Un Unfair Burden? - Undocumented Immigrants Just Part of Larger Uninsured Problem for ERs

• WASHINGTON   

    As immigration and healthcare continue to be at the forefront of debate by our state and national leaders, hospital emergency rooms face their own healthcare-immigration debate; how much will this cost us and how do we pay for it?

“We seek to provide effective, compassionate care to those we serve, especially the poor and the underserved,” said Don Beeler, president and CEO of CHRISTUS Santa Rosa Hospital in San Antonio.  “The greatest financial challenge is to care for those who do not have the ability to pay and still operate in the black.”

A study commissioned by the United States/Mexico Border Counties Coalition released in 2002, concluded that border hospitals in the 24 counties in Texas, California, Arizona, and New Mexico that adjoin the Mexican border spent over $200 million combined in hospital emergency rooms treating undocumented immigrants that do not have health insurance; $74 million of that was spent by the 15 Texas border counties.  Only California spent more with $79 million.

These amounts do not account for financial losses associated with physicians who treat patients in emergency rooms, nor losses related to extended or follow-up care, because they are billed separately and were outside the scope of the study.

“The impact of undocumented/uninsured varies based on the county you live in and it places an unfair burden on the county that does provide the services,” said Leni Kirkman, executive director of Public and Media Relations for the University Health System at San Antonio, one of only a few public hospital systems in the state. 

When speaking to hospital officials, they can’t pinpoint how much they spend on the undocumented, but they do have a hold on the amount being spent on the uninsured, which may or may not be undocumented. 

“In total we see about 110,000 patients a year in our emergency room; we don’t know how many of those are undocumented because we don’t ask that question,” said Beeler “The uninsured is a big concern.”

He estimates the uninsured at his facility make up nearly 20 percent of the hospital’s emergency room operating budget totaling about $4 million in uncompensated or uninsured care.

U. S. Census Bureau data indicates that Texas ranks first in the number of uninsured patients in the country with one in four Texans under sixty-five not having any form of health coverage. 

Surprising to most, the vast amount of uninsured in Texas are not necessarily immigrants; though, they do make up a portion of the uninsured.

Studies show that while non-citizens/immigrants do have high uninsured rates of about 40-50 percent due to their employment in low-wage jobs that are less likely to offer health coverage, their overall uninsured numbers are small compared to the uninsured U.S. population as a whole.  Seventy-nine percent of the uninsured are American citizens.

According to reports released by the Henry J. Kaiser Family Foundation, undocumented immigrants do make up a large portion of the uninsured; however, the largest numbers of uninsured between 2000 and 2003 were citizens who lost their coverage due to a lack of employer sponsored insurance programs, or drops by the state and federally supported insurance programs including Medicaid and CHIP.

The Kaiser Commission Report on Medicaid and the Uninsured released in October 2005 looked at three different time periods between 1994 and 2003 and concluded, “Immigration trends are not responsible, in large part, for the increase in the numbers of uninsured in this country.”

The report evaluated the time periods of 1994-1998; 1998-2000; and 2000-2003 to reflect differences in the economy and levels of immigration.  Researchers concluded that aside from 1998-2000 when employer sponsored insurance rates for documented and undocumented individuals were high due to an “extreme rapid economic growth and very tight labor market,” the growth in the uninsured is largely among native citizens.

“Over the 2000-2003 period, the number of newly uninsured native citizens was three times greater than the number of newly uninsured non-citizens. We conclude that the 1998-2000 period was an aberration and the periods both before and after 1998-2000 suggest that native citizens account for most of those losing coverage,” stated the report.

Most working-age Americans rely on and receive health insurance through employer-sponsored health coverage for them and their families.  In Texas, the working-age population with employer-sponsored coverage is fifty-three percent, which is well below the nation of sixty-one percent, and it continues to decline. Small business owners are even less likely to offer health insurance due to the rising premium costs.

“The uninsured is a nationwide issue; in Texas it is a much bigger issue than it is nationally,” said Beeler.  “We have a system based on employer-based coverage and yet employers are not required to provide it or it is too expensive for their employees to obtain it.” 

“The system we have in place is inconsistent and it is kind of a random system,” he added. “I don’t believe everyone has minimum access.”

For most hospitals, the changes in immigration reform won’t solve the healthcare crisis issue. Changes in healthcare reform will do more to solve that. 

“We don’t track if they are undocumented, but rather we track if they are a resident of the county, and we are seeing tremendous numbers of individuals in our emergency rooms that reside outside of Bexar County,” said Kirkman. “We are trying to find resources for these uninsured people living outside the county.  It is a huge concern and a reflection on the broken health care system.”

