Catastrophe in Care
Hospitals are being crippled by the costs of treating illegal
immigrants--and that could be just the start of an immigrant-related
health crisis
By LEO W. BANKS
Leo W. Banks
"It's not unusual to have one UDA (undocumented alien) cost $5,000,
and we know we're not going to get that back," says Josie Mincher,
emergency room manager at Copper Queen Hospital.
Leo W. Banks
"Until we have comprehensive immigration reform, we need to bear the
health-care costs for undocumented workers, whatever those costs are,"
says Rev. Tom Buechele.
If you drive along Southern Arizona's border with Mexico long enough,
you might see a lone illegal wandering the desert. Or maybe he's
hunched at the roadside sipping water from his milk jug. What's he
doing there, and where are his compatriots, the people he broke into
the country with?
The uninformed might ask those questions, but those who live with the
daily invasion across our open borders can make a pretty good guess
what's happening. The fellow got bounced from his group by the
coyote-guide. Two transgressions will get an illegal cut loose with
certainty: Either he can't pay, or he shows signs of tuberculosis.
You think these coyotes are fools? They don't want some hollow-eyed
lunger hacking and coughing blood on them. So it's adios, pal, and now
you're America's problem. But they know that already. Every illegal
realizes that if he makes it to an emergency room in Southern Arizona,
or anywhere around the country for that matter, he can get treatment,
free of charge.
It's federal law, and has been for 20 years. In its evolution, the
policy has become a kind of federal health insurance program for
illegals, and its rising costs are eating up resources that could
otherwise go to poor and uninsured American citizens. It has created a
financial nightmare for border hospitals and contributed to cutbacks
in services at Tucson hospitals.
Is this an outrage? A scandal? Some think it's both. But going back to
our active TB sufferer, here's something even worse: The guy can't get
treatment anywhere, goes underground and takes a job at a restaurant
in Tucson or L.A., and coughs his way to infecting scores of others.
Talk about a Hobson's choice. But as with everything in the ongoing
crisis of illegal immigration, the hard choices would largely
evaporate if the federal government fulfilled its constitutional duty
and took control of our border.
The threat illegal immigration poses to American public health plays
out every day at Arizona's hospitals. Until recently, the issue
remained only marginally public, a problem medical people batted
around among themselves, not with the media. Even today, several
hospitals contacted for this story declined comment.
The Copper Queen Hospital in Bisbee, one of the hardest hit, helped
break that barrier when CEO Jim Dickson began returning reporters'
calls, even though the subject, as he puts it, has become "like the
third rail. You don't want to touch it."
But his problem had grown severe. Dickson's uncompensated costs for
treating illegals rose from $35,000 in 1999 to $450,000 in 2004. His
total shortfall now sits at about $1.4 million, a hefty deficit for a
14-bed hospital. To make ends meet, he had to close, in June 2000, the
Copper Queen's long-term care facility, and cut back on staff and
hours, forcing some employees to take second jobs to survive.
The hospital has seen a ray of light, however. In the first months of
2005, the Copper Queen has gone back into surplus, in part because
more illegals are in Border Patrol custody when brought in to the
hospital. That means the Border Patrol must reimburse the Queen for
the cost. In the past, agents would drop injured illegals not in their
custody at the ER and take off, sticking the hospital with bills that
never got paid.
Another reason for the decrease, says Dickson: the Minuteman Project.
"It's been terrific for us in April," he says, cutting down on the
number of people coming across and therefore the number requiring ER
treatment. Dickson says the hospital wrote off about $6,000 in losses
in April this year, compared to about $35,000 in April 2004.
The central issue, though, remains in place--the hospital has had to
scale back health services to American citizens to treat illegals.
Bisbee isn't alone.
The most comprehensive study on the subject found that 24 counties in
four states bordering Mexico wracked up $190 million in unpaid
emergency medical bills caring for illegals in the year 2000. The
study, commissioned by the U.S.-Mexico Border Counties Coalition,
found that California spent $79 million of that; Texas, $74 million;
Arizona, $31 million; and New Mexico, $6 million.
Bear in mind that these numbers, the best available, are from 2000. We
can assume, with increasing rates of crossings since then, the costs
are considerably higher today. Nor do the above figures take into
account non-border counties. Treating illegals in Maricopa County
costs as much as $50 million a year, according to an estimate used by
Republican Sen. Jon Kyl. Nationally, American hospitals lose $1.45
billion a year.
The Medicare reform bill passed in 2003 allocated $1 billion to
reimburse states for federally mandated ER care given to
illegals--about $45 million a year of that to come to Arizona over
four years. But even that, some hospital staffers say, is little more
than a Band-Aid on a huge problem.
