Undocumented Patients — Healthcare Dilemma, Social Work Challenge
By Alice Kitchen, LCSW, MPA
Social Work Today
Vol. 5 No. 3 P. 32

Despite what legal violations may exist, social workers see undocumented patients as individuals with healthcare needs. Meeting those needs is both a challenge and an opportunity for advocacy.

Social workers who have worked with undocumented patients in healthcare settings across the United States need no introduction to the major challenges these patients and their families present. While no case could be called typical, the following examples suggest the range of interventions that are frequently required.

Two Cases
Pediatric Case
A 12-year-old girl arrives in the emergency department (ED) of a Midwestern hospital with a diagnosis of a fast-spreading cancerous facial tumor. The mother brought her daughter from a small pueblo in central Mexico at the recommendation of a relative living in the United States. The ED staff consulted with the oncology department, and the child was admitted. Due to the nature of the diagnosis, the child was stabilized, as is required by the Emergency Medical Treatment and Labor Act (EMTALA).

Continued follow-up treatment was extensive as the condition trajectory was life-limiting and, as is true for a large percentage of patients with this condition, the patient died within one year. The social worker made sure the basics were covered—interpreter services provided, assessment (case finding) completed, social and emotional impact of the medical condition discussed, supportive services given, and connection to culturally appropriate community resources made. In cases such as this, where the family is from outside the United States, the task of finding a local support system requires extra tenacity.

Young Adult Case
A 17-year-old male was brought to a pediatric hospital by way of Life Flight air ambulance from a small town near a large urban community. The young man was in a coma without family or anyone to tell the paramedics what happened or where the nearest relatives could be found. The social worker spent extensive time doing investigative work through the paramedics to trace the referral to the small town. Several weeks later, thanks to laboriously tracking down all leads, a relative surfaced and eventually connection was made with the patient’s mother in southern Mexico.

Daily, the medical staff followed all leads to diagnose the condition with little information to work on. Lab and test results were sent to a number of other medical centers across the United States. Every possible diagnosis was considered—from drug overdose to rabies. After many months, the social worker, with the assistance of the state senator’s office, was able to assist the family in an air flight transfer to the patient’s home in Mexico. This is not the typical outcome of many of these cases. The patient often languishes in the hospital or nursing home for months and sometimes years.

On November 10, 2004, the Consortium of Health Care Social Work Organizations approved a position paper titled “Undocumented Patients: Health Care Dilemma.” The purpose of the paper was to pull together information on public policies regarding undocumented patients and to review these within the framework of social work values. It is hoped that, with the information the paper provides as a foundation, social work practitioners will be better prepared to respond to the daily challenges this population presents and to advocate for needed changes. This article highlights the points made in the position paper.

Challenges and Dilemmas
Some challenges an undocumented individual faces when needing healthcare include the following:

• No healthcare insurance can mean no treatment or delayed treatment. Sometimes, emergency care may be covered but inpatient treatment is billed. Available coverage for both inpatient and outpatient care varies from state to state.

• Needed care is often delayed due to fear of being reported and deported.

• Language barriers frequently create communication obstacles that interfere with patient care.

• Unpaid bills may be sent to collections despite a lack of resources to pay—and collection agents are often relentless in pursuit of nonexistent funds.

The U.S. healthcare system faces many challenges when treating undocumented individuals—several of these being the opposite of the challenges faced by the patient—including the following:

• It is difficult to find reimbursement for treatment. Limited sources of public or private insurance are available due to eligibility regulations or lack of employer coverage.

• The limited availability of primary care physicians who will take undocumented patients often causes a domino effect of delaying treatment, which in turn means choosing emergency care as the entry point to the system.

• Political considerations can inhibit treatment when resulting from individual and institutional beliefs and values about citizenship and entitlement to healthcare.

• Regulatory and legislative actions sometimes restrict healthcare treatment for undocumented individuals.

Among the dilemmas the healthcare providers regularly face are: What can the provider do if treatment was started prior to realizing the patient’s noncitizen status? Can a healthcare provider stop the course of medical care?

EMTALA requires providers to stabilize the patient. Patients who come into the hospital through the ED are often transferred to intensive care and ongoing treatment. Patients who do not come through the ED may be refused treatment in some settings. Clearly, many providers continue care regardless of ability to pay or citizenship status. Some providers have policies that do not provide medical treatment for those outside their geographic catchment area.

The social worker likewise faces numerous dilemmas. If the patient is not insured, who will be the payor? If the patient needs follow-up care, who will provide the care and who will cover the care if the social worker finds a skilled nursing home or other appropriate setting? Social workers juggle the competing roles of being an advocate for the client and working for an institution that places high value on staying solvent.

Public Funding of Healthcare for Noncitizens
At present, there is no coherent public policy on undocumented patients. On the global level, competing tensions between law enforcement and immigration services are worsening. Despite the fact that immigration is a federal responsibility, medical providers, who have a legal and ethical responsibility to save lives regardless of immigration status, and state and local governments currently bear most of the costs for services provided to immigrants. In September 2004, according to Senator John McCain, “the U.S./Mexico Border Counties Coalition found that our nation’s hospitals spent close to $190 million in 2000 to provide healthcare to undocumented immigrants.”

EDs have become the “safety net” for the uninsured, many of whom are undocumented. Considerable evidence exists that traces the reality of the EDs’ experience in serving this population. EDs are open 24 hours a day, even when the emergency assistance pantry and free health clinic are closed.

Starting in 1986, as a result of SOBRA (the Sixth Omnibus Budget Reconciliation Act) federal funding changes, states were allowed to elect emergency- and pregnancy-related coverage for immigrants who did not previously meet the residency or categorical guidelines. Not all states have elected to provide either or both types of coverage because of the burdensome federal requirements to participate.

