Doctor, Bill Thyself


When someone shows up at the Hennepin County Medical Center's bustling emergency room, it doesn't matter whether the cause is a ruptured appendix, a broken arm, or a gunshot wound. By law and by physicians' longstanding interpretation of their oath, everyone is entitled to emergency medical care. At least in theory, questions about payment can wait until later. If it turns out the patient has no insurance, John and Jane Q. Public have long been expected to shoulder a hefty chunk of the unpaid bills. Hospitals and physicians bear the rest.

Another question that's not asked is whether the patient is a legal resident of the United States. Consequently, no one knows with certainty how much of the unmet costs are for care for undocumented immigrants. Even conservative estimates put the tab in the billions. And while estimates of how much the problem is costing Minnesota vary, there's widespread agreement it's a growing crisis.

"This is a growing problem and eventually the government is going to have to weigh in," says David Feinwachs, general counsel of the Minnesota Hospital Association. "It is silly to deny a pregnant woman prenatal care, [because] the moment that child is born as a U.S. citizen, the system takes over. It just seems to exacerbate the problem."

In late 2003, President George Bush signed into law the Medicare Prescription Drug, Improvement and Modernization Act of 2003. While the act is probably best known for its prescription drug provision, the infamous Part D, buried in the miscellany is the innocuous-sounding Federal Reimbursement of Emergency Health Services Furnished to Undocumented Aliens. The measure was meant to revive and update a provision from the Balanced Budget Act of 1997, which provided $25 million yearly in emergency care reimbursement to the 12 states with the highest number of undocumented aliens. The updated provision allots $1 billion, to be spent $250 million per year over four years, to reimburse hospitals, physicians, and ambulance operators for undocumented immigrants' health care in all 50 states and the District of Columbia.

To health care providers, the federal funds might be more of an affront than the magnanimous gift they're meant to be. The Center for Immigration Studies estimates that in 2002, more than $17 billion was spent in the U.S. providing care to the uninsured. Estimates of the number of uninsured who are undocumented immigrants range from a few percentage points to more than 20 percent.

It is estimated that more than 9 million undocumented residents, most from Mexico and other parts of Latin America, call the U.S. home. Approximately 80,000 to 85,000 lived in Minnesota in 2004, according to the Office of Strategic Planning and Results Management. Some officials put the figure closer to 50,000; in either case, the state ranks in the upper half of undocumented immigrant populations nationally.

Yet few of the federal dollars will make it here. Minnesota gets just $1.4 million a year, while the lion's share goes to the six states where the most illegal aliens are detained. Texas receives almost $47 million, and California more than $66 million. To put that in perspective, last year California's total cost was $1 billion.

Minnesota's allotment might be representative of the pool demographically, but it isn't enough, say health care providers. "Hospitals don't even waste the time to fill out the form" to apply for reimbursement, says Feinwachs. "It isn't worth the doing the paperwork."

For undocumented immigrants and their health care providers, the funding gap is a double-edged sword. Some used to sneak into the system, but Medicaid has begun requiring proof of citizenship for new applicants. While federal law requires hospitals to treat all emergencies, individuals with chronic diseases such as diabetes or asthma typically are left to wait in long lines at overburdened charity care clinics. If they don't get help, their conditions can spark full-fledged emergencies and they will end up at the emergency room anyhow.

Not all unpaid care is borne by providers and patients. In 2005, undocumented immigrants cost Minnesota health assistance programs more than $35 million, according to state figures. The state paid about half those costs and separate federal programs picked up much of the rest. According to published reports, Minnesota's spending jumped from $12.5 million in 2003 to $17.4 million in 2005. With both the amount of bad debt carried by hospitals and the number of uninsured going up, Feinwachs guesses that the cost of Minnesota providers' uncompensated care at least equals that dollar amount. The numbers are so fuzzy, he admits, that this might be "pure speculation."

The strain on the system goes well beyond state health programs. Partly this is because of the way hospitals define their patients. In 2005, HCMC wrote off more than $33 million in uncompensated care, a number that includes charity care, bad debt, and care for the insufficiently insured and the uninsured. Hospital administrators say they can't be sure exactly how much of this is attributable to undocumented immigrants, but note that some $3.2 million was spent on interpreter services last year. Approximately one third of all immigrants, legal and illegal, lack insurance, according to the Center for Immigration Studies. That's two-and-a-half times the rate for citizens.

Large, publicly funded hospitals like HCMC will always bear a disproportionate share of the cost of providing care for the uninsured and underinsured, but Minnesota's small-town facilities are especially strained by the impact of large undocumented populations. Many of the immigrants using urban health care are refugees who, as legally displaced people, often receive subsidized care. But towns with economies largely based on manufacturing or agriculture are doubly susceptible to the twin impacts of large migrant populations and unreimbursed health care.

During its annual meeting in June, the American Medical Association passed a resolution demanding change. "For starters," the American Medical News reported, "physicians want the U.S. Office of Customs and Border Protection or another government agency to start paying for undocumented people that federal agents bring to local hospitals for care."

The government has yet to react to the physicians' call, but until that time, little will change in the way emergency health care is delivered. "Hospitals just keep doing what they've always done," says Feinwachs. "If someone comes in, they treat them."