Running head: UNDOCUMENTED WORKERS AND HEALTH CARE

Undocumented Workers in America and Their Rights, Their Impact on Cost and Quality of Health Care, and What Needs to be Done About It Adrian Boone Jefferson Community College

Running head: UNDOCUMENTED WORKERS AND HEALTH CARE Undocumented Workers in America and Their Rights, Their Impact on Cost and Quality of Health Care, and What Needs to be Done About It Coming into the 2012 election year, the issues of health care and undocumented immigrants have become prevalent issues in a way that they have never been before: lengthy segments of GOP debates are dedicated to discussions about both concerns, and dozens of pundits on both sides of the political line have formed a grand echo chamber of speculation and conversation. Each topic is often discussed in a vacuum, but the two are inextricably linked. While it is true and unfortunately, often inevitable that discourse regarding illegal immigration is occasionally fueled by bigotry in the guise

of patriotism, the two issues share a connection that must be recognized and responded to. As it stands, America's approach to handling the health needs of illegal immigrants is deeply flawed. The nation's hospital system is often ill-equipped to deal with the needs of immigrants unfamiliar with the American health care system, and the way in which hospitals deal with the lack of paperwork and proper medical documentation exacerbates the issue. When hospitals have to soak up the expense of emergency care for undocumented non-citizens, it sends medical costs skyrocketing, making it more difficult for American citizens to afford preventative care. A new system must be developed a system that can elegantly handle the problems provided by undocumented workers and illegal immigrants in the hospital system, while simultaneously allowing them to retain their dignity, their rights, and their freedom as human beings. Granting service to and treating illegal immigrants and undocumented workers poses a unique question to those at the upper echelons of the health care industry: when should profit be set aside in favor of a non-citizen's well-being? How does a corporation an entity designed from the ground-up to make money for its shareholders above all else decide how much income they are willing to sacrifice for the sake of social obligation to your fellow man? As it turns out, they do not have much of a choice

Running head: UNDOCUMENTED WORKERS AND HEALTH CARE in the matter. In 1986, the United States Congress passed a law known as the Emergency Medical Treatment and Active Labor Act. ... (the) law, commonly known as the anti-dumping law, requires providers to stabilize patients regardless of their ability to pay, their insurance plan or their status as

U.S. citizens. (Trossman, 2004) Any health care provider that receives money from the Department of Health and Human Services under the Medicare program is obligated by federal law to treat a patient in an emergency situation, and to only discharge or transfer them under their own informed consent or if their condition requires transfer to a hospital better equipped to handle their needs. EMTALA is a godsend to undocumented workers and other non-citizens, as their immigration and legal status prohibits them from acquiring health insurance, and their often-dire financial situation often prevents them from being remotely capable of paying costs out of pocket. When faced with a lack of generalpurpose, all-encompassing federal health care program, a law that ensures those in emergency, potentially life-threatening medical situations receive the care they need no matter what is the next best thing. But how can America as a society do more? Stripping away the economics of hospitals and the law, the issue can boiled down to a single question: does society have a moral and ethical obligation to provide health care to its citizens to provide for their health and promote their continued well-being? As an extension of that topic, do societies have a moral and ethical obligation to provide health care to individuals who are not explicitly citizens of said society? James Dwyer makes a compelling case for the affirmative when he states: Why should society take responsibility for people it tried to keep out of its territory, for people who are not social members? Because in many respects illegal immigrants are social members. Although they are not citizens or legal residents, they may be diligent workers, good neighbors, concerned parents, and active participants in community life. They are workers, involved in complex schemes of social co-operation. Many of the most exploited workers in the industrial revolutionchildren, women, men without propertywere also

Running head: UNDOCUMENTED WORKERS AND HEALTH CARE not full citizens, but they were vulnerable people, doing often undesirable work, for whom society needed to take some responsibility. Undocumented workers' similar role in society is one reason that the social responsibility to care for them is different from the responsibility to care for medical visitors. (2004, 34-41)

A piece of commonly-heard rhetoric in the debate about undocumented workers and illegal immigrants it that they somewhere around 9.3 million unauthorized migrants (Cleaveland, 2010) ostensibly do the jobs that most Americans do not want to do low-paying, unskilled jobs such as agricultural harvesting and entry-level manufacturing and that as such they fill an important role in our production economy. While the theory of American unwillingness may or may not be actually true there are very few statistics to back up such an idea it cannot be denied that migrant workers make up an extremely integral piece of our economic system. Removing them from the equation would be akin to slicing the bottom off of a styrofoam cup: the nation's production economy would grind to a halt. It can therefore be successfully argued that due to their importance in the country's economy, migrant and undocumented workers are as important to society as genuine citizens are, and deserve to be treated with equal respect and consideration. Communication with an illegal immigrant or undocumented worker poses a difficult challenge to the doctor or nurse. As it stands, the hospital system in the first world revolves primarily around communication, record-keeping and documentation. When faced with a patient who may or may not speak English, and may or may not have any kind of documentation or past medical record the practitioner must wonder: where do they begin? What approach do they take? The system hospitals currently track patient data is only effective when operating under the assumption the patient is a legal citizen; the system retains and searches for information by Social Security number. If the patient does not have a Social Security number, such as an illegal immigrant or undocumented worker, the patient is for all intents and purposes invisible to the system. This makes the job of the medical practitioner much