The Emergency Medical Treatment and Active Labor Act, known as EMTALA, requires hospital emergency rooms to treat patients, yet provides little, if any, financial support for treating undocumented immigrants or uninsured individuals.

“It is just like saying, ‘if people don’t have money for groceries, then let HEB cover it all’,” said Beeler. “It doesn’t work that way. The reality of it is, healthcare and hospitals specifically have a huge economic impact on jobs and if we don’t reinvest in that, then we can ultimately affect our own economies.”

The purpose of the law written in 1986 was to ensure that all patients received necessary emergency treatment regardless of their ability to pay.  The intention of the law was to keep hospital emergency rooms from turning away patients.

“As ERs throughout this country are getting more and more crowded, it does become more of an access issue,” said Beeler. “The federal government keeps cutting Medicaid rates and well physicians can’t just keep running a business like that. EMTALA clearly shifts it back to the ER.”

Health insurance coverage is a major determinant of access to care, as well as access to a regular source of care and having a recent contact with a health care provider, concluded the Centers for Disease Control (CDC) and Prevention in their 2005 Chartbook on Trends in the Health of Americans. 

In 2003, uninsured persons under sixty-five years of age were about three times as likely as insured persons to have had no health care visits within the past twelve months, indicated the report.

When the uninsured do become sick, they turn to emergency rooms because they do not have access to primary care and they know they will be seen and treated in the emergency room.

The National Coalition on Health Care concludes that about 20 percent of all people who lack health insurance report turning to the ER for what is often general or routine care. In contrast, only 3 percent of those with insurance coverage use the ER for basic care.

“We see people with significant problems coming into our ER—cancer, for example. But if the person is not a resident in our county, then we don’t have a way to help,” said Kirkman.  “We would treat her for her immediate pains (in the ER) but not chemotherapy.  We would refer her back to her county or other local clinic, and good luck in finding an oncologist who will be willing to serve her if she does not have a way to pay.”

As a whole in 2004, Texas hospitals expended $9.2 billion in uncompensated health care costs, which includes all bad debt and charity care; that’s according to the American Hospital Association annual survey done in conjunction with its Texas counterpart.  Nationally, $25 billion was expended in uncompensated health care costs.

In order to remain in operation, hospitals must make up the shortfalls of caring for the uninsured.  Shortfalls are typically covered by shifting costs to other areas including increased rates for insured patients and employers.

“Nationally, healthcare is a problem being borne by local tax payers,” said Kirkman.  “The uninsured are a burden on hospitals and the result is a cost shift to the funded patients.  Hospitals are having to increase rates to cover their costs to keep the lights on and such.”

As more and more patients use the hospital emergency room as their primary source of care, prices continue to rise resulting in less individuals and employers able to afford already high insurance premiums. Consequently, more and more Texans are becoming uninsured.

“First we need to deal with it and put it at a higher priority in the country—at a federal and state level and focus in on prevention,” said Beeler “We have a greater healthcare system than most nations, but we spend more money on emergency care than most other nations do.”

Hospital systems throughout the state and nation have become creative in their efforts to reduce overall hospital expenses.

Project Access in Dallas County began in 1998 as a way to increase access to healthcare for the uninsured.  Today, they reach over 600 patients that are working, but make 200 percent below the federal poverty line and can’t receive coverage from any other source. There are over 700 physicians in all areas of practice that provide services. Also involved are 15 hospitals and many other clinics and pharmacies throughout the area. 

According to their Web site the working poor residents of Dallas have received more than $3.3 million in free care and $387,000 in medications. 

A current study underway through funds provided by the CDC is looking at Project Access and whether it has reduced the use of emergency room visits of the uninsured in the area by using community based assistance. 

“I can tell you that our preliminary findings indicate a significant relationship between reduced emergency department utilization and costs on the one hand, and enrollment in a care delivery system where patients can receive access to care on the other,” said Mark J. DeHaven, Ph.D. associate professor and vice chair chief of the Division of Community Medicine at the University of Texas Southwestern Medical Center Department of Family and Community Medicine in Dallas, who is currently conducting the research. “I believe our findings indicate that prevention works.”

“We/our policymakers need to make sure that we have a system in place that provides the same level of coverage for everyone,” said Beeler.  “We look at it from a societal perspective for other services that we know we must have to protect the common good like roads, fire departments and police.”

“As a society, we have an overall responsibility to ensure that our citizens are educated and healthy,” he added. “We need to treat this issue as big of a concern as we do the threat of terrorism; if people in our community don’t have access to healthcare, it threatens their ability to learn for kids and get better jobs.  Health and education are two key components that we need to put high priority on.” • DT