Ethics Questions Raised As Strapped Clinics Reduce Or Eliminate Non-Emergency Care For Undocumented Immigrants
SACRAMENTO, March 16, 2009
Graciela Barrios, an undocumented immigrant who relies on her county health clinic for tests and medication for her diabetes, checks her blood sugar at her home in Sacramento, Calif., on Saturday, March 14, 2009.
(AP) Graciela Barrios, an undocumented immigrant with few resources, has long relied on her county health clinic for the advice, the medication and the tests that kept her diabetes under control.
But next month, Barrios and thousands like her will be on their own, with many more people across the nation facing the same fate.
Bowing to recession-related budget pressures, Sacramento County recently took the drastic step of cutting non-emergency health services to illegal immigrants. Contra Costa County will vote on a similar measure on Tuesday.
Local health systems in other states also are facing such decisions as health officials find themselves trapped between their dwindling federal, state and local funding streams and the growing number of newly uninsured who need services.
"The general situation there is being faced by nearly every health department across the country, and if not right now, shortly," said Robert M. Pestronk, executive director of the National Association of County and City Health Officials, based in Washington, D.C.
Data on the cost of health care for unauthorized immigrants is hard to come by, because community clinics and hospitals usually do not ask patients for their immigration status. But the Pew Hispanic Center estimates that of the 11.9 million illegal immigrants living in the United States, about 59 percent have no health insurance, making up about 15 percent of the nation's approximately 47 million uninsured.
As the financial crisis takes a toll on local health systems and job losses spike the number of uninsured, health providers are finding it increasingly difficult to meet the needs of those they serve, said Pestronk.
More than half of local health departments across the country laid off or lost employees in 2008, according to a survey in January by the health officials association. About one-third predicted layoffs in 2009.
In Sacramento County, such cuts at first meant closing three of six clinics. In February, with less money and mo1re patients lining up, county supervisors and health officials had to decide: close one more clinic, firing up to 40 staffers to save $2.4 million, or cut services to the approximately 4,000 illegal immigrants treated annually.
"It was very difficult ethically for me," said Keith Andrews, head of primary health services at the Department of Health and Human Services in Sacramento County. "People I've been caring for for years will be hurt."
Cutting care, you save $100 today, but you may end spending $500 tomorrow when that person shows up in the emergency room because you didn't provide them with basic medication. It's shortsighted.
National Immigration Law CenterContra Costa County officials are doing the same hard math: if they vote to cut services to the 5,500 illegal immigrants they serve a year, they will save about $6 million.
After letting go social workers, cutting mental health services and watching a delivery room built to handle 120 births a month accommodate 240, there were few other options, said Contra Costa Health Services Director William Walker.
"We've never had this crisis before," said Walker, who submitted the plan being voted on Tuesday. "We've tried to carefully slice what we thought we could without cutting off our ability to respond. Now we're looking at bad choices among bad choices."
Counties may legally cut services to illegal immigrants. Although hospitals receiving Medicaid funds must provide emergency care for anyone who needs it, there is no law requiring health providers to offer primary care.
Health officials and immigrant advocates say they do not know how many local health systems provide primary care to undocumented immigrants. Officials note that many hospitals and clinics do not ask a patient's immigration status, in part because treating chronic conditions such as asthma and hypertension keeps patients from emergency room visits that are far less effective and more expensive.
The fraying of the safety net provided by local health systems could have serious consequences - not only for illegal immigrants, who are among the most vulnerable, but for the rest of the population, said Sonal Ambegaokar, health policy attorney at National Immigration Law Center.
"Cutting care, you save $100 today, but you may end spending $500 tomorrow when that person shows up in the emergency room because you didn't provide them with basic medication," said Ambegaokar. "It's shortsighted."
Asking local health officials to verify immigration status is problematic, said Julia Harumi Mass, staff attorney with the American Civil Liberties Union of Northern California.
"The devil's in the details. Asking county workers to act as immigration officials puts them in a difficult position," Mass said.
For Barrios, the economic crisis has come home as well. The same economic forces that slashed Sacramento County's sales and property tax revenues took her husband's job in a landscaping firm, and the family's bills are piling, she said.
"I have no insurance, no resources, nothing to fall back on," said Barrios, who has one daughter. "I have no idea what I will do