transport and present significant logistical problems once theyarrive at the ED.”

Dr. Peter Grant, a senior emergency staff specialist based atSt. George Hospital in Sydney who co-authored a 2004 reviewarticle in Emergency Medicine Australasia titled “EmergencyManagement of the Morbidly Obese,” has studied what mightbe done to address the logistical issues raised by large patients inthe ED.3 Some of Grant’s suggestions to optimize care are inthe next section.

A SYSTEMATIC APPROACH● Out-of-hospital ambulance protocols should provide

adequate notification to receiving hospitals, or bypass ofpatients to facilities adequately equipped to providespecialized care. This can be tricky, however. In Michigan, acommunity hospital transferred an obese patient with anorthopedic injury because it didn’t have an operating roomto handle him. The patient died en route to an academiccenter hospital. The man’s family sued.

● Hospitals should acquire specially designed heavy duty beds,or have processes in place for their timely delivery via hiringcompanies with 24-hour call centers. Patients will often needto be admitted to 2 bed spaces to accommodate them.

● During their planning to accommodate larger patients,institutions should also develop a specific list of narrowdoorways or corridors where access with heavy duty beds will

be a problem. Hospitals should also educate staff to assist inpreserving privacy and dignity for these patients.

● As part of their care, bariatric patients should receive earlymultidisciplinary involvement from such areas as clinicalnutrition, dermatology, and psychiatry. They should also receiveearly and aggressive deep venous thrombosis prophylaxis andpressure care.

● Aggressive management decisions should be based on presentillness and comorbidities rather than size alone. There is limitedevidence to support the notion that patients will haveprohibitively poor outcomes from major surgeries or ICUtreatments.“There are no easy answers,” said Schenkel, from Baltimore’s

Mercy Medical Center. “These are difficult challenges andhospitals must carefully consider where they spend their moneyto ensure the proper patients get proper care and equipment. Alot of what we’re talking about is the basic respect involved inensuring people get taken care of in a respectable way.”

doi:10.1016/j.annemergmed.2007.08.014

REFERENCES1. Sturm R. Increases in clinically severe obesity in the United

States, 1986-2000. Arch Intern Med. 2003;163:2146-2148.2. Platts-Mills TF, Burg MD, Snowden B. Obese patients with

abdominal pain presenting to the emergency department do notrequire more time or resources for evaluation than nonobesepatients. Ann Emerg Med. 2005;12:778-781.

3. Grant P, Newcombe M. Emergency management of the morbidlyobese. Emerg Med Australas. 2004;16:309-317.

EMERGENCY CARE FOR THE UNDOCUMENTED: WHO BEARS THE BURDEN AND WHERETO DRAW THE LINE?

By Robin MejiaSpecial Contributor to Annals News & Perspective

When Paula Gomez, executive director of a communityclinic in Brownsville, TX, saw a 12-year-old girl with failingkidneys recently, she and the clinic doctors found they couldnot arrange a transplant. Because the girl’s parents had broughther to this country illegally as a toddler, she’s not eligible,though she certainly will die without it.

The girl’s case illustrates the politics and compromise that havecharacterized the issue of medical care for the undocumented. Thefederal government has moved toward paying for emergency care,an unfunded mandate for 20 years, but defining what constitutesan emergency can have tragic consequences. Hospitals are supposedto provide emergency care to all patients who come in the door,regardless of their ability to pay or their immigration status. Therequirement is in line with the Hippocratic Oath and enshrined infederal law, specifically the 1986 Emergency Medical Treatmentand Labor Act (EMTALA).

“We don’t turn people away at the door. We’re morally andlegally bound to treat people,” said Carla Luggiero, a directorfor federal relations at the American Hospital Association.

But once a patient is stabilized, the obligation ends. In thecase of the 12-year-old in Brownsville, that meant she’d beeligible for emergency dialysis when her potassium levels gothigh enough to pose a risk of killing her immediately, but notfor a transplant or even for regularly scheduled dialysis.

“She’s not bleeding, she’s not having a heart attack, she’s not havinga baby,” said Gomez. Because she was undocumented, the girl didn’tqualify for any coverage that would have enabled treatment.

WHO PAYS?Historically, Medicare has only covered legal residents,

meaning hospitals must absorb most of the cost of treatingundocumented immigrants who cannot pay. Recently, that hasbegun to change. A few years ago, Congress authorized partialreimbursement for the cost of providing this care under Section1011 of the Medicare Modernization Act of 2003. Hospitalgroups and local officials applaud the act, but it has yet to provea panacea. The program’s launch was slowed by debates overrequirements, and when it did launch, hospitals were slow to

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enroll, in part claiming the administrative burden was too high.(The Center for Medicare and Medicaid Services contractedTrailblazer to set up and manage the program.)

The funding is allocated by region, in an attempt to steer money toborder states, whose hospitals are believed to treat the largest share ofundocumented immigrants, but there is no way to reallocate funds ifone region doesn’t claim its total. Groups such as the AmericanHospital Association and the Border Counties Coalition are still doingoutreach and education to ramp up participation.

