Emergency Care for 'Illegal Immigrants'

[Peter Parker]

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Having rotated at Houston's main county hospital (Ben Taub), I'm inclined to follow the Parkland model discussed in the article ... where doctors aren't forced to become immigration police.

Thoughts? (let's keep it civilized, guys)

http://www.nytimes.com/2006/07/18/us/18immig.html

 

[GeneralVeers]

Having rotated at Houston's main county hospital (Ben Taub), I'm inclined to follow the Parkland model discussed in the article ... where doctors aren't forced to become immigration police.

Thoughts? (let's keep it civilized, guys)

http://www.nytimes.com/2006/07/18/us/18immig.html

It's a serious problem for us in South Central L.A. Our ED is often clogged with illegal immigrants, most of whom speak no English. This means increased wait times, and less access to healthcare for U.S. citizens who happen to be poor.

As tough as it sounds, we need to stop providing non-emergent care to illegals (i.e. no clinic visits, no treatment for leg pain x 15 years, etc).

Some days I'm so frustrated and pissed off, that I wished we had an INS bus in front of the hospital, so I could write an order for: "Discharge to INS van out front".

 

[BKN]

It's a serious problem for us in South Central L.A. Our ED is often clogged with illegal immigrants, most of whom speak no English. This means increased wait times, and less access to healthcare for U.S. citizens who happen to be poor.

As tough as it sounds, we need to stop providing non-emergent care to illegals (i.e. no clinic visits, no treatment for leg pain x 15 years, etc).

General Sir,

This is the word from the border, where we've been dealing with this for 50+ years. It isn't very simple. If you stop the non-emergent care, you'll just have more ED visits by sicker patients with neglected disease. If you want to lower the cost to us, provide the primary care and the meds.

BTW These folks live here, work here, pay taxes and social security here and have relatives who are citizens here. They are integrated into our society and provide work that few Americans are interested in doing. We can't do without them. Clearly we have to do something, but it won't be simple.

BKN

 

[TysonCook]

The only thing that really burns me (I agree w/BKN on the health part), is that 90% of who I see have been here for 5-10 years, yet speak zero english. I'm starting to learn spanish, just to speed up the dispo.

If you're new to america, I can understand, but if you've skipped learning to speak english for 10 years, I have a problem.

Just my $.02

 

[GeneralVeers]

General Sir,

This is the word from the border, where we've been dealing with this for 50+ years. It isn't very simple. If you stop the non-emergent care, you'll just have more ED visits by sicker patients with neglected disease. If you want to lower the cost to us, provide the primary care and the meds.

BTW These folks live here, work here, pay taxes and social security here and have relatives who are citizens here. They are integrated into our society and provide work that few Americans are interested in doing. We can't do without them. Clearly we have to do something, but it won't be simple.

BKN

None of that is an excuse or justification for breaking the law.

 

[ElZorro]

None of that is an excuse or justification for breaking the law.

I don't think we can possibly play the legal card here. Yes, it is illegal. But it would be essentially immoral for them not to come here. I mean think about it, if you had a family and lived in Mexico, and woke up every day in your crappy 1 bedroom hut (and that is being rather generous, I have seen how the poor in Mexico live) with your wife and kids, would you really care what the law in another country said? I think if you didn't take every action you could (w/in the code of morality) to provide a better life for your family you would be immoral, screw illegal. The problem is with the US not providing a more accesible route of immigration and regulating the businesses that hire them, and with Mexico for despite being wealthy in natural resources and an important geographic trade center, their corrupt government still battles poverty on a scale to rival the poorest countries in the world. But then again, its easy to identify the problem, just not the solution. I don't have a problem with people that want to work hard and earn an honest wage. I bet if you offered them a decent and fair health insurance plan most would take it. My problem is with the people who don't want to work, and would rather stay poor and on Medicaid / uninsured than take any personal initiative to solve their own problems. Thats a rant for another day...

 

[ElZorro]

repeat

 

[trkd]

Well put ElZorro. Agreed!

