Washington; Aug. 27, 2004 – A new proposal that calls for detailed questioning of immigrants after they receive emergency medical care is drawing criticism from both immigrant rights advocates and healthcare providers. Critics say such questioning may cause immigrants to avoid seeking emergency health services out of fear that information gathered by hospitals will be shared with other government agencies.
Congress has allocated $1 billion to hospitals for emergency care of undocumented immigrants over the next four years. But under the new proposal, healthcare providers wanting to be reimbursed from the funds would have to question patients in detail about their immigration status and provide information about the cost of such care.
The Centers for Medicare and Medicaid Services (CMS), an agency that manages federally funded health services for 70 million Americans, has drafted a proposal for the immigrant questionnaire program and submitted it for public comment. Final approval on the proposal lies with the US Department of Health and Human Services (HHS)
Those against the proposal say that immigrants would be much less likely to seek emergency healthcare to avoid facing questions about their immigration status. The proposal does not include provisions that prevent patient information from being shared outside of CMS, possibly even with immigration authorities.
Questions that patients would be required to answer include:
- Are you a United States Citizen?
- Are you a lawful permanent resident, an alien with a valid and current employment authorization card, or other qualified alien?
- Are you in the United States on a non-immigrant VISA?
- Are you a foreign citizen that has been admitted to the U.S. with a 72-hour border-crossing card?
â€œIt will be a very bad situation, if people are afraid to seek emergency medical help. Suppose someone is extremely ill with something contagious. Keeping them away could cause health crises across entire communities.â€
Â Â Â --Jennifer N. Ngâ€™andu, Health Policy Associate at the National Council of La Raza
"No one wants to reveal that kind of information, unless they know itâ€™s for medical use only," said Jennifer N. Ngâ€™andu, Health Policy Associate at the National Council of La Raza (NCLR), a nonprofit Hispanic advocacy organization. "Legal or undocumented, people will worry about how this information could be used, and whether it could lead to their deportation or hurt their chances for citizenship," she said.
"It will be a very bad situation, if people are afraid to seek emergency medical help. Suppose someone is extremely ill with something contagious. Keeping them away could cause health crises across entire communities."
Gabrielle Lessard, staff attorney at the National Immigration Law Center (NILC) in Los Angeles, said the policy proposal is insensitive to immigrantsâ€™ fear about who will see the information. "I think that thereâ€™s a lot of misdirected government energy into probing peopleâ€™s immigration status under the guise of national security. People are concerned not only about the information being collected, but how it will be shared," she said.
In written comments submitted to CMS, Lessard cited an immigrant healthcare survey conducted by the California Immigrant Welfare Collaborative, of which Lessardâ€™s organization is a member. The survey, which was designed to identify barriers to healthcare for immigrants, includes reports of people who avoided health care because of fears related to a family memberâ€™s immigration status.
"The consequences of such deterrence included complications from untreated asthma; diabetes and hypertension; serious untreated vision problems, such as a childâ€™s glaucoma; cancers that progressed while untreated; and a child who suffered a burst appendix," Lessard wrote. "In one case, a childâ€™s untreated strep throat progressed into a heart condition. This childâ€™s case illustrates the public health risks of deterring families with undocumented members from seeking health care. It is unknown how many other classmates and other individuals were infected after exposure to this child."
Laura Leon, program director for the Illinois Maternal and Child Health Coalition, a group that advocates on women and child health issues said: "Itâ€™s a dangerous situation to have immigrants so fearful to seek needed medical care. I can tell you, especially after 9/11, with all the homeland security issues, our health providers are reporting that immigrant families are especially hesitant to seek medical attention, especially applying for health benefits that they or their children qualify for. To get an undocumented person to come to the doctor is already a problem. People are hesitant enough as it is.
"Our coalition includes a variety of health providers and social services agencies that service the Arab, Korean,Polish and Hispanic communities. Everyone's concerned. This effects immigrants across the board."
Undocumented immigrants contacted by The NewStandard chose not to comment, but even Green Card holders and naturalized US citizens of varying ethnic origins are concerned about the proposal.
"If I could be sure the questioning was for medical reasons only, Iâ€™d be okay with it," said White Joshua, a business graduate student in Washington, DC, and a naturalized citizen originally from Sudan. "But Iâ€™d be worried if they were looking into my background for reasons beyond that."
Bippin Badhe, an IT projects administrator from Mumbai, India, said: "If I had a really critical problem I would go to the hospital, but for a lesser emergency Iâ€™d try to fix it on my own to avoid the questioning. Over the past few years, immigrants face so much mental pressure from fear of deportation. Even though I have a Green Card, Iâ€™d be offended and worried if [healthcare workers] started asking me about my visa status."
According to CMS, collecting this information will help assess the cost of emergency care for undocumented aliens. In May, Congressâ€™ Government Accountability Office issued a report, which asserted there was a "lack of reliable data on this patient population," and that "the lack of proven methods to estimate their numbers make it difficult to determine the extent to which hospitals treat undocumented aliens and the costs of their care."
CMS spokesperson Mary Kahn said the money was set aside to "help compensate hospitals and healthcare providers for the tremendous financial burden on them in providing emergency healthcare services toward illegal aliens."
The federal government would distribute this money over a period of four years, with the largest amounts going to states most heavily populated with undocumented immigrants.
But according to Lessard of the National Immigration Law Center, undocumented immigrants compose a minority of uninsured emergency patients.
"Thereâ€™s an exaggerated sense of the burden on healthcare providers from undocumented aliens," she said. "They are actually pretty small figures, though people are always trying to prove otherwise."
The US-Mexico Border Counties Coalition, an advocacy group made up of representatives of county governments, issued a report in 2002, showing that in border counties where there are large groups of undocumented aliens only 25 percent of the uncompensated costs for hospitals resulted from emergency medical treatment provided to undocumented immigrants.
In addition to fears about immigrants avoiding emergency care, healthcare officials are concerned about the task of collecting the information.
J. Brian Hancock, President of the American College of Emergency Physicians (ACEP) said that requiring hospital workers to fill out the questionnaires "will place a burdensome task on emergency department personnel." ACEP is a Dallas-based organization with 53 chapters, representing more than 22,000 emergency physicians nationwide.
Hancock submitted written comments to CMS, in which he said the questionnaire approach appeared "burdensome and impractical," and "may be potentially dangerous to the health of emergency patients, as well as to others in the community, if people avoid care out of fear that information on their immigration status will be used to deport them."
"More alarming," wrote Hancock, "is the risk of individuals...with infectious diseases or pregnancies forgoing timely emergency care."
Both immigrant rights groups and health care providers have suggested alternative methods of determining eligibility for hospitals, recommending that CMS provide advance reimbursement to hospitals based on statistical analysis such as Medicaid data, or going by the number of physician claims. ACEP asks that CMS should also consider imposing some minimum threshold level of uncompensated care for eligible physicians and hospitals.
Rights groups also complained about the review process set up by CMS. Ngâ€™andu of the National Council of La Raza said the proposalâ€™s comment period was too brief. "It was done in a very interesting way," she said. "There was not sufficient public notification. It was not published in the Federal Register."
The proposal states that the "normal 60 and 30 day comment periods will be abbreviated to ensure that the procedural requirements and associated policies are approved by OMB [Office of Budget Management] prior to the statutory implementation date of September 1, 2004."
Speaking for CMS, Kahn said the proposal has received more than 100 responses, which CMS is currently reviewing. "We hope to have final plan by September 1," she said.