Ruth Kish, director of patient care services at Copper Queen, expects
that under the repayment formula, her hospital will receive only 10
cents of every dollar they spend on illegals. "But every bit helps,"
says Kish.
Another factor: The counties in the above-mentioned study spent an
additional $13 million in 2000 on emergency transportation, such as
helicopters and ambulances, to pick up illegals injured after sneaking
across the line.
The Bisbee Fire Department's ambulance responds to about one of these
calls a day during the summer, says Chief Jack Earnest. Asked how many
of these patients pay up, Earnest wasn't sure, and recommended
contacting the billing office in Sierra Vista. The billing office knew
exactly how often illegals pay their ambulance bills--never.
But there's another category--Mexicans injured in Mexico who call
American ambulances for help. By federal law, they have to respond,
which makes Bisbee's Copper Queen the trauma center of choice for
Sonora's northern frontier.
The calls come from Naco, Sonora, the town across the line just south
of Bisbee, where, in spite of widespread poverty, cell phones are
popular, and everybody knows the Americans are bound by law to treat
them.
"When we get a call we go, and we don't ask where the person's from,"
says Earnest. Naco residents needing care go to the port of entry and
declare an emergency to American officials. When they're waved
through, they're transported to the Copper Queen's ER in Bisbee's
ambulance, or they drive themselves in private cars.
The policy is called Compassionate Entry, and it applies to hospitals
up and down the line. The Copper Queen averages about five such cases
a month. Some abuse the privilege, says ER Manager Josie Mincher.
She's seen Compassionate Entries with bad sore throats and others who
aren't sick at all. One pregnant girl landed in the ER recently
complaining of morning sickness.
Most are seriously sick, though, and the staff rushes to help,
"because that's what we do," says Mincher. But it doesn't take much to
blow the budget. "Just walking in the door is $400," says Mincher.
"It's not unusual to have one UDA (undocumented alien) cost $5,000,
and we know we're not going to get that back. We're playing with
monopoly money here."
Here's an example of how one patient can wrack up a huge bill:
A young Mexican man had a bad auto accident across the line and was
taken to Douglas' Southeast Arizona Medical Center with severe
neurological problems. After being stabilized there, he was
transferred to Barrow's Neurological Center in Phoenix.
He spent a costly month there, courtesy of the Center, and was
transferred--with a tracheotomy tube in his throat and supplies to
clean it, also provided gratis by Barrow's--to a hospital in
Hermosillo. That facility kept him less than a day before releasing
him to his home in Naco. But for reasons no one can explain, the
Hermosillo hospital kept his trach kit and cleaning supplies.
As a result, he became septic--a bad infection--and came through the
Naco port under Compassionate Entry to the Copper Queen. He spent
three days there, then the staff sent him off, with more free
supplies, to a clinic in Agua Prieta for continued care.
How much did this fellow cost the American health care system? A
figure of a quarter-million dollars would surprise no one. Cost to the
Copper Queen? Almost $6,000, and they got none of it back.
Northern Cochise Community Hospital is in Willcox, far enough from the
border that it doesn't get patients crossing the line for health care.
But that doesn't mean it escapes the invasion.
CEO Chris Cronberg loses about $100,000 a year caring for illegals,
mostly those injured in traffic accidents when their loaded vehicle
flips while speeding north. "It's not make or break for us," says
Cronberg. "But as a small hospital, we depend on cash, and those are
dollars that aren't coming in, so it has an impact."
The same is true at Sierra Vista Regional Health Center, according to
Vice President Marie Wurth. She expects the hospital to lose $250,000
this year treating those who jump the line, get hurt doing it and
don't pay their bills.
The big squeeze is on in Tucson, too. Tucson Medical Center loses an
estimated $4 million every year treating illegals.
The corresponding figure at UMC, which includes some foreign
nationals, was $3.5 million for fiscal 2004, a $2 million increase
from the previous year. Part of that is attributable to UMC, in July
2003, becoming Tucson's only Level One trauma center, meaning it saw
the most serious cases.
Chief Financial Officer Kevin Burns says the hospital's re-payment
rate for treating illegals is about 5 cents on the dollar. "It's very
expensive for us and continues to grow," says Burns, who says many
illegals, as well as uninsured Americans, use his ER like a primary
care physician. "We hear anecdotally that people come here from across
the border because they know they can get cared for, and if they
present at the ER, they can get that care at no cost."