“I think the first thing we appreciated about 1011 was that thiswas recognition by the Congress, by the President that this was aburden that we were seeing in border hospitals,” noted StevenEscoboza, president and CEO of the Hospital Association of SanDiego and Imperial County. “In terms of funding, it doesn’t covercosts yet.” Escaboza didn’t have an exact ratio of how much of SanDiego hospital’s expenses were reimbursed, but continued, “I cantell you clearly, it does not cover the total cost for servicesrendered.”

Others echo that concern, including David Austin, who,working with a group called the US/Mexico Border CountiesCoalition, lobbied for the Section 1011 funding, and alsoLuggiero, the director for federal relations at the AmericanHospital Association.

For the 2005 fiscal year, when states were first able to seekreimbursement, $58 million out of $250 million allotted wasapplied for. For 2006, $170 million was applied for. Somehospitals complained about the enrollment process, especiallygiven the limited reimbursement. “It was a very burdensomeprogram. It has gotten less burdensome,” said Luggiero. “Thetrend lines I’ve seen show that an increasing number of hospitalsare participating in the program.”

Escaboza agrees. “I think it took a while for hospitals tounderstand what’s required for claiming reimbursement,” hesaid. “In the last year or so, we have seen here in San Diego andthroughout California . . . hospitals earnestly and appropriatelysubmitting claims.”

Right now, the unclaimed funds from 2005 and 2006 arestill available, as the money rolls over from year to year. So far,the AHA has already had to lobby against one Congressionalattempt to redirect unused Section 1011 funds (the attempt wasdropped), and Luggiero remains cautious about the future.

HOW BIG IS THE PROBLEM?No one knows exactly how much hospitals spend on emergency

care for undocumented immigrants. Shelton Brown, an assistantprofessor at the University of Texas School of Public Health inBrownsville, notes that researchers in border regions can’t outrightask if a patient is a US citizen. If they do, the interview ends.Similarly, most hospitals don’t attempt to document citizenship. Infact, when Congress debated adding language to MedicareModernization Act of 2003 that would have required doctors todocument a patient’s immigration status, and, if the person was notin the country legally, contact the Department of HomelandSecurity, hospitals groups lobbied to get the language removed. Inaddition to fearing the rule would prevent some patients from

seeking needed emergency care, doctors argued that alreadyoverburdened ED staff shouldn’t be asked to take on theresponsibility of border control agents.

So, while just about everyone seems to agree that it costs a lotof money to treat undocumented immigrants withoutinsurance, hard numbers are hard to come by.

One of the most cited studies was done in 2000, when agroup of 24 counties in Texas, Arizona, New Mexico andCalifornia came together to form the US/Mexico BorderCounties Coalition. Officials in those counties wanted thefederal government to address the costs of federally mandatedcare for undocumented immigrants, and Arizona Senator JonKyl secured funding for a study to try to assess the magnitude ofthe problem. The Border Counties Coalitions contracted MGTof America, a consulting and research firm, to conduct it.

The final report from that study, called “Medical Emergency:Costs of Uncompensated Care in Southwest Border Counties,”used a variety of statistical techniques to estimate that in 2000,in the border counties, hospitals incurred costs of $190 millioncaring for undocumented immigrants, about 25% of $832million total spent on uncompensated care in the region.

The Border Counties Coalition used the study to successfullylobby Congress for the Section 1011 funding, which provided$250 million a year for the years of 2005-2008, divided betweenall 50 states. Two-thirds of the appropriation was based on theestimated number of undocumented immigrants in each state.The other third was set aside for the 6 states with the highestnumbers of arrests of undocumented immigrants (Arizona,Texas, California, New Mexico, Florida, and New York).

And the issue has gained national attention. “Where 10 or 15 yearsago, this wasn’t much of an issue, over the years, I’ve been hearing moreand more frequently from hospitals even in other parts of the country[away from the border] that have large numbers of documented andundocumented immigrants,” said Luggiero.

However, spending in border states still seems to outpace therest of the country. In North Carolina, a state that’s had arecent influx of immigrants, Annette DuBard at the Universityof North Carolina at Chapel Hill and Mark Wayne Massing ofthe Carolinas Center for Medical Excellence decided to look atthe issue. Federal guidelines do allow states to use Medicaidfunds to provide some emergency medical services toundocumented patients that fall in a Medicaid-eligible categorysuch as children, pregnant women, elderly or disabledindividuals. DuBard and Massing analyzed all North CarolinaEmergency Medicaid claims between 2001 and 2004. A total of48,389 patients received care reimbursed under the programduring those 4 years; most patients were eligible due topregnancy, and more than 99% were undocumentedimmigrants. However, total Emergency Medicaid spending wasstill less than one percent of North Carolina’s total Medicaidexpenditures during the period studied.

“There tends to be a lot of rhetoric around the burden placedby undocumented immigrants on medical expenditures,” saidDuBard. “And it’s less than one percent.”