Until the passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), noncitizens qualified for Medicaid coverage if they met income guidelines and were lawfully admitted for permanent residence or were living permanently in the United States. They continue to be eligible for Medicaid if they are here on a green card (permanent resident alien) or have other legal status. The eligibility criteria for unrestricted Medicaid have changed for those who entered after the 1996 act, requiring that certain residency criteria be met.

Eligibility for other categorical programs such as TANF (Temporary Assistance to Needy Families) and food stamps reflected the same new restrictions, creating a subpopulation that became financially more at risk while decreasing their ability to secure medical care. Programs that previously had been available to a legal resident were no longer available unless the individual met both the need and earned income criteria (eg, Supplemental Security Income).

The flexibility offered to the states has created an enlarged network of legal residents who are uninsured or underinsured, depending on where they live. Those most affected are the undocumented who may have resided and worked in the community, paying taxes and supporting the economy, but are unable to utilize the benefits. However, even the recent immigrant, legally admitted, can no longer depend on a safety net given the vagaries of the economy.

Implications for Social Work Practice
Social work practice in the United States has its origin in the settlement house movement starting with Hull House in Chicago. Settlement houses served the immigrant population, with public health clearly part of Jane Addams’s agenda. Distinctions between legal and not legal seldom show up in the literature. In 1996, the PRWORA changed the eligibility for many of the public benefits, impacting the more recently arrived legal resident aliens. This was a major shift in public policy. It was aimed at reducing illegal immigration as well as protecting public resources but had the unintended consequence of exacerbating the burden on the disproportionate provider. Previously, some of these individuals could have been eligible for some public benefits, including healthcare. Now the reimbursement varies, depending on the state of residence and the state’s buy-in to the restricted program such as emergency- and pregnancy-related services for undocumented residents.

Social workers see the deleterious effect of this policy change on this underserved population. Social workers in healthcare see these individuals as patients with healthcare needs. Legal status is not a criterion for social work services. Services generally focus on adjustment to illness, crisis intervention, counseling, assessment of possible abuse/neglect, connection to basis resources (food, lodging, transportation), and financial assistance to name a few. Services rendered unique to the undocumented population are connection to legal services from Legal Aid, free law clinics or law practices specializing in immigration matters, and understanding their rights for services.

Social workers face daunting challenges when patients are admitted to the hospital with no support system, have limited English proficiency, and no money. This dilemma is multiplied when the patient needs to be transferred to a nursing home, rehab center, or specialty setting. Untold dollars are wasted when a patient is stuck in an acute care facility simply because he or she cannot be placed due to a lack of benefits. Individual states have addressed this problem by utilizing Medicaid under PRUCOL (Permanent Residence Under Color of Law), which allows Medicaid for otherwise ineligible patients who require long-term placement.

The Worst Is Yet to Come?
There are a growing number of voices wanting to prohibit the use of public healthcare dollars for services for the undocumented. Legislation with this aim has been introduced at the federal and state levels. Legal opinions have been given in response to the ambiguity posed by the shift in public benefits under the PRWORA.

One opinion given by the Texas Attorney General in 2000 found that a large Houston public hospital would be violating the law if they gave discounted or free care to noncitizens. The opinion further stated that the district could be sanctioned for spending public funds for an unauthorized purpose. This chilling interpretation of the law raises serious ethical and humanitarian concerns, not only for social workers but public health officials and communities at large that recognize the benefits of preventive care in reducing the overall cost of medical care.

Advocacy by Social Workers
Social work practitioners can bring an important voice to the table during public policy debates on healthcare for undocumented persons. Here are some steps social workers can take to get started:

1. Study public healthcare funding sources, including Medicaid, publicly sponsored high-risk pools, and public health funding for noncitizens (documented and undocumented) in your state.

2. Review the availability of safety net clinics, free health clinics, and community mental health services.

3. Become familiar with other resources available to noncitizens in your state.

4. Gather data on the estimated number of noncitizens in your state. Seek out information by state on the amount of uncompensated care. Also seek information on numbers of those paying employee taxes into the system without hope of benefiting from their taxes.

5. Seek out patient care information and uncompensated cost figures for the undocumented patients in your organization.

6. Push for full compliance in your organization for the implementation of the Civil Rights Act on Limited English Proficiency regulations.

7. Advocate for increased funding for those providers who do provide treatment for the undocumented and for your state to buy into emergency- and pregnancy-related restricted Medicaid, if they are not already participating.

8. Work with your legislators serving on the healthcare committee to influence the expansion or restoration of coverage for noncitizens.

9. Review the federal legislative proposals that impact noncitizens—the DREAM (Development, Relief, and Education for Alien Minors) Act and the guest worker program of the administration, and NAFTA (North American Free Trade Agreement) and the laws governing legal immigration (state department) and border control (homeland security).

10. Encourage your institution to implement the national standards for Culturally and Linguistically Appropriate Services in Health Care.

11. Advocate border justice by expressing concern to federal-level elected officials about the policies that support legal avenues for migration and engenders economic conditions in the home country to reduce the out-migration to the United States.

12. Work with your congressional delegation to support a mutually beneficial public policy toward our neighbors to ensure that those countries have economies that provide the means for their citizens to support their families.

— Alice Kitchen, LCSW, MPA, is the director of social work and community services, Children’s Mercy Hospitals and Clinics. This department includes the International Patient Program and Interpreter Services. Kitchen teaches at Kansas University School of Social Welfare, is past president of the Society of Social Work Leadership in Health Care, and former member of the American Hospital Association Political Action Committee.