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Hospitals Fly Immigrants Back To Native Countries

MICHEL MARTIN, host:

I'm Michel Martin, and this is Tell Me More from NPR News. Coming up, our international briefing focuses on Africa today. We'll get an update on the coup in Mauritania and new charges of French collaboration in the Rwandan genocide. But first, we want to talk about healthcare and illegal immigration.

Healthcare has become a major front in the battle over illegal immigration, as many Americans have become convinced that long waits in emergency rooms are the result of uninsured illegal immigrants getting care they can't pay for and don't deserve. And indeed, healthcare providers already struggling to pay for other uninsured patients are facing tough questions about how to balance ethical and legal obligations with their rising costs.

Now, the New York Times reports that some institutions have become unlikely immigration enforcers, effectively deporting seriously ill undocumented immigrants who cannot pay for long-term care. Joining us to talk about this issue is NPR health correspondent Joanne Silberner. We also hope to be joined by Dr. Jay Wolfson, who is a professor of public health and law at the University of South Florida. Welcome, thank you for talking to us.

JOANNE SILBERNER: Well, thank you.

MARTIN: Joanne, this recent New York Times report says that some hospitals have begun transporting seriously ill illegal immigrants and, in fact, some legal immigrants who require long-term care back to their home countries. I think most people are under the impression that hospitals have to treat people regardless of their status or ability to pay. So how is this possible that they can even do this?

SILBERNER: It's the long-term care part of it. They are required to stabilize - to treat and stabilize anyone who comes through their doors. If they've got an open working emergency room, they have to take care of them, but once the person is stabilized, they can transport them. I'm not aware of any federal law that says that they can't transport them out of the country.

MARTIN: So the issue is that there's a gray area there or a lack of guidelines, if you will?

SILBERNER: There's a lack of guidelines in terms of the transport. Afterwards, there is some case law now in Florida that - there's been a judicial decision there, but there's no - the federal government has not addressed this issue in any way except to say that, if you show up in an emergency room, and you're having a heart attack, or you're having some other extreme immediate problem, they have to take you in. They have to stabilize you.

MARTIN: But once that you've been stabilized, that's kind of where it's sort of up in the air.

SILBERNER: That's where that gray zone begins.

MARTIN: But the Times focus on the case of a man named Luis Jimenez. He is an undocumented immigrant. He was sent back to Guatemala by Martin Memorial Hospital in Florida. I should mention that we invited a representative of Martin Memorial to join our conversation, and they declined. But can you tell us a little bit more about this case? Joanne, what is it that - why did the hospital feel that they need to transport him back?

SILBERNER: Well, it's really an interesting case and a lot of ethical angles and it - I'll start at the very beginning, and it was eight years ago that Mr. Jimenez was hit by a drunk driver who is driving a stolen car. This guy was uninsured. The hospital couldn't - when Mr. Jimenez came to the door, he was in very bad shape. In fact, he was in a coma for a year and a half. They had to take him in. They had to stabilize him.

Then they started looking for somewhere else to go. They ended up spending a million and a half dollars on him. That's a lot of money. And somebody has to pay that money. They couldn't find a place for him. They contacted the Guatemalan government, which finally agreed to take him in. They put him into a clean and nice - in Guatemalan terms, a nice rehab hospital, the nicest one that they had there. In our terms, visitors said that there wasn't a lot of sophisticated equipment like you would find in the U.S. hospital.

So and then that hospital, after treating him pretty well, discharged him to a public hospital that, according to all accounts, was not a place anybody would want to be or be sent. And then finally, his family came and saw him there. They took him home. Then the story gets interesting in its own right because you're thinking this a tragedy. This is horrible.

But a group who went out to see him, including a priest and a lawyer and a paralegal, came away saying, in this little home, this little tiny hilltop home in Guatemala where he was with his mother, he was actually happy. He seemed to be doing well. So in the end, it might have been a good thing for him, but you can see where it could be a tragedy if things had gone wrong.

MARTIN: But the particular issue was at this hospital in Guatemala, which was not able to match the level of care he was getting in the U.S., but there was nobody in the U.S. to pay for this care.

SILBERNER: Exactly.

MARTIN: That's the issue. Dr Wilson, I understand he has joined us. Dr. Wilson, I'm sorry, Dr. Wolfson, thank you for joining us. And I guess, we've lost him again. So Joanne, we'll stick with you. How wide - Dr. Wolfson, are you with us?

Dr. JAY WOLFSON (Professor of Public Health and Medicine, University of South Florida): I'm there. I'm here with you, yes.

MARTIN: All right. Thank you so much for joining us. Dr. Wolfson, you're familiar with the - sort of the facts of the cases reported by the New York Times. How widespread do you think this practice is of hospitals transporting seriously ill patients because they don't have any other way to pay for their care and transporting them back to their home countries?

Dr. WOLFSON: Well, we don't really know a lot about how often it happens except for those documented cases that were presented in the Times article. If it happens, oftentimes, it'll be done quietly. It'll be done between the family and the hospital or between the hospital and the government, and it really is going to depend on the country.

I think it would be very different doing things with Europe, Eastern Europe and other parts of the world than it might be with places in South America. It will be different between Argentina and Guatemala because of the political realities. So I think what you're seeing is probably just the tip of an iceberg.

But it really relates to something fundamentally more important, and that is, for many years in this country, we've had a problem with how do we pay for care to the medically indigent, whether people are citizens or immigrants or illegal immigrants or otherwise. We don't have the resources, the time, the energy oftentimes to provide care, especially for the chronically ill.

So hospitals and healthcare providers for many years have had to juggle the tough decision about their obligation to care and the need to follow through with complete care. So questions of cost, quality, access, and equity come in across the board in this nation's health care system.