I am American due to my parents LEGAL migration here many years ago (not from Mexico). Their motive was to provide a better life for my brother and I. They were successful in doing this.

Now lets say that my parents never did this and I am living a sh** life across the border in Mexico. I know if I could just make it across the border to have a SEMI-decent life for me and my future kids. You bet this law-abiding girl I am today would be doing anything possible to get there, legally or not. It is not a matter of morals, it is a matter of survival sometimes. If it wasn't, would people be riding over the border under the hoods of semi's for 14 hours to get here. I think not. It may be a problem, but MY MORALS don't allow me to turn away these HUMAN BEINGS. Lets not be so cocky, people. Lets try to put ourselves in others' shoes. The fact that many of them are so hard working makes them more valuable than many people in our society that are citizens. If you don't believe me, swing by SoCal, Tex, Arizona, etc to see how hard they are working for mere pocketchange. Makes our doc salaries embarrassing.

I agree that I don't have a solution to this problem of adequate healthcare. However, I don't think turning these people away is the solution either.

 

[Ceez]

General Sir,

This is the word from the border, where we've been dealing with this for 50+ years. It isn't very simple. If you stop the non-emergent care, you'll just have more ED visits by sicker patients with neglected disease. If you want to lower the cost to us, provide the primary care and the meds.

BTW These folks live here, work here, pay taxes and social security here and have relatives who are citizens here. They are integrated into our society and provide work that few Americans are interested in doing. We can't do without them. Clearly we have to do something, but it won't be simple.

BKN

Very well put!!

 

[DropkickMurphy]

There's a belief that I hold that sometimes morality must lead one to violate or ignore the law in order to do what is right. Granted there are a few extreme exceptions to this (cannibalizing your dead friends to survive after a plane crash in the Andes, etc), but in this circumstance the moral thing to do is to provide care with essentially a blind eye turned towards someone's status with the INS. Our place is not to limit care to anyone, because that puts us on a very slippery slope towards rationalizing limiting access for other groups that are marginalized within society.

 

[Peter Parker]

BKN's argument is quite solid ... the issue of a patient's immigration status doesn't reduce the burden of disease on the system; it just shifts what is otherwise primary care to the ED (where EMTALA mandates coverage).

Removing non-emergent care for 'illegal immigrants' will mean that these individuals will present to the ED with even LATER-stage complications of manageable diseases like diabetes, all at a societal cost that is going to be greater in the long-run. Since they are now presenting with non-emergent care, it behooves us to take care of it then and there.

One (admittedly idealistic) solution to all this may involve national health insurance that is not employer-based. Do any of us have the time, will, or resources to consider breaking the private insurance oligopoly of 20% margins and 'cream-skimming?'

 

[DropkickMurphy]

The day there is national health insurance is the day the American health system begins it's nosedive into the ground as opposed to the recoverable flat spin we currently find ourselves in.

 

[ElZorro]

I've never understood why a city's hospitals can not join together to form their own insurance company. Hospital run, so no more of this crazy bill for 10,000 get 3000 business. The hospital bills the pt for the actual cost of the procedure + hopefully extremely minimal administrative cost. You could offer health insurance to all the citizens of a city at what I suspect would be a much cheaper rate than going with private insurance. Cut out the middle is basically what I am thinking. Give people a couple of different options as to the plan they might want. Maybe it only cover emergency and inpt care for a very cheap price. Make it available to immigrants...whether or not they are here illegally, I would prefer to get paid when I treat them. I really think this would work in a medium sized city- like 800,000. Somewhere where there are enough hospitals around to defray costs but not so many that you will get a logjam of bureaucracy. It really makes me mad when I think about insurance companies making fortunes off of doing nothing- they don't really provide any service, there job is to be the middle man. Make sure the pt pays more than they need to and make sure the doc makes less than he bills for. I really think a system that embraced immigrants in terms of incorporating them into the health care system would not only take a huge burden off health care, but also stand to be rather well compensated because believe it or not, there is alot of money to be made by providing services to this group.