Running head: UNDOCUMENTED WORKERS AND HEALTH CARE

more difficult without easy access to a patient's records and information, going through the process of discovering their medical history, including allergies and past surgeries and pre-existing conditions becomes an episode in frustration. As Schoevers writes for Ethnicity & Health: For vulnerable transient groups in our society like undocumented immigrants and the homeless, record keeping of sufficient quality is complicated. In these groups, access to health services is not available in a traditional manner. Patients often visit different physicians in different places. Therefore, it is difficult to obtain medical record information about patient history, test results, X-rays, and medication and management. The absence of this information is likely to influence the quality of care, because continuity of care contributes to a better quality of care. (2009, 498) These problems are worsened exponentially when a medical practitioner must deal with a patient who may only speak very little English, assuming that they speak English at all. While the high rates of multiculturalism in urban areas often makes it easier to find a temporary translator, in rural areas finding proper translation can be extremely problematic. The elaborate complications tied to simply being a non-citizen can instill a deep-seated fear of punishment and authority into an undocumented worker or illegal immigrant; this is troublesome to a health care practitioner, whose work depends heavily on trust and displays of authority and confidence. Such a negative legal environment breeds contempt and distrust, and can lead to drastic consequences. Patients are capable of outright denying assistance, and since this allows the hospital to discharge the patient without violating EMTALA normally an offense that can result in tens of thousands of dollars in fines levied against both the hospital and the individual practitioner that allowed the discharge hospitals can and will simply allow the patient to discharge himself, and be left to his own devices. There is nothing a hospital can do to retain a patient against his will by any legal means, and when a distrustful, paranoid or stubborn patient refuses care he is completely within his rights to deny it and

Running head: UNDOCUMENTED WORKERS AND HEALTH CARE leave. While this frees the hospital from financial obligations, it can be damaging to its reputation and prestige as a place of recovery and healing. Most regrettably at all, this breakdown in communication can lead to patient exploitation by hospitals and medical practitioners. When Martin Memorial Medical Center in Stuart, Florida chartered a private jet for an illegal immigrant in a vegetative state to be flown back to his home country of Guatemala, hospital officials claimed that they were simply honoring the patients wishes, but critics claimed that the hospital sought only to foist the cost of his care onto his home country. As written in Healthcare Risk Management: Court documents indicate the 37-year-old patient had been in a vegetative state for more than a year and the hospital had spent more than $1.5 million on his care over three years, says Tonello. The records indicate that Gaspar, his legal guardian, initially supported Jimenezs return to Guatemala, but then changed his mind Gaspar eventually won his appeal when a court ruled that a state judge doesnt have the power to decide immigration cases, Tonello says, but by then, Jimenez was in Guatemala. (2009) Jimenezs status as an illegal immigrant which ostensibly prevented him from receiving health insurance compounded with already-high costs of care and the social stigma of being an illegal

immigrant in America to have him be effectively deported by the Florida hospital, against the wishes of his legal guardian. In the face of such evidence, one can only come to the conclusion that the method by which the American medical system handles doctor-patient and hospital-patient interactions is deeply flawed, and is in serious need of revision, updating, and to be brought into the 21st century in ways that do not merely involved improved record-keeping algorithms and fancier equipment. It is not enough to treat them with the bare minimum of effort required simply for the sake of avoiding a violation of EMTALA; healthcare providers must treat them with the same respect and concern as they

Running head: UNDOCUMENTED WORKERS AND HEALTH CARE would treat a fully-ensured citizen of America, and nothing less. Opponents to the amnesty of illegal immigrants quote many talking points and motivations in their arguments, but one of the most frequently-cited claims is that liberal politicking and the cost of indigent care for undocumented workers and non-citizens has increased the cost of health care for

legitimate citizens, making it essentially impossible to afford any sort of emergency care without health insurance or federal assistance. The political rhetoric behind these claims is mostly unfounded EMTALA, the anti-dumping law was passed in 1986 under the Reagan presidency, deflating any claims of liberal or quasi-socialist ideology but a statistics do prove that treatment of illegal immigrants does cost hospitals and health care providers exorbitant sums of money. It stands to reason that when hospitals are then forced to eat those costs in the name of non-violation of EMTALA, that they must increase costs of health care to make up the difference. As Afua Baiden writes for JOCEPS: the Journal of Chi Eta Phi Sorority: Undocumented immigrants are costing the New Jersey state alone over a quarter of a billion dollars annually in health care alone. The annual cost of hospital Charity Care in New Jersey is almost one billion dollars. The burden of treating undocumented immigrants is estimated to be at least half of the uncompensated charity care and that brings the cost of treating this population to about half a billion dollars a year. (2010) Charity Care, as defined by the author of the article, is a payment assistance program put into place by New Jersey. It offers free or heavily-reduced-cost care to patients who receive in- and out-patient treatment at hospitals and acute care centers in the state. Charity Care can be seen as a logical extension of EMTALA: rather than being forcibly coerced by Congressional law into providing care for indigents, the state took the next step and began to offer discounted emergency care to those who cannot afford it. From a moral viewpoint, this is a very admirable act. It does wonders for the reputation of the hospital and ensures that nobody is ever denied emergency care due to cost or