The federal law that put the hospitals on the hook for the medical
bills of illegals goes by the acronym EMTALA--Emergency Medical
Treatment and Active Labor Act. It says that anybody who shows up in
an ER must get screened, treated and stabilized, regardless of
citizenship or ability to pay.
But since its passage in 1985, the definition of emergency has evolved
to include just about anything, and because Congress didn't fund the
requirement, hospitals have had to eat the costs as word has spread
that the federal goodie wagon is parked at the ER door.
In cities with huge illegal populations, such as Los Angeles, the
effects have been disastrous. In its spring 2005 issue, the Journal of
American Physicians and Surgeons reported that between 1993 and 2003,
60 California hospitals closed because, for several reasons including
EMTALA, half of their services became unpaid.
Another 24 are near closing, says author Madeleine Pelner Cosman. She
also writes that in 1983, before EMTALA, L.A. County put together a
trauma network that was "one of America's finest emergency med
response organizations."
A mere 22 years later--again, in part because of EMTALA--Cosman says
the system is coming apart, with most trauma hospitals having left the
network, along with physicians, surgeons and others.
The law has caused a similar situation in Tucson, on a smaller scale.
"With EMTALA, the government created an unfunded national health
insurance program, and it has caused real problems in this community,"
says Dr. Herb McReynolds, who works for a company that manages the ER
department for St. Mary's Hospital, which treats a large number of
illegals.
Lawmakers wrote the legislation to prevent patient dumping--in which
one hospital refuses to accept, say, an uninsured woman in labor,
telling ambulance personnel to take her to the county hospital
instead.
It stopped that practice. But it has caused a big increase in the
amount of un-reimbursed care that hospitals provide, and in
McReynolds' words, "made physicians rethink their careers and
lifestyles."
"The price of it has come over time, because after so much
uncompensated care, it forces physicians off our call list," says
McReynolds. "Physicians have a practice to go to the next day and a
family, and ask themselves, do I really want to be up at 2 a.m.
providing care when I won't get comp, and I can still get sued?"
Some docs have removed themselves from on-call lists by going to work
at outpatient surgical centers not affiliated with a hospital. Others
stay on call, but limit the amount of time they're available. A
neurosurgeon might take call one day a week, and that satisfies the
law. EMTALA says that you must provide a reasonable amount of
coverage, without being strict or specific about how much that is.
McReynolds says that EMTALA--in tandem with the malpractice
crisis--has caused the loss of medical coverage at many hospitals
around the country and in Tucson, including St. Mary's.
"Several years ago we had five neurosurgeons on staff here, and now we
have two," he says. "We had hand surgery coverage every day, and now
we have it one week a month. We used to have full ob-gyn coverage, and
now they've left and gone to TMC. We have no ob-gyn and one
gynecologist on staff covering emergencies one day a week."
With docs all over Tucson running for cover, trying to stay off call
and away from ERs, the variety of emergency health care available to
Tucsonans has seriously diminished. And here's the most maddening
irony of all: The feds now reimburse American hospitals for treating
non-paying illegals, but not for treating American citizens.
Exception: Those eligible for care under Federal Emergency Services, a
fairly restrictive program.
For a year and a half now, UMC has approached non-paying illegals in a
novel way--it actually reports them to immigration officials.
"Some people find that cold, but we have a responsibility to protect
this charitable asset (hospital)," says CFO Burns, adding that UMC's
status as a public entity requires a different approach. "Our belief
is that to the extent people have ability to pay, we expect them to."
After triaging and stabilizing an ER patient, the hospital sets out to
learn who that patient is, and how he or she plans to pay. To those
who are uninsured and underinsured, the hospital offers the option of
applying for its innovative Charity Care program. Under it, the
hospital charges the patient the same rate it would receive for that
service from Medicare, a possible reduction of up to 70 percent.
Patients unable to pay at that discounted rate are eligible for
further discounts that can tear up the bill entirely. To apply for
Charity Care, the patient need only return to the hospital with a W-2
or other documents. Those who cooperate and return with the required
documents don't get reported to the feds.
But the hospital does report those who take the medical care and run.
How many illegals cooperate with this generous offer? Ten percent.
Burns says UMC began reporting the 90 percent who don't pay in
November of 2003. So far, they've reported 565 persons. Why start
reporting?
"Maybe a bit of it was born of frustration because people use our
resources and make no effort to work with us and pay," he says. "Even
if part of the population doesn't pay, I still have to hire new people
and buy and upgrade equipment, which costs $15-$20 million a year.
When you have these strains on resources, from foreign citizens and as
well as Medicaid patients, you have to manage cash flow very
carefully."
As with most issues related to the illegal invasion, those who live
along the Mexican border, the scene of the crime, have the best view.
