My patient, from Europe, had a problem: his stump was infected.
Years ago, homeless and lost in a country he did not truly know, he had taken to sleeping outside a train station at night. While this strategy served him well in the summer, it failed him horribly in the winter. On a particularly frigid night, armed with little else than a thin sheet masquerading as a blanket, he developed a severe case of frostbite. By the time he got to the hospital, it was too late: his leg had to be amputated.
As traumatic as the loss of a limb had been, my patient adapted to his new life relatively well. He had become an expert at using a wheelchair and found a stable housing situation. All things considered, things were going pretty well for him by the time he noticed the pus oozing from his stump. Soon he was back at the hospital, this time under my care.
His stay was uncomplicated, but his discharge was difficult. He revealed to me that he was undocumented and lacked health insurance. While this did not affect his hospital stay, it made it challenging to set-up follow-up care. Every doctor’s office I called told me the same thing: without insurance, there’s nothing we can do. Subacute rehabilitation, which prepares recently hospitalized patients to function independently at home again, and visiting nursing services, which could have helped him manage his wound and prevent reinfection, were simply out of the question.
Having gone through this before, my patient was unfazed. But I was devastated. The typical services and specialized care available to an insured patient were out of his reach. I wondered if he would have been in the hospital in the first place if he had had access to regular care. Lacking options, I finally scheduled an appointment for him at a nearby free clinic. While the doctors there would take good care of him, he needed more than we could offer.
The 11.3 million undocumented immigrants in the United States face numerous challenges in obtaining affordable health insurance. They are generally ineligible for benefits under the Children’s Health Insurance Plan, Medicaid, and Medicare, and they cannot receive federal subsidies under the Affordable Care Act. Instead, they are left to choose from a menu of less appealing options, including buying unsubsidized private insurance, acquiring employer-based health insurance (if they can find a job that offers it), enrolling in a state- or city-specific program (if available), or remaining uninsured.
Given these limited options, it should not be surprising that 5.4 million undocumented immigrants are uninsured and have few options when it comes to accessing care. Approximately 1400 federally qualified health centers and 1200 free and charitable clinics nationwide provide primary and preventative care regardless of insurance status or ability to pay. The Emergency Medical Treatment and Labor Act (EMTALA), passed by Congress in 1986, requires hospitals to stabilize any sick patient who comes to the emergency room. If a patient is admitted, he or she can apply for Emergency Medicaid to cover inpatient costs, though what is covered varies widely by state.
As a physician who frequently treats undocumented patients, I find this arrangement to be incredibly frustrating. Many patients with chronic conditions present for treatment late in the course of their illnesses, making their diseases harder to treat and often leading to repeated health emergencies.
Patients with end-stage renal disease (ESRD), for example, require outpatient dialysis several times a week to remove toxic wastes and excess fluid from their bodies. Undocumented, uninsured patients often cannot afford these visits. In most states they are only eligible to receive emergent hemodialysis, which requires them to go to an emergency room when they are sick. This adds up to many hospital visits at steep personal cost. A 2017 study found that these patients reported significant personal and family distress, debilitating physical symptoms, and frequent fears of death.
Our current system denies undocumented immigrants proper care at the end of their lives, too. Hospice provides comfort and supportive care to patients with less than six months to live, but nearly one-third of hospice agencies limit access to these services for undocumented patients. Even dying becomes harder when you are undocumented.
Some would say that this sad state of affairs is justified. Undocumented immigrants broke the law and taxpayers should not reward them by providing benefits. But aside from betraying a shocking lack of empathy for this group of vulnerable Americans, this line of thinking ignores the reality on the ground. If a sick, uninsured patient walks into an emergency room, EMTALA mandates that they be stabilized, and in many states they go on to receive costly hospital-based care, both of which are ultimately subsidized by taxpayers anyway. At times, in fact, this strategy of care is far more expensive than if we had just provided health insurance in the first place.
Instead of repeating this pattern, why not just give these patients access to affordable health insurance? After all, such an approach could yield significant benefits. A 2016 study compared Arkansas and Kentucky, which both expanded Medicaid, to Texas, which did not. Expanding Medicaid increased patients’ access to primary care and lowered their out-of-pocket costs. Patients had fewer ER visits, skipped taking their medications due to costs less frequently, and reported being in better health. There’s no reason to believe that these benefits wouldn’t extend to newly-insured undocumented immigrants. Undocumented children could benefit the most, as healthy kids tend to become healthy adults.
A better solution would be to permanently resolve the immigration status of these individuals in a grand bargain akin to that signed by President Reagan in 1986. But that is likely a nonstarter under President Trump. At a time when the ruling class in Washington is obsessed with trying to repeal the Affordable Care Act and considering a wall on the southern border, expanding healthcare coverage to encompass undocumented immigrants seems like the least likely outcome. But it’s the right thing to do. Access to health insurance would substantially benefit undocumented patients. And it would finally realign America’s policies with its identity as a country that welcomes the world’s huddled masses.
Kunal Sindhu is a resident physician in New York City. You can follow him on Twitter @sindhu_kunal.