Running head: UNDOCUMENTED WORKERS AND HEALTH CARE ignorance many Americans are completely ignorant to the existence of EMTALA, despite its heavy influence on the current costs of care by heavily advertising and promoting the service. However, from a purely financial standpoint the concept of Charity Care is a nightmare. Baiden claims that the annual cost of Charity Care in New Jersey is almost one billion dollars. That is an astronomical sum of money, and it does not take much of a stretch to assume such costs injure the bottom line of the hospital to a painful degree. On a federal level, the problem is even worse. As written by Jeff Tieman for Modern Healthcare: Last year's Medicare reform law set aside $1 billion over five years to help compensate hospitals that treat illegal immigrants in their emergency departments. That money has yet to be distributed, and won't be until the CMS determines what data it expects hospitals to produce to show how many immigrants they serve. As previously stated, $1 billion is a lot of money, and that figure has raised hackles among the right-

wing and conservative members of American society and the government. It is not an acceptable option to merely sever the lifeline, repeal EMTALA and pare back programs like Charity Care; such a destruction of infrastructure and support would be absolutely catastrophic to a demographic such as illegal immigrants, who are already massively disadvantaged due to their social and economic status in the West. It is difficult enough for undocumented migrants to acquire healthcare services at all, especially for those who reserve a percentage of their income to send to family members in Mexico as the authors of Access to and use of health services among undocumented Mexican immigrants in a US urban area write in said study: respondents sending remittances to family and friends in Mexico were less likely to report health insurance coverage, and those earning more informal income were not any more likely to

Running head: UNDOCUMENTED WORKERS AND HEALTH CARE

report health insurance coverage or access to a regular health care provider than were those who earned less informal income these results suggest that undocumented immigrants' financial resources,and spedfically their capacity to obtain formal employment, may be central determinants of their access to health services and likely of their health status overall. Day laborers who can barely scrape together enough income to feed themselves and their families across the border have enough trouble making ends meet without conservative lawmakers attempting to slash their benefits and social programs meant to assist them. To repeal or rescind these programs would be an incalculable blow to civil rights and civility in general it would reveal a viciousness and cruelty in the American political system that has not been seen since the Jim Crow era. As America presses further onward into the 21st century and the Information Age, all of the country particularly those in the healthcare industry must race to keep up. The systems and mechanics by which hospitals treat and inform their patients needs to change, and the inherent stigma and bigotry directed towards illegal and undocumented citizens must be broken down. Budgets need to be drawn to accommodate for the costs of these immigrants, and party lines must be blurred and breached for the sake of compromise. Illegal immigrants, undocumented workers, day laborers: all of these individuals provide an indispensible and invisible service to our nation, and they deserve to be treated with the same reverence and respect as anyone else; anything less would be morally reprehensible.

Running head: UNDOCUMENTED WORKERS AND HEALTH CARE References Baiden, A. (2010). The impact of undocumented aliens on healthcare: the case of a Northern New Jersey hospital. JOCEPS: The Journal Of Chi Eta Phi Sorority, 54(1), 5-6.

10

Cleaveland, C. (2010). "We are not criminals": social work advocacy and unauthorized migrants. Social Work, 55(1), 74-81.

Dwyer, J. (2004). Illegal immigrants, health care, and social responsibility. Hastings Center Report, 34(1), 34-41.

Hospital sends undocumented, uninsured immigrant home for care, wins civil suit. (2009). Healthcare Risk Management, 31(10), 109-112.

Nandi, A., Galea, S., Lopez, G., Nandi, V., Strongarone, S., & Ompad, D. (2008). Access to and use of health services among undocumented Mexican immigrants in a US urban area. American Journal Of Public Health, 98(11), 2011-2020.

Schoevers, M., MET, & Lagro-Janssen, A. (2009). Patient-held records for undocumented immigrants: a blind spot. A systematic review of patient-held records. Ethnicity & Health, 14(5), 497-508.

Tieman, J. (2004). Immigrant care costs hospitals. Modern Healthcare, 34(23), 14-15.

Trossman, S. (2004). No easy answers: addressing the needs of undocumented immigrants. American Nurse, 36(6), 1.

Running head: UNDOCUMENTED WORKERS AND HEALTH CARE

11