 

[Peter Parker]

The day there is national health insurance is the day the American health system begins it's nosedive into the ground as opposed to the recoverable flat spin we currently find ourselves in.

Many would argue that we're already in the nosedive, perhaps even in terminal velocity.

Sure, the argument exists that a piecemeal system is holding things in place ... but that rosy thought gives way to the reality (faced in EDs all over the country, says the IOM) that the system is overstretched far beyond anything sustainable.

It's hard to see the situation improving without something drastic (apart from sops like Medicare Part D). Any suggestions out there?

 

[Peter Parker]

ElZorro, I think you're on to something ... I've heard of a community insurance program in New York City (perhaps affiliated with NY Methodist?) that covers ED and primary care.

Something on the order of $50 per family per month, offered to residents in a catchment area that includes an extraordinarily high percentage of uninsured in Brooklyn -- of all types of immigration status.

I believe the enrollment was a major success, and the revenues from the program were used to cover area ED deficits. To encourage enrollment and keep prices low, the hospitals reduced the standard insurance margin of 20-30% to a break-even amount, and offered a basic-care package. Sounds reasonable to me.

 

[ElZorro]

Having a community type health insurance would also decrease the burden on the ED if done correctly. A huge problem emergency physicians are faced with is the acute exacerbation of a chronic problem, that typically would not have occured given proper management/f/u with PCP. If you got the PCP to somehow be involved in this system, you would provide incentive for the pt to f/u regularly (they could actually afford it) and incentive for the PCP to greatly encourage his patients to f/u. Afterall, if we are part of the same system, an ED visit from his diabetic costs everybody a lot more than an office visit.

 

[MedicinePowder]

It's a serious problem for us in South Central L.A. Our ED is often clogged with illegal immigrants, most of whom speak no English. This means increased wait times, and less access to healthcare for U.S. citizens who happen to be poor.

As tough as it sounds, we need to stop providing non-emergent care to illegals (i.e. no clinic visits, no treatment for leg pain x 15 years, etc).

Some days I'm so frustrated and pissed off, that I wished we had an INS bus in front of the hospital, so I could write an order for: "Discharge to INS van out front".

stop whinning. when you're out in practice and you're able to suture-up lacerations and put in central lines, reduce dislocations etc etc with your eyes closed, it was these "criminals" that you owe your skills to. in my experience, latino people aren't whinners and in fact are very thankful of the care rendered--so i'm sure they naively over-looked your learning curve on them. so do me a favor, suck-it-up or either go to a residency with all White patients or leave the medical field and become an INS agent--that way you'll be happier.

 

[Jeff698]

My problem is with the people who don't want to work, and would rather stay poor and on Medicaid / uninsured than take any personal initiative to solve their own problems.

Agreed. In my experience the people you're talking about aren't the ones who went through hell itself to get here and work for crappy wages. They're born citizens. Makes me so optimistic for our future. Of course, maybe the work ethic of those 'damn illegals' will wear off on our legal citizens.

Take care,
Jeff

 

[Jeff698]

The day there is national health insurance is the day the American health system begins it's nosedive into the ground as opposed to the recoverable flat spin we currently find ourselves in.

You mean like Medicare, CHAMPUS, etc?

Yep, good thing there is no national health insurance.

Keep in mind universal health insurance, whether national or not, is not the same as federally provided health care.

Take care,
Jeff

 

[Miami_med]

It seems to me that without health insurance at all, most people on small wages could afford to pay for care of basic conditions. It is the existance of the current half government/half private insurance scheme that has driven the cost so high. How much can 15 minutes with a PCP and some generic meds cost every month or two. This has to average to less than the cost of cable or internet, or cigarettes.