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THE PROBLEMS WAX AND WANEIn addition to the Border Counties Coalition survey, less formal

measures indicate that costs are likely higher in border regions. SanDiego County has increased its own efforts to understand use ofemergency care in recent years. Hospitals do not collect data on apatient’s immigration status but use proxy measures, such as aninability to provide an address, that indicate likely undocumentedstatus. In recent years, it looks like approximately 10 to 12% of EDvisits were by undocumented immigrants, Escaboza said, a dropfrom several years ago, when the numbers were closer to 25percent. He cited increased border enforcement as the most likelycause.

“I’ve seen things go from bad to worse and then improve,but that could change again,” he said. He noted thatanecdotally, it appears that illegal migration routes have movedto Arizona as enforcement has increased along the southernCalifornia border.

In Texas, health economist Shelton Brown kept running intothe question of whether undocumented immigrants put a strainon border hospitals. The question isn’t directly related to hisacademic research, which looks at how distance migratedcorrelates to insurance status, but he decided to see what hecould determine from the Texas Health Care InformationCollection Center, a division of the state Department of HealthServices. That data notes whether care was covered by privateinsurance or a government program. Patients without anycoverage, including Medicare or Medicaid, are likely to beundocumented. He found that both the percentages of hospitaladmission through the emergency department and patientslisted as self-pay were comparable in the hospitals in bordercounties and hospitals in the rest of the state. In fact, the rateswere a smidge lower near the border.

As with all proxy measures, the status as a self-pay patient isan imperfect indicator of immigration status.

“I’m assuming that if the hospital could have signed them upfor Medicare or Medicaid they would have done that. But I’mnot sure of that,” said Brown.

A LIFELINE, BUT NOT A SOLUTIONAdvocates argue that Section 1011 funding still isn’t enough to

offset the true cost of providing health care to undocumentedimmigrants.

“It’s far from sufficient in terms of the dollar impact. And weare concerned about getting it reauthorized. We want to makesure that we get it reauthorized and hopefully at a higher level,”said Austin. “What we’d like to see is an expansion of theprogram. . . . A good next step would be to get it expanded toinclude community health clinics.”

Politically, this is a less clear cut issue. However, some statesare taking the initiative to expand coverage to undocumentedimmigrants. In California, for example, GovernorSchwarzenegger has proposed health care reform that wouldprovide coverage to all children, regardless of immigrationstatus. And in a piece written for the Los Angeles Times Web site,

Daniel Zingale, a senior advisor to Governor Schwarzeneggerand chief of staff for Maria Shriver, wrote “In the case ofundocumented immigrants, the governor is trying to movethem out of costly emergency rooms and into clinics. . . . Thegovernor’s plans would redirect funds towards prevention andprimary—rather than emergency—care.”

In North Carolina, a state just learning to deal withimmigration issues, DuBard agrees with the value ofpreventative care, noting that treating a communicable diseasein its early stage could avoid more costly emergency care andalso prevent transmission to others. Similarly, it’s moreexpensive to treat complications of pregnancy than it is toprovide birth control and prenatal care. Pregnancycomplications accounted for 83% of the emergency carespending documented by DuBard’s study.

“I think these data suggest that an investment in primary andpreventative care might pay off even from a strictly financialstandpoint,” she said.

DuBard also sees the issue as a doctor, not just a numbercruncher. About half of the patients in her practice are recentimmigrants. “What I see in my own patient population is hardworking families who don’t have a chance against our health caresystem,” she notes. “They’re working for employers who don’tprovide health care, and because of their immigration status they’renot eligible for our public system.”

Paula Gomez, of the Brownsville Community HealthCenter, agrees.

“We have a serious problem with drug resistant TB on theborder and nobody seems to care. . . . We have issues withdengue, we have issues with typhoid,” she said.

THE TRAGEDY AMONG THE STATISTICSThen there are patients like the 12-year-old who needed, but

couldn’t get, a kidney transplant. It’s a heartbreaking situation. Noone wants to tell a 12-year-old she can’t get life saving treatment.Yet, a kidney transplant is an expensive procedure. And kidneysthemselves are a scarce commodity; not even all legal residents areable to obtain needed organs. According to the Web site of theNational Kidney Foundation, patients listed for kidney transplantsin 1999 faced an average wait of more than 3 years.

Gomez recalls explaining to the girl that she couldn’t arrangethe treatment.

“She looked at her mom and said, ‘Why don’t we just goback to where my aunts and uncles are in Mexico City, and if Ihave to die, at least I’ll die with people who care,’” said Gomez.Eventually, the girl’s parents agreed and took her back to benear family. “She’s probably dead by now. There’s no way shecould get the kidney transplant. It’s hard enough to get overhere, let alone over there.”

“We can sit hear and argue what’s legal and not legal,” shecontinued. “When you’re in the health profession that’s notwhat you’re taught, you’re not taught to be a policeman.”

doi:10.1016/j.annemergmed.2007.08.015

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