By the terms of a 1986 federal law, illegal immigrants (and uninsured citizens) cannot be denied hospital “emergency” medical care. In practice, this has meant that all hospitals (public and private, profit and nonprofit), fearing lawsuits, examine and treat all who enter their emergency rooms and admit them to the hospital if necessary whether or not such patients have any ability to pay for the services rendered. In some cases the required hospital care can cost millions of dollars and can go on for years. For many hospitals this is a substantial financial burden as well as a burden on the citizens of the community which the hospital serves.
In a widely watched case, on July 27, 2009 a jury in Stuart, Florida found that a local hospital, Martin Memorial Medical Center (located in Martin County, Florida), did not act unreasonably when it chartered a plane at a cost of $30,000 and sent a seriously brain-damaged illegal-immigrant Guatemalan patient to a medical facility in his home country in 2003 after treating him from 2001 to 2003 at a cost of $1.5 million. The jury reached its decision in about one day of deliberations following a three week trial in which Martin Memorial was the defendant in a civil case. This case highlights the Catch-22 problem hospitals have with those indigent patients for whom hospitals receive little or no reimbursement for medical expenses: they cannot legally discharge the patient if the patient still needs medical care and there is no rehab facility or other hospital facility in this country or in the patient’s home country who will agree to take the patient. This Martin Memorial case may be the first to test the legality of cross-border transfers without the consent of patients or their guardians.
Following the jury’s decision the hospital’s chief executive praised the decision and decried the failure of politicians to provide reimbursement to hospitals for unpaid immigrant medical care. Moreover, he noted that: “Unfortunately none of the proposed national health care reform bills currently being debated in Washington address the issue.”
Details related to this case and some general comments about similar hospital cases may be found in Deborah Sontag, “Immigrants Facing Deportation by U.S. Hospitals,” New York Times (August 3, 2008) and Deborah Sontag, “Jury Rules for Hospital That Deported Patient,” New York Times (July 28, 2009).
The following is from the April, 2009 testimony of a representative of Martin Memorial given before a committee of the Florida legislature:
“I am Carol Plato. I am from Martin County, and I am Director of Corporate Business Services for Martin Memorial Medical Center. I just have a brief couple of stories to tell you about. In 2001 we had a Guatemalan, an illegal patient, in our hospital. He was there from 2001 until 2003. He had over $1.5 million in healthcare services. We forcibly returned him to his home country of Guatemala at our own cost of $30,000. You ask why am I telling you about a case that happened in 2003? Because today that case is not over; we have spent and are spending up to a quarter of a million dollars in legal fees because his family here in the United States is suing us because they think it was inappropriate for us to return this illegal patient to his home country. Currently, as of today, I have a patient from Mexico who has been in my hospital for 760 days. He has severe brain damage, he has no family, no friends. His charges to date for almost 2 years is $1.5 million and we have contacted the Mexican Consulate four times; we have contacted Immigration, and nobody will help us return this patient to Mexico. We are even willing to spend our own $30,000 to return this patient. We can’t get anyone to help us with that. . . . One of the major problems that healthcare institutions have today that you need to be aware of is ongoing care. If somebody comes into our emergency rooms, we don’t turn them away, but if somebody comes into our emergency room and they have renal failure, and they require dialysis -- right now I have six patients, illegal, undocumented patients that we are seeing every 3 days for renal dialysis. For all of this that I’ve talked to you about, we have received no reimbursement. This obviously affects all of us in this room, our healthcare costs are severely affected by this. I also would like to end with pointing out that a large percentage of the babies born in our facility are from illegal parents.”
Chairman:
“Thank you. I do have one quick question from Representative (?)”
Representative:
“Sorry, I know there are a lot of speakers. Ma’am, when you know that they are illegal and come to your hospital, do you report them to the federal authorities to come get them?”
Carol Plato:
“We have tried and we have been told on numerous occasions that they are only interested if a crime has been committed. And from what I understand it seems like they are not even interested then.”
Representative:
“So the fact that they are illegal is not enough crime.”
Carol Plato:
“Correct”
As noted in Brian Grow and Robert Berner, “Fresh Pain for the Uninsured,” BusinessWeek, December 3, 2007: “When they don’t get paid immediately, hospitals typically recover around 10 cents on the dollar owed, even when they hire collection specialists.” The underlying theme of this article as suggested by its title is that “a growing number of hospitals, working with a range of financial companies, are squeezing revenue from patients with little or no health insurance.” Thus uninsured or underinsured American citizens may have to pay hospitals something after using hospital services, depending on their ability to pay. In the cases of illegal immigrants who have no financial resources or who give hospitals fictitious names and addresses, hospitals are not likely to recover any money at all for services rendered.
Most illegal immigrants do not have health insurance and pay very little in taxes because their incomes are so low and because an estimated 50 percent work “off the books,” and therefore pay no income or social security taxes at all. Moreover, many illegals have parented children here giving rise to still more health bills as well as public education expenses which average about $8000 per pupil per year in public schools. In addition, our poor immigrants access various forms of public assistance and other public services. Most assistance or public services used by immigrants or their families are paid for by citizen taxpayers.
In the case of health care, hospitals receive little or no state or federal reimbursement for immigrant use of hospital services which means that hospitals must pass on these costs through in higher charges to paying patients, primarily users with some form of health insurance, or close their doors. Consequently, users or their employers end up paying more for health insurance policies and/or face higher deductibles and co-pays as a direct result of the unpaid medical expenses of illegal immigrants and their children. In 2007 the passthrough of unpaid hospital expenses was estimated to cost each insured Californian about $455 per year (see an op-ed written by the chief executive of Scripps Health in San Diego County, Chris Van Gorder, “Health Care – The Governor’s Plan,” San Diego Union - Tribune, March 2, 2007). In this same op-ed it is noted that financial pressures contributed to the closure of 65 emergency rooms and 70 acute care hospitals in California during the previous decade. In the words of C. Duane Dauner at the time he was president of the California Hospital Association: "Emergency rooms and hospital doctors are forced to subsidize the lack of immigration enforcement by the federal government." Quote from: Julia Preston, “Texas Hospitals’ Separate Paths Reflect the Debate on Immigration,” New York Times, July 18, 2006.
To date most of the illegal immigrant users of unreimbursed hospital medical services likely work and live in the U.S. and have low incomes and few asssets. Many are working off the books or as independent contractors without health insurance. Others work part-time or are otherwise not covered by any employer health plan.
In the future we may see increasing numbers of non-citizens with serious illnesses visit the U.S. for the primary purpose of obtaining free high quality health care unavailable to them in their own countries. Given the ease of entering the U.S. legally (for example, as tourists, to visit relatives, or for educational or business purposes) or illegally, given our existing law requiring hospitals to treat all who enter their emergency rooms, and given the desperation of seriously ill people of little means in the many countries with inadequate or non-existent health care systems for the poor, it is to be expected that over time we will become the medical salvation for increasing numbers of the world’s poor – all at the expense of American hospitals and American citizens.
Still another set of users of unpaid and unreimbursed hospital medical services are pregnant women who come to the U.S. to have their childbirth within a higher quality medical situation than is available to them in their home country. An additional attraction to these women is the knowledge that under American law any childbirth within the U.S. conveys to the newborn automatic American citizenship irrespective of the status of the parents.