MARTIN: I have to say that, even as we were talking about the story among ourselves, it just occasioned some very intense feelings. I mean, on the one hand, you know, some people would say this is just horrible. How could any - how could a medical professional essentially discharge someone to the unknown without even knowing whether there was appropriate care? Others say, you know, what else are they supposed to do because the care has to be paid for somewhere, and if the federal government intended for people in these circumstances to be cared for, then they should pay for them. Dr. Wolfson, what do you say about that?

Dr. WOLFSON: Well, that's, again, a two-edged sword. These are not-for-profit healthcare organizations that have as an obligation the provision of care to people in need. But it can only go up to a certain point. The hospital did all it could and all it should to care for this man, brought him back to life twice, saved his life twice, invested a great deal of resources.

But then they were not able to place him in a setting that would allow him to remain in skilled care, basically. He didn't need hospital care. He needed skilled nursing care, and there's no means by which to pay for that here because Medicaid pays for that. And most nursing homes are private, and they don't have the same obligation of care that a not-for-profit hospital does.

So the hospital fund is often in a bit of a quandary. And I think each of us would feel the same kind of difficult pulls. You know, the guy needs care. He doesn't need hospital care. The hospital spent millions of dollars on him, hundred of thousand of dollars. They need the resources to provide care to other people in their community. Their profit margins have diminished dramatically in the last few years. All hospitals have experienced that.

MARTIN: I'm sorry, but I thought most hospitals were operated as not for profits.

Dr. WOLFSON: No, they're not. Most hospitals are. Some hospitals are not. For example, Hospital Corporation of America…

MARTIN: Is not.

Dr. WOLFSON: For profit investor on hospital corporation, there are a number of those.

MARTIN: But most long-term care facilities are for profit and that's...

Dr. WOLFSON: Many long-term care facilities are for profit...

MARTIN: I see.

Dr. WOLFSON: And they don't have the same tax obligation that a not-for-profit does to provide community based services free of charge.

MARTIN: OK. I just need to pause here just to say that, if you're just joining us, you are listening to Tell Me More from NPR News. I'm speaking with NPR health correspondent Joanne Silberner and Dr. Jay Wolfson about the whole issue of hospitals deporting immigrants who need - illegal immigrants who need long-term care and can't pay for it.

And we're also interested in what you think. We're particularly interested if you have a personal experience with this issue. If you're a medical professional who's been confronted with the question of caring for a patient, particularly an undocumented patient who cannot pay, or if you are an immigrant who needs long-term health care but doesn't have insurance, you can join the conversation by calling our comment line at 202-842-3522. Or you can go to npr.org and click on Tell Me More.

Joanne, is there any sense of policies catching up with this dilemma (unintelligible). Is there any, are there any, is there any discussion in Congress? Is there any discussion in the policy realm of this issue and how this issue should be addressed?

SILBERNER: I think the numbers are small enough. The answer is no or nothing, no buzz that I have heard. Nothing is really heard above the water line on this. When you think about it, the public hospitals have so many other issues going on, crowded emergency rooms, taking care of other uninsured. This is a small proportion, so this isn't their main focus. The advocacy groups may be active on this, but I haven't heard that much. It will be interesting to see whether this article has an effect.

Dr. WOLFSON: I agree with Joanne.

MARTIN: Yes, I was going to ask you, Dr. Wolfson. What do you think?

Dr. WOLFSON: Yeah, I agree with Joanne. This is a relatively small issue compared to the challenges of operating public hospitals in the United States.

MARTIN: Do you have a sense that medical professionals are - feel themselves ethically challenged by this?

Dr. WOLFSON: Of course they do, and I think hospitals do as well. But there is the ethical dilemma of obligation to provide necessary care, which they did, and then the obligation to figure out how you follow through in paying for a long-term chronic expensive care and where the obligation of a community or public institution ends and that of someone else begins.

MARTIN: I thought, generally, you accept this whole ethical guidelines about treating non-citizens?

Dr. WOLFSON: You know, a hospital has an obligation, whether it's public or private, in many of our views, to treat anybody who walks in the door, especially with an emergency, and to stabilize them, and the federal government requires them to do that. And that's why they received certain additional funds through Medicare and Medicaid while they received tax-exempt status.

But after somebody has been stabilized, as it was the case here, there comes the question, what's the obligation of the institution and the community and the individual practitioners? What do they do? Who's going to pay for it? That's a big question. It's an ethical question as well as a financial question.

MARTIN: And Joanne, a final word to you with the minute that we have left. It's terrible to ask reporters to predict things. But I do want to ask, do you feel - is this is an issue that's so, I don't know if the word is shocks the conscience or so sort of pulls ethics - sort of competing ethical and moral and financial concerns of these hospitals that this will sort of occasion a policy response, or is it just, you think, that the numbers are so small that people just can't wrap their heads around it, given all else that we're dealing with?

SILBERNER: I think there's so much more going on in healthcare, with the, you know, the 48 million uninsured. This is a drop in the bucket, but it's an important one because when you think about it, do you want hospital personnel making these decisions, being able to turn people away? That's a hard call for them.

MARTIN: Joanne Silberner is a health correspondent for National Public Radio. She was kind enough to join us here in our Washington studio. Dr. Jay Wolfson is a professor of public health and law at the University of South Florida. He joined us on the line from his office. I thank you both so much for joining us.

SILBERNER: Oh! Thank you.

Dr. WOLFSON: Thanks. Transcript provided by NPR, Copyright NPR.

NPR transcripts are created on a rush deadline by an NPR contractor. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.