The problem is the idea of equality as a virtue that outshines quality itself. Just as in Canada, with it multi-month waits for simple tests, equality always equals rationing, as the majority cannot afford cutting edge treatment. Giving someone high quality care that is ten years old (and was cutting edge at one time), while allowing those that are better off to finance the new cutting edge procedures will eventually cause a trickle down effect. 10 years later those expensive drugs and procedures become cheaper. The drugs are now generic. Eventually everyone is getting BETTER treatment.

Cash is the solution to the illegal immigration debacle and healthcare. Providing basic healthcare at a reasonable price (Without coding schemes, billing specialists, etc.) would allow basic services (Treatment of DM as an example) to be affordable for most on a menial wage and avoid the ED. Someone has to pay. If immigrants pay cash to a PCP, they are not taxing the system.

 

[flighterdoc]

We neither should stop providing medical care to illegals, or need to. All we need to do is secure the borders. Keep them out, and the costs will stabilize, and go down.

The US could build and man a secure wall across the US-southern border for far less than what illegals cost medicare in 1 year.

 

[SoCuteMD]

...yeah, I'm really tired.

 

[DropkickMurphy]

You mean like Medicare, CHAMPUS, etc?

Yep, good thing there is no national health insurance.

Keep in mind universal health insurance, whether national or not, is not the same as federally provided health care.

Take care,
Jeff

Excellent point Jeff, I overreacted. I hear anything involving national health care, and immediately envision my chosen career degrading into something like the mess in Canada.

 

[GeneralVeers]

As a LEGAL immigrant to this country, I will be taking my oath on Friday. It's taken 9 years and tons of time and effort to get this far. It was hard work, but I did it legally

I find it offensive that our government decides to look the other way and allow a select group of people to break the law because it's financially convenient to a group of business lobbyists. Fine, the Mexicans are wonderful, angelic people. Now come here legally, and respect the laws of this country.

 

[MatNeo]

I sympathize with people like GeneralVeers, who go through the trouble of becoming a legal US citizen, because if anyone can run/swim across the border and if it doesn't make much difference once they are here...what is the point of jumping through hoops??

As a country, the US has 2 immigration problems that it doesn't want to deal with at this (or any) time. First is the ability to enter the country illegally, too many people can slip across the border and move in unchecked. The second is what to do with the illegal immigrants living here, some have lived here for many years.

Unfortunately, this is an unpopular political place, because most political leaders only care about the number of supporters, and there are huge amounts of voting Mexican-Americans who are fierce supporters of the illegal immigrants. This is similar to the slavery issue before the civil war, no president could get a majority by taking a side, and when a strong-willed president came to office, the south left...I am way off topic here, so I'll end this rant...

BTW, I'm all for treating anyone in need of treatment, and though not being able to communicate can slow things down, I'd really rather not have to deal with the consequences of not treating the illegal immigrants.

 

[leviathan]

Excellent point Jeff, I overreacted. I hear anything involving national health care, and immediately envision my chosen career degrading into something like the mess in Canada.

Forgive me for my ignorance, but as a Canadian citizen who has used the medical system from time to time, I've got nothing but positive things to say about it. Likewise for older relatives and other seniors I talk with, their surgeries and medical care is also quite prompt and effective.

From an EM perspective, it seems to me like our emergency departments see wait times that are no longer than your departments. For most minor treatments in the ED, I usually see patients in and out the door within 1-3 hours, but I don't know how that compares to a US emergency department. The issue I see is one of long-term care patients who have to wait in an ED bed for sometimes up to 36 hours before a bed becomes available upstairs on the wards.

 

[MedicinePowder]

As a LEGAL immigrant to this country, I will be taking my oath on Friday. It's taken 9 years and tons of time and effort to get this far. It was hard work, but I did it legally

I find it offensive that our government decides to look the other way and allow a select group of people to break the law because it's financially convenient to a group of business lobbyists. Fine, the Mexicans are wonderful, angelic people. Now come here legally, and respect the laws of this country.