Where health issues are concerned, it's not a pretty sight.
Residents say they've come across ground dotted with discarded pills,
syringes containing nobody knows what, and used needles. Some report
riding horses along creek beds, popular pull-up areas for groups
heading north, and finding 70 or 80 piles of human feces, some of it
blackened and running with blood.
It's as disgraceful as it is disgusting--and it raises a question:
What happens when rain washes all this into the water supply? Is it a
threat to spread diseases such as hepatitis? Some believe it might be.
What happens when cows drink from these contaminated creeks? And what
happens when this constant flow of Third World humanity goes north,
fanning out all across Arizona and the country? What kind of diseases
do they bring with them?
ER workers like Mincher live with that question every day. "We protect
ourselves best we can," she says, "but if somebody comes in with a
contagious disease, I might as well buy the farm, because I don't know
what it is. A lot of times, they don't know what they have either. If
they came off a ranch in southern Mexico, they've had no
immunizations, no health care, nothing."
Most of what she sees at Copper Queen--around 75 percent--is
orthopedic, falls suffered while jumping fences, for instance.
Dehydration, too. Some of these are pregnant women nine months along,
who, in Mincher's words, "are so desperate to have their babies born
in the U.S., they'll do whatever it takes."
She sees cardiac-related cases among illegals who've been given crack,
methamphetamine or speed by their coyote so they can keep walking. But
she's also treated illegals with active chicken pox, tuberculosis, all
varieties of hepatitis and AIDS.
The Web and print media are full of stories about the diseases
illegals carry, and their effect on American health. But some writers
make alarming claims with sketchy evidence at best. In the cases of
two diseases, however--Chagas and tuberculosis--the evidence is
clearer that they're indeed coming across our border.
Chagas, a potentially fatal illness spread by contact with the feces
of the reduviid bug, called the "kissing bug," is prevalent in South
and Central America. Fifteen million people in that region are
infected with the parasite, and 50,000 die of it every year, according
to the World Health Organization. A person can be infected for 10 or
20 years or more before showing symptoms, making it particularly
insidious. At its most severe, the disease can cause the heart to
fail, and literally explode.
In the United States? Louis Kirchhoff, of the University of Iowa
Medical School, estimates that between 80,000 and 120,000 Latin
Americans with Chagas live here. Matching prevalence studies and
immigration numbers, Kirchhoff figures about 10 Chagas-infected
persons entered every day from Mexico alone in the 1990s.
The disease can be transmitted four ways, but for Americans, the most
worrisome is the blood supply. In the United States overall, the
chance of contracting Chagas from a blood transfusion is small, one in
25,000, according to David Leiby, a research scientist at the American
Red Cross in Washington.
But in cities with high populations from Latin America, the numbers
fall to much riskier levels. In Miami, for example, the chance is one
on 9,000. In L.A., 1 in 5,400.
Researchers have confirmed seven cases of people contracting Chagas
through blood transfusions--five in the U.S., two in Canada--and they
say the number of unknown cases is probably much higher.
"A rate of one in 5,400 is something we're concerned about," says
Leiby, adding that the FDA is still a few years away from a useable
blood-screening test. "Chagas is overlooked by the health care system
in the United States. Our physicians aren't aware of it and wouldn't
recognize it in most cases."
Tuberculosis, which also shows up in high rates in Mexico, is
migrating north as well. Many assume a place like Cochise County,
right on the border and overrun by illegals, would have a high
incidence of TB. But it doesn't, says Edith Sampson, of the Cochise
County Health Department. "The immigrants only pass through here on
the way to Atlanta, or whatever city they're going to," she says.
Exactly the problem--which is a big reason why 53 percent of the TB in
the United States in 2003 was among foreign-born persons, up from 29
percent in 1993, according to the Centers for Disease Control. In
L.A., again because of its huge illegal population, the figure is
closer to 80 percent.
Only 15,000 Americans suffer from active TB, the only dangerous kind
because it can be passed to someone else, usually by coughing and
expelling the bacteria from the throat or lungs. That's a small
number, but the New York Academy of Sciences estimates that each
victim will "infect 10 or 20 or more people--in whom the disease will
likely remain latent, creating the potential time-bomb effect."
The State Health Department says that Arizona had 295 reported cases
of active TB in 2003, a jump from the previous year. Why the increase?
More of the disease was found among kids under 5 years old and
prisoners. The latter were mostly Immigration and Customs Enforcement
detainees--in other words, illegals.
Sixty-eight percent of Arizona's foreign-born TB cases are from
Mexico, says state health. Will TB return to the United States in a
big way?
