion through the Medicaid program for non-patient purposes such as resident doctor training – a funding stream so substantial that the New York hospital industry is fighting tooth and nail to keep it safe from federal budget cuts. Medicaid seems to pay hospitals very well, and yet these same hospitals choose to provide segregated and unequal care to Medicaid beneficiaries. Why?
As with many things, these bizarre dynamics cannot be understood without accounting for race, and for the fact that the vast majority of publicly insured individuals in New York City are black and brown. We have heard how top-flight specialists want to be able to choose the patients that they treat, which is invariably code for avoiding people of color who are perceived to be more “complicated” and “non-compliant.” Elite NYC hospitals eager to attract these specialists happily comply to doctors’ demands by giving them fancy facilities to see their preferred patients, while the Medicaid patients are separated out into “clinics”, where they are treated by a rotating band of doctors-in-training.
In addition to wanting to attract renowned specialists, the hospitals want to attract the “right” kind of patients – that is, wealthy, white, suburban patients. Behind closed doors administrators will openly argue that their “‘paying’ patients will not want to sit in the same waiting room as people on Medicaid,” so it is simply better for the hospital to segregate the two groups.
Worse still, these biases become a part of the culture of how medicine is taught, with students and residents working with Medicaid patients in the clinics learning very early on that some patients—the kinds of patients they get to practice on, the poor patients of color—are less worthy than others. Indeed, research has suggested that by the end of their medical education, student doctors actually become more biased than they were when they began medical school. These biases, whether conscious or not, permeate the medical system at both an individual and systemic level, affecting the quality of care that Medicaid beneficiaries receive.
From our perspective, the debate about Medicaid is less about left-and-right and more about black and white. The conservatives’ sleight of hand is to point to quality of care problems for Medicaid beneficiaries and to jump from there to the conclusion that the Medicaid program is to blame, which obscures the mediating role that institutional racism plays in ensuring poor outcomes for Medicaid patients. Meanwhile, supporters of Medicaid effectively erase race from the debate as well by closing their eyes to the many challenges Medicaid beneficiaries face in accessing high-quality health care, despite the fact that they are walking in the door with an insurance that research shows is pretty good. A more nuanced position would acknowledge differences in care without accepting defeat. It is not the Medicaid program that must be dismantled, but the biased attitudes and policies that lead Medicaid patients to get inferior quality of care.
Tomorrow, Friday, February 18, is the deadline for members of Governor Cuomo’s Medicaid Redesign Team to submit their “scores” for 49 proposals given to them by the New York State Department of Health that are supposed to generate $2.85 billion–yes, billion–in cuts to the Medicaid program. These 49 were culled from the several thousands received via a severely flawed public hearing and online/written submission process that took place over the last several weeks in cities across the state. Not only were many proposals put forward by consumers and members of the public entirely excluded from the 49 that the Team will ultimately be deciding on, the few that did make it in were inaccurately captured in the bizarre spreadsheet format being used to capture major policy proposals to restructure the state and the country’s largest health insurance program for the poor. Oh, and did we mention that the proposals are going to be scored using Survey Monkey? That’s right, Survey Monkey.
In response, the Save Our Safety Net Campaign, of which we are a part, issued this open letter to the members of the Medicaid Redesign Team, instructing them how to vote on certain key proposals. This is not to say that we accept or buy into the ridiculous “process” that has been put in place by the MRT, but we also can’t remain silent on issues that will significantly impact the communities we care about. You can click here to download a copy of the letter.
Please let us know if you have any comments or concerns. There will still be other opportunities to weigh in on this process. On February 24th, the Medicaid Redesign Team will be meeting to discuss the scored proposals. The meeting will take place in Albany, and it’s important to have consumer voices out in full force. March 1 is when the final recommendations of the Team will be announced. We are planning activities in New York City around the announcement and will keep you posted about details. And, of course, state elected officials will have to weigh in on the recommendations too, and we are hoping that if you are a New York resident that you will tell your representatives how you feel about the Medicaid program and why it is important to you and your community.
Critical decisions about the health care system in New York should not be made from on high, but from the ground up.
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.
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.
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.