If you don't like this country, why don't you go back where you came from? Or better yet, why'd you come in the first place? If you are unhappy about treating a partcular ethnic group, you should've done your homework and not applied to a los angeles inner city residency. you would be better suited worrying about how to manage DKA in a CHFers than day dreaming about how a large INS bus can wisk away your patients who show up asking for help.

 

[GeneralVeers]

If you don't like this country, why don't you go back where you came from? Or better yet, why'd you come in the first place? If you are unhappy about treating a partcular ethnic group, you should've done your homework and not applied to a los angeles inner city residency. you would be better suited worrying about how to manage DKA in a CHFers than day dreaming about how a large INS bus can wisk away your patients who show up asking for help.

I take back everything I said. Illegal immigrants are wondeful. The United States should be spending our resources to improve the lives of the poor and dispossessed all over the world. Everyone else in the world is ENTITLED to take advantage of the United States, and we're obligated to spend our money to help them.

My argument has nothing to do with race/ethnicity. I have no difficulty treating hispanic patients who have gone to the effort of obtaining U.S. citizenship.

Approximately 30-40% of our patients are illegal immigrants. It's gotten to the point where I cannot even make a clinic appointment for any patients within 6 months time (I usually have them call to try to get "worked in"). If that 40% were legal U.S. residents with private insurance through an employer, or access to medicaid then the hospital clinics would have enough reimbursement to increase capacity in the clinics for all patients. L.A. County healthcare is on the verge of collapse right now, and county has been threatening to close or reduce services at all three county hospitals due to the enormous subsidies required to keep them running. I'm sure the problem is not unique , and most States have similar issues.

 

[Siggy]

If you don't like this country, why don't you go back where you came from? Or better yet, why'd you come in the first place? If you are unhappy about treating a partcular ethnic group, you should've done your homework and not applied to a los angeles inner city residency. you would be better suited worrying about how to manage DKA in a CHFers than day dreaming about how a large INS bus can wisk away your patients who show up asking for help.

Because we should be happy allowing criminal immigrants (since the term "illegal" is politically uncorrect) to stay in the country? Ohh, and discussion and debate on the how America should be is unamerican now?

 

[AmoryBlaine]

The day there is national health insurance is the day the American health system begins it's nosedive into the ground as opposed to the recoverable flat spin we currently find ourselves in.

Would that be a nosedive into a healthier, longer-living society like exists in all of these countries with national health care? Just wondering.

http://news.bbc.co.uk/2/hi/health/778385.stm

 

[Bill59]

The US could build and man a secure wall across the US-southern border for far less than what illegals cost medicare in 1 year.

... of course you'll need to hire illegals to do this.

 

[Miami_med]

Would that be a nosedive into a healthier, longer-living society like exists in all of these countries with national health care? Just wondering.

http://news.bbc.co.uk/2/hi/health/778385.stm

I'm not sure that a couple of years worth of life expectancy can be the judge of healthcare quality in a country. These statistics are also usually manipulated and not totally reliable to the month (Such as with the infant mortality stats where the US counts certain births and deaths infant mortality while other countries consider them infant deaths). These are also outdated by 5 years and are definitely low for many of the countries listed.

Besides, look at Americans. 2/3 overweight, horrible nutrition, etc... We have higher levels of street violence and traffic deaths than almost any developed country on earth. The fact that we can even compete is a compliment to how well the system is still functioning. Don't tell me that all of this would get better if people had more doctor counseling about eating habits, because I seriously doubt it. Everyone complains about the insurance companies and government reimbursement. Then people want to write to poorly functioning systems into stone.

By the way, before government started paying for healthcare in the US to the degree that it does, I believe we were doing relatively better compared to other countries at the time. We just administer a pseudosocialized system inefficiently. The vast majority of people die on Medicare and have coverage.

 

[Ceez]

... of course you'll need to hire illegals to do this.

LOL! Ain't that the truth.

 

[GeneralVeers]

Carlos Mencia had a joke about building the wall. He said that government would need illegals to build the wall, then have them "inspect" it on the Mexican side. While doing that they'd finish the wall and end up there.