It hasn't yet, says Lee Reichman, executive director of the New Jersey
Medical School's National Tuberculosis Center. But he adds that with
globalization--the ability to get around the world in 20 hours--and
because "we can't stop people from getting in to this country, no
matter how hard we try," the potential exists for a new epidemic.
His particular concern is with multi-drug-resistant TB, fatal in 60
percent of cases. This strain requires a long regimen of costly drugs
that illegals are unlikely to take, or have access to. Arizona has a
small number of MDR-TB cases, and all of them in the past five years
have been among foreign-born persons.
"The reason you haven't heard about TB here is that good public health
is working," says Reichman. "People who are symptomatic go to
physicians, and the physicians don't ask questions. As soon as you
have to ID yourself, or say we're going to send you back to Mexico,
these people go into hiding and spread more TB. Any physician who
cares about being a physician isn't going to ask those questions,
because he took an oath to treat sick people."
The Copper Queen's Rush Kish says that under Medicare reimbursement
guides, her hospital cannot ask patients if they are in the country
illegally. But how do you bill the feds to get money back for treating
illegals if you can't ask if someone is illegal?
Well, you play a little Orwellian word game, probing around the issue
with a list of government-approved questions, then make educated
assumptions. But the illegal holds the trump card, because he can
refuse to answer every question. "We don't know yet what evidence
Medicare will accept when we apply for reimbursement," says Kish. "But
at least we can begin documenting the enormity of this problem."
The question isn't whether those with genuine emergencies should get
treatment. Of course they should. In Naco, residents have no access to
ER care and many would die if they didn't get to the Copper Queen. The
real question is: Who pays?
Rev. Tom Buechele, pastor at St. John's Episcopal Church in Bisbee,
thinks it's appropriate for the federal government to keep ponying up,
as long as American companies "maintain their illegal trafficking in
human labor."
"Until we have comprehensive immigration reform, we need to bear the
health-care costs for undocumented workers, whatever those costs are,"
says Buechele, who, for almost a year now, has been running a free
monthly clinic in Naco, Arizona, catering to the poor and uninsured on
both sides of the line.
Although they talk a different language, politicians, even
Republicans, promote policies that further Buechele's liberal vision.
They boast to constituents that they've saved border hospitals by
pushing through the Medicare reimbursement plan, which provides a
relatively small amount of money over four years.
But that's another Hobson's choice, which is to say no choice at all.
What do you do, let hospitals go under? Kyl, who pushed to get the
reimbursement money, says an emphatic no.
"If we want those ERs to be there for us, then we'd better keep them
in business," says the Arizona senator. "If our hospitals are required
by federal law to treat anybody who comes into the ER, and the federal
government has failed to control the border, then it's appropriate for
the government to reimburse these hospitals."
But some argue that the system as it stands now, with EMTALA firmly in
place, is rigged to produce two results: The federal treasury will
remain wide open to illegals, and that all but guarantees that more
and more of them will bust the line to get here.
After all, this is the end of the rainbow for them, where jobs await,
education is free, health care is free. Who wouldn't come? And the
more they come, the more American health suffers--from such diseases
as Chagas and TB, further cutbacks in hospital services to American
citizens, and even possible closures.
Where's the compassion in that? Copper Queen ER nurse Josie Mincher,
herself Hispanic, puts her health, and possibly her life, on the line
to treat illegals. Listen to the emotion in her voice as she describes
what that's like:
"I go to work every day feeling like I'm on a torture wrack. My
heartstrings get pulled in one direction by these sick people I want
to help. Because I'm Hispanic, I know how they live. And I'm pulled in
the other direction, too, thinking that if our hospitals aren't
around, where do I take my own kids?
"But we have to treat them because of EMTALA. It says that anybody who
comes within 250 yards of an ER gets treatment. What would happen to
Safeway if the law said anyone who comes within 250 yards of the store
gets free food? They'd go out of business. Well, we're a business,
too."
Mincher's solution? "Send the bills to Mexico. If it affected them
financially, they might do something about all these people coming
across. My grandparents came here legally, and it took a long time and
a lot of money. They respected the law. These people just walk across
now. They weren't brought up the same way."
Burns at UMC says he wants the U.S. and Mexican governments to work
together to find a solution. But, as Kyl cautions, don't expect any
breakthrough soon. Mexico benefits far too much from our illegal
immigration nightmare--in jobs for its citizens and cash sent home--to
step up with money to care for its own people.
Until the border brought under control and the invasion stopped, we'll
continue to pay the bills of people who illegally tiptoed across the
line in the dead of night.
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