Health Care for seriously injured and ill immigrants - Examined by The New York Times
10 11 08 - 12:56
Deported in a Coma, Saved Back in U.S.
By DEBORAH SONTAG
GILA BEND, Ariz. — Soon after Antonio Torres, a husky 19-year-old farmworker, suffered catastrophic injuries in a car accident last June, a Phoenix hospital began making plans for his repatriation to Mexico.
Mr. Torres was comatose and connected to a ventilator. He was also a legal immigrant whose family lives and works in the purple alfalfa fields of this southwestern town. But he was uninsured. So the hospital disregarded the strenuous objections of his grief-stricken parents and sent Mr. Torres on a four-hour journey over the California border into Mexicali.
For days, Mr. Torres languished in a busy emergency room there, but his parents, Jesús and Gloria Torres, were not about to give up on him. Although many uninsured immigrants have been repatriated by American hospitals, few have seen their journey take the U-turn that the Torreses engineered for their son. They found a hospital in California willing to treat him, loaded him into a donated ambulance and drove him back into the United States as a potentially deadly infection raged through his system.
By summer’s end, despite the grimmest of prognoses from the hospital in Phoenix, Mr. Torres had not only survived but thrived. Newly discharged from rehabilitation in California, he was haltingly walking, talking and, hoisting his cane to his shoulder like a rifle, performing a silent, comic, effortful imitation of a marching soldier.
“We’re trying to be good stewards of the resources we have,” said Sister Margaret McBride, a hospital vice president. “We’re trying to make sure that the acute-care hospital is available for individuals who need acute care. We can’t keep someone forever.”
By contrast, the other hospital, El Centro Regional Medical Center in California, said it never sends an immigrant over the border. “We don’t export patients,” said David R. Green, its chief executive. “I can understand the frustrations of other hospitals, but the flip side is the human being element.”
Hospitals are required to screen and treat all those who arrive at their emergency rooms. But they receive only partial compensation for illegal immigrants, through emergency Medicaid and, for the last few years, through Section 1011 of the Medicare Modernization Act of 2003, a program that expired in October. That partial coverage ends when the patient is stabilized.
But hospitals are also required to discharge safely patients who need continuing care, leading to their quandary: they generally cannot find nursing homes to accept illegal immigrants, or legal ones with less than five years’ residency, because long-term care is not covered by emergency Medicaid.
Some states and localities provide their own long-term care coverage for uninsured immigrants, and those exceptions demonstrate the demand. In California, the Medi-Cal program spent about $20 million on about 460 patients last year. In New York City, illegal immigrants occupy about a fifth of the 1,389 beds in the public nursing home on Roosevelt Island.
Hospitals have limited options in discharging immigrant patients who need continuing care: keeping them indefinitely, with or without providing rehabilitation; finding them charity beds or subsidizing them at nursing homes; sending them home to relatives; or repatriating them.
“We have to be very, very creative,” said Cara Pacione, director of social work at Mount Sinai Hospital in Chicago.
Foreign consular officials say that areas with longstanding immigrant populations tend to handle such patients more humanely — with the exception of Arizona, where hostility toward illegal immigrants is high and state financing for their care is low.
“We put an asterisk by Arizona,” said a Mexican diplomat in Washington.
Hospitals need consulates’ assistance in finding relatives and health care options in patients’ homelands as well as in obtaining travel documents. The relationship is complicated and often contentious, as expressed bluntly by Alan Kelly, vice president of Scottsdale Healthcare in Arizona.
“The Mexican consulate here is — how do I put it? — obstructionist,” Mr. Kelly said.
He described the situation with illegal immigrant patients as he sees it: “Somebody falls out of a walnut tree. They show up in our Trauma One center. We don’t have any problem with treating or stabilizing them. It’s the humane thing to do. That’s not where the costs run up. The costs run up after they’re moved out of the trauma unit into a regular bed. Nobody, no nursing home, wants to take them. Then, it’s like, ‘Mexican government, take responsibility for your own citizens!’ But you play games with them. They turn away. They basically say, ‘No habla.’ ”
Mexican officials, unsurprisingly, see it differently. “We cooperate with the families, not with the hospital,” Jorge Solchaga, a Mexican consular official in Phoenix, said. “Our principal objective is to help our compatriots.”
Still, Mr. Solchaga said that his office worked collaboratively with hospitals and oversaw 80 medical repatriations from Phoenix to Mexico in 2007.
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“In Arizona, apparently, they see us as beasts of burden that can be dumped back over the border when we have outlived our usefulness,” the elder Mr. Torres, who is 47, said in Spanish. “But we outwitted them. We were not going to let our son die. And look at him now!”
Antonio Torres’s experience sharply illustrates the haphazard way in which the American health care system handles cases involving uninsured immigrants who are gravely injured or seriously ill. Whether these patients receive sustained care in this country or are privately deported by a hospital depends on what emergency room they initially visit.
There is only limited federal financing for these fragile patients, and no governmental oversight of what happens to them. Instead, it is left to individual hospitals, many of whom see themselves as stranded at the crossroads of a failed immigration policy and a failed health care system, to cut through a thicket of financial, legal and ethical concerns.
That creates a burden. “It’s a killer,” said Brian Conway, spokesman for the Greater New York Hospital Association. But it also establishes the potential for neglectful and unethical if not illegal behavior by hospitals.
“The opportunity to turn your back is there,” said Dr. Stephen Larson, a migrant health expert and physician at the Hospital of the University of Pennsylvania. “You’re given an out by there not being formal regulations. The question is whether or not litigation, or prosecution, catches up and hospitals start to be held liable.”
In October, the California Medical Association, responding to an article in The New York Times about the medical deportation of a brain-injured Guatemalan, passed a resolution opposing the forced repatriation of patients. The American Medical Association is to take up the matter on Sunday at a national meeting in Orlando.
“While we empathize with hospitals that must provide uncompensated care to undocumented immigrants,” said Dr. Robert Margolin, a trustee of the California association, “we overwhelmingly oppose the practice of repatriating patients without their consent.”
An examination by The Times of cases across the country involving seriously injured and ill immigrants shows patients at the mercy of hospitals and hospitals at the mercy of a system that provides neither compensation nor guidance. Taken together, the cases reveal a playbook of improvised responses, from aggressive to compassionate.
In the case of Elliott Bustamante, a hospital in Tucson moved speedily, and ultimately unsuccessfully, to transfer a sickly infant to Mexico, ignoring the mother’s opposition and the fact that Elliott was an American citizen born with Down syndrome and a heart problem at that very hospital.
In the case of Kong Fong Yu, in contrast, a Manhattan hospital has proceeded less decisively, keeping Mr. Yu, a stroke victim, as a boarder for 18 months now as it grapples with whether to send him back to China or to subsidize him in a nursing home indefinitely.
And in the case of Darwin Castro, an illegal immigrant from Honduras, an Oklahoma City hospital forwent repatriation yet discharged Mr. Castro, a brain-injured patient who needed 24-hour care, to a young relative who also happened to be an illegal immigrant, living in the shadows and ill-equipped to care for him.
The Dilemma
Hospitals consider these fragile patients to be a vexing challenge. Theirs are protracted, expensive cases that force hospitals to make fateful decisions or assume long-term responsibility for needy immigrants who are, essentially, left at their doorsteps.
The two American hospitals treating Antonio Torres approached his case from distinctly different perspectives. St. Joseph’s in Phoenix, with a focus on keeping down the rising cost of uncompensated care, repatriates about eight uninsured patients a month.