Sunday, August 03, 2008

The intersection of homelessness, undocumented immigration, and hospital care in the United States

Health is a human right.

In Michael Moore's film Sicko, we saw a video clip of a homeless patient hastily discharged from a hospital ER, and dumped by taxi at the steps of a shelter. That's utterly reprehensible.

However, there is another side to the story. All hospitals in the US that operate an emergency room must stabilize all patients without regard to their ability to pay or even their immigration status. That effectively means that all hospitals with an ER must provide some charity care.

There is a Disproportionate Share Hospital program that attempts to compensate hospitals which deal with high proportions of uninsured patients. There may also be State programs; California has some programs that try to offset Medicaid expenses. There aren't enough funds going around, though, to compensate for all uninsured.

The homeless present a special challenge. A new law in Los Angeles, which has a very large homeless population, makes it a misdemeanor for hospitals to transport patients to other locations without their written consent.

A Wall Street Journal article shows the hospital perspective: (the article is now free but may become subscribers-only after a week or so)

While the hospitals say they accept their responsibility for the patients' medical care, they say they are being asked to house them after they are treated. The average length of stay for a homeless patient is 4½ days longer than that for others with comparable conditions, says James Lott, executive vice president of the hospital association.

Los Angeles doesn't have enough "recuperative beds," a type of transitional housing for discharged hospital patients who need further medical attention. To help alleviate the shortage, county agencies and private hospitals are financing a pilot project to add 30 beds, bringing the total to 75. Hospitals are also revising procedures for discharge planning, including specialized training for staff members.

A financial crisis in the county's public-health-care system in recent years has led to the closure of many community clinics where homeless people used to go for primary care, so now they are more often going to hospital emergency rooms, Mr. Lott says.

In hospitals, patients have a "nice, warm bed, three meals a day and maybe even a television and people waiting on them. They are literally saying to us, 'I don't want to go. If you discharge me, I will call the L.A. Times,' " says Carol Meyer, director of governmental relations for the Los Angeles County's Department of Health Services.

Thirty to 50 homeless people who no longer have a medical need to be there stay at the county's downtown hospital every night, she says.

Some hospital officials and employees say the new law is being used as an excuse by shelters to deny priority to homeless people after they are well enough to leave the hospital. "When you call a shelter and say, 'We have a patient with no acute-care needs that we would like to send,' all they say is, 'Have them go stand in line at 3 p.m.,' " Ms. Meyer says. Hospitals have little choice but to spend more than an average $1,350 for a homeless person to spend the night, Mr. Lott says.

Last year, one homeless man in his 40s spent several months at Methodist Hospital in Arcadia, Calif., a Los Angeles suburb, after his medical condition had stabilized, says Gloria Nuesch, director of the hospital's care-coordination department. He didn't want to leave, so the hospital kept him until it was able to enroll him in a government-assistance program. Complying with the city's new law is difficult, she says, because about half the hospital's homeless patients won't sign discharge consent forms. "We can't force them," she says.

A lot of hospitals in the US are just hanging on financially. Homeless patients who overstay pose a huge financial burden.

Additionally, undocumented immigrants are not covered by any government programs. States which try to enact programs that compensate hospitals for treating undocumented immigrants will surely attract the attention of the lunatics.

A video by the New York Times shows a hospital that got stuck with an undocumented immigrant with a severe traumatic brain injury. He was in a coma for a year. Care for TBIs is very expensive.

The hospital ran approximately a $1.5m bill for his care, plus a few hundred thousand more when they got sued for deporting him on a medical flight to Guatemala, his home country.

The action was reprehensible. The hospital put him on a medical ambulance to Guatemala, without his guardian's consent. He did not receive the complex care he needed there. He is totally and permanently disabled, and will be a ward of his family until he dies.

That said, there was no good solution here. The hospital in question ran up a huge bill. Hospitals cannot afford to give free care to every complex patient who shows up without getting reimbursed.

Health is a human right, but someone has to pay for the healthcare. Richer nations should be as generous as possible to immigrants from poorer countries who develop complex conditions. The US has failed to do so. But even the countries with universal insurance or healthcare aren't able to treat every person who shows up.


W said...

Ah, another one of the anti-immigrant lunatics.

Everyone who's in the healthcare industry knows about cost-shifting: hospitals don't get their costs from government payers and the uninsured covered, so they charge more to the privately insured.

However, the healthcare industry also recognizes a duty to care. You obviously aren't in it, but we don't turn patients away when we can treat them.

Your reading comprehension is obviously defective, because the entire article is about the conflict between not wanting to turn away folks who can't pay, and the problem of somehow having to pay for that care.

If only we could include basic reading comprehension as part of a citizenship test. Then we could deport all the *&#!ing lunatics and be done with it.

W said...


I decided to permanently remove your comment.

be respectful on my blog. be especially respectful when you are criticizing my own industry when you're not working in it.

besides, you weren't saying anything worth a damn, anyway.