Illegal immigration and the cost of hospital care

Garret Condon:

A 42-year-old Chinese man was taken to Yale-New Haven Hospital after suffering a heart attack and a massive stroke at Foxwoods Resort Casino in February 2004. Doctors, therapists and a nearly 'round-the-clock translator helped him improve. He was soon ready to leave the hospital.

Most patients on the road to recovery would do a short stint in a rehabilitation facility and then head home, perhaps with help from visiting nurses and other professionals.

But the man was an undocumented immigrant who didn't qualify for federal Medicaid or Medicare to pay for post-hospital care. Hospitals are required to keep patients until they can be discharged to a medically safe situation. Most private nursing homes won't take such charity cases.

Two months and about a half-million dollars in care later, Yale-New Haven officials spent about $50,000 flying the man and a medical escort back to his home in Tianjin, China's third-largest city. His wife, who was already caring for her aging parents, eagerly welcomed her husband home and agreed to get him the local follow-up care he required.

"Logistically, that was the only alternative we could come up with," said William Gedge, senior vice president of Yale-New Haven Hospital.

That same year, a 38-year-old Egyptian man was struck by a car in Windsor Locks and sustained multiple bone fractures, traumatic brain injury and a brain hemorrhage. Doctors quickly determined that he would be in a wheelchair for life. He required two months of intensive care but stayed for 10 months at Hartford Hospital. His only local relative was a brother, who could not take care of him.

In August, the hospital paid to fly the man back to his family in Egypt and to have his brother accompany him. The hospital also sent medical supplies to help the man make the transition to the Egyptian health care system, according to Monica Fowler, manager of social work services at Hartford Hospital.

As the number of illegal immigrants increases in the United States and in Connecticut, more are arriving at hospital emergency rooms. But some, who require extensive post-hospital care - like the Chinese heart attack patient and the Egyptian man - create a conundrum for general hospitals.

Gedge estimates that Yale-New Haven sees hundreds of undocumented immigrant patients a year, and about a dozen get stranded at the hospital for weeks or months. He said that they share many of the barriers to care faced by citizens and legal residents who are poor, uninsured and speak limited English. In addition, these immigrants may avoid care until almost too late for fear of revealing their citizenship status.

"It's increasing," said Ron Bianchi, corporate senior vice president at St. Vincent's Medical Center in Bridgeport. "We had several cases a year that got into real complicated placement issues." Two years ago, one patient who needed regular dialysis had to stay at St. Vincent's for a year, he said, accounting for about $1 million in care. Stays of weeks or months are more typical, he said.

Bianchi said that St. Vincent's has tried to send patients back to their home countries, but sometimes finds that the country will not take them back or will not promise to provide needed care, "which means we would be sending them into a situation where they could die," he said. "This is something we cannot and would not do."

A woman from Nigeria who needs a bone marrow transplant is currently hospitalized at Yale-New Haven. She will need ongoing immunosuppressive drug therapy, which she can't afford and which may not be available to her in Nigeria. A man from Ghana who has serious intestinal illness is likely to die in a month without daily, intravenous nutrition, which could give him six to seven years more. But he may not be able to get this in Ghana. Gedge said that Yale-New Haven officials are working on solutions for both patients.

The Washington-based Urban Institute estimates that more than 10 million undocumented immigrants were in the United States in 2004, including about 75,000 in Connecticut. Federal data show that the number of undocumented immigrants in this country doubled between 1990 and 2000.

Figuring out how many illegal immigrants are being treated in U.S. hospitals is difficult, the U.S. Government Accountability Office acknowledged in a May 2004 report, noting that it could not gauge the impact of illegal immigrants on total uncompensated hospital care because of a lack of data. Most Connecticut hospitals haven't formally tracked such patients. Hospital administrators say that questions about citizenship often chase a sick or injured person out the door.

Fowler said that each year Hartford Hospital typically has a dozen or so tough cases involving undocumented immigrants, costing the hospital several million dollars. The Hospital of St. Raphael in New Haven reports five to eight cases. St. Vincent's Medical Center estimates five to eight a year.

Dr. Matthew Miller, chief medical officer and vice president of medical affairs at Danbury Hospital, observes that it is a national issue. "Obviously it's less of a problem in Connecticut than it is in the border states," he said.

A study done for the U.S./Mexico Border Counties Coalition, a policy forum established by 24 U.S. counties along the Mexican border, showed that border hospitals in the Southwest alone spent $190 million in 2000 on care for illegal immigrants - about a quarter of the hospitals' total uncompensated care. In Connecticut, a smaller fraction of uncompensated care goes to treat undocumented immigrants, according to local hospital administrators, but some believe that fraction is growing.

Hospitals receive some reimbursement under Medicaid for emergency care they provide even if patients are illegal residents. Such patients must otherwise be eligible for Medicaid. But many undocumented individuals don't qualify. Medicaid only pays hospitals to stabilize such patients, according to Gedge, and typically provides a payment of less than $10,000.

Hospitals that serve large numbers of low-income patients do get government supplements to help ease the burden of uncompensated care. And hospitals usually also have free-bed funds, which can be used to help pay for the care of undocumented patients, but some of these funds may be restricted for certain uses or populations.

As of Oct. 1, another source of Medicaid reimbursement became available for the care of undocumented immigrants not otherwise eligible. This is a four-year program that provides $250 million annually. Most of the money is intended for states with the highest proportion of undocumented immigrants. Participating hospitals in Connecticut will draw from a $930,000 pool of funds during the current fiscal year

The lack of adequate reimbursement means that hospital care for undocumented immigrants "is essentially an unfunded mandate at this time," said Kim Hostetler, vice president for administration and communications at the Connecticut Hospital Association.

Whatever the costs of that care, it hardly amounts to a bonanza for undocumented immigrants, observes Leighton Ku, a senior fellow at the Center on Budget and Policy Priorities, a non-partisan Washington think tank. Ku notes that it is expensive, illogical and inhumane to provide only emergency care for these residents.

"Research about what happens with the undocumented is always a little slippery," he said. "In general, undocumented aliens get substantially less health care than citizens, have huge health care needs and in many cases have never seen a doctor in their lives."

Stephen Zuckerman, a health economist at the Urban Institute, said undocumented immigrants are part of the larger population of uninsured individuals who can't afford to pay for care and end up putting it off until it becomes more serious and more expensive.

Gedge said businesses that employ illegal immigrants seem to take no responsibility when the workers get injured or sick. Ironically, the cost of uncompensated care is borne largely by the employers who pay for health coverage and, increasingly, by their employees through higher co-payments and premiums.

Immigration Implies Higher Health Care Costs