Katie Rucke
British comedian Gina Yashere once joked that if she were to be hit by a car in Los Angeles and lose her leg, it would be cheaper to buy two first class tickets back to England — one for her, one for her leg — than it would be to go to an American hospital without health insurance. But for many non-U.S. citizens, costs of the American health care system are no laughing matter — just ask the some undocumented 600 immigrants who have been sent back to their home countries in the past five years once U.S. hospitals learned the patient didn’t have enough money to cover their treatment.
In a report from the Center for Social Justice at Seton Hall University, “medical repatriation” cases were documented in at least 15 U.S. states, and involved patients from El Salvador, Guatemala, Honduras, Lithuania, Mexico, the Philippines and South Korea.
Polish people have also been affected. Barbara Latasiewicz was working as a housekeeper in the Chicago area and had no health insurance. While she was cleaning a bathtub in 2009, she had a stroke and became paralyzed on her left side. Latasiewicz came to the U.S. in 1990 on a temporary visa, but never left.
Adventist La Grange Memorial Hospital cared for Latasiewicz for two-and-a-half years, at a cost of more than $1.4 million. The hospital tried to find her long-term care, but she was denied by 30 facilities because she was undocumented.
In early 2012, the hospital arranged to move Latasiewicz to a stroke-specialty unit in Poland. Though she refused to consent to the transfer, fearing she would never be able to return to the U.S. — her home for the past 20 years — the hospital obtained a judge’s order allowing the transfer.
Another high-profile case involved a man from Mexico, Quelino Ojeda Jimenez, who was severely injured and needed support for quadriplegia after falling off a building at Chicago’s Midway Airport in 2010. Jimenez was working at the time and was brought to Christ Medical Center. The Chicago hospital used technology, such as a mechanical ventilator, to keep him alive and provided him with an appropriately skilled attendant to care for him.
Under the Emergency Medical Treatment and Active Labor Act, hospitals are required to treat all patients present for emergency care, regardless of ability to pay, immigration status or other accidental demographic features. But the law says nothing about caring for a patient once stabilized.
An immigrant’s inability to pay poses a large financial problem for hospitals once the “critical care” phase ends, since unlike American citizens, immigrants don’t qualify for government assistance for their medical bills. This inability to pay and lack of financial assistance results in many rehabilitation or long-term care facilities denying admittance to immigrants, and hospitals can’t keep patients long term.
Jimenez was kept at Christ Medical Center for four months, which cost about $650,000. Then in December 2010 — despite protests from his family — the hospital put Jimenez on a flight bound for Mexico. Jimenez was unable to speak, but cried as he was removed from the hospital.
The Mexican hospital Jimenez was moved to lacked the rehabilitation services he needed and was not able to afford new filters for his ventilator. After suffering two heart attacks and a septic infection, Jimenez died on Jan. 2, 2012.
Ethical deportation?
Mark Kuczewski is a professor of medical ethics at Loyola University Chicago Stritch School of Medicine. He says that when hospitals are caring for a patient, finances impact a decision on whether a patient should be sent away.
“The absence of a source of payment is a powerful disincentive for any facility to accept a patient in transfer from the hospital. In addition to the fiscal challenge treating these patients poses, it is perhaps equally disheartening to hospital caregivers to deliver long-term care once the patient’s acute medical needs have been met and the patients stabilized. The hospital is simply not a long-term care facility, but the patient typically must remain within the hospital for lack of an appropriate and willing provider.”
Kuczewski says the hospital’s decision to discharge a patient and send them back to their home country can be appropriate and is referred to as “medical repatriation.”
“I make the case that this can be an ethically acceptable option if particular conditions are met. Those conditions are: (1) Transfer must be able to be seen by a reasonable person as being in the patient’s best interests aside from the issue of reimbursement. (2) The hospital must exercise due diligence regarding the medical support available at the patient’s destination. (3) The patient or appropriate surrogate must give fully informed consent to being returned to another country.”
Bruce D. White is a board-certified pediatrician, a pharmacist and an attorney with fellowship training in clinical medical ethics. He says Kuczewski’s “conditions” for medical reparation are absurd.
“Using Dr. Kuczewski’s standard – one must ask if it will ever be possible to repatriate a foreign national to their native country’s medical system without obtaining consent – or what really amounts to permission – from the patient?
“Hospital frustration in dealing with the extended care of illegal immigrants has reached a pitched fever. The frustration seems akin to the political angst seen in Arizona and Alabama with their recent legislative attempts to deal with the illegal immigration problem at the state level given the inability of the federal government to better the situation at the national level. Hospital frustration with illegal immigrants’ unmet medical needs may lead to some facilities actually closing in a few communities because of unavailable financial resources, such as the closing of the outpatient dialysis service at Grady Memorial Hospital in Atlanta.”
While some legal scholars have suggested that these forced transfers are illegal, Kuczewski argues they are unethical based upon the values we hold in common regarding hospitals.
Still, White says if hospitals don’t deport immigrants, the health care the American public receives will be negatively affected.
“Closing services to all in the community versus sending illegal immigrants requiring prolonged rehabilitation needs back to their home country? That may be the choice that health care providers must face in the future as available financial resources become more scarce.”