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Dialysis and the Undocumented Immigrant

Dialysis and the Undocumented Immigrant. Should it be covered by Medicare?. Sue Manfredi RN, MBA. Introduction. Explore the implications of undocumented immigrants (UI) receiving federal funding for dialysis services

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Dialysis and the Undocumented Immigrant

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  1. Dialysis and the Undocumented Immigrant Should it be covered by Medicare? Sue Manfredi RN, MBA

  2. Introduction Explore the implications of undocumented immigrants (UI) receiving federal funding for dialysis services Discuss burden of providing uncompensated care to UI at great financial cost to an already stressed health care system Does politics and policy place clinicians in an ethical juxtaposition when providing care to UI patients?

  3. Background • Unauthorized (undocumented) immigrant population is defined as foreign-born citizens who are not legal residents (Hoefer, et al. 2012) • 11.5 million unauthorized immigrants living in the US (Hoefer, et al. 2012) • Estimated 5,500 UI with ESRD (Campbell, Sanoff, and Rosner, 2010) • Estimated annual costs in 2005- $69,758 per UI for chronic care (Campbell, Sanoff, and Rosner, 2010)

  4. Background cont’d • Federal funds may not be used to provide non-emergency health care to UI (Campbell, Sanoff, and Rosner, 2010). (State and local governments can offer funds) • Together Medicare and Medicaid provide $20 billion dollars annually to qualified hospitals to support uncompensated care (Gusmano, 2012). • The PPACA calls for an $18 billion dollar reduction in Medicaid DSH and a $22 billion reduction in Medicare DSH payments through 2020 (Gusmano, 2012) • Under health care reform UI will not receive benefits and are likely to represent larger % of nation’s uninsured (Gusmano, 2012).

  5. Who currently pays for this care? Currently 3 options: • Medicaid – emergency medical only • Medicaid DSH – to hospitals serving larger numbers • Taxpayers Campbell, G. A., Sanoff, S., & Rosner, M. H. (2010, January). Care of the undocumented immigrant in the United States with ESRD. American Journal of Kidney Diseases, 55(1), 181-191.

  6. Legal History • Medicare –ESRD is the one and only area of medicine where Americans already have a guaranteed coverage • The Social Security amendment of 1972 ensures access to kidney dialysis but only for US citizens (Campbell, Sanoff, and Rosner, 2010) • Medicaid – plays a critical role in protecting low-income individuals access to needed and preventative healthcare covering them with needed government funded health insurance (Nam, 2011 )

  7. Legal History cont’d • Personal Responsibility and Work Opportunity Reconciliation Act (1996) AKA Welfare Reform • Imposed ineligibility restrictions on non-US citizens • Non-citizens not eligible if not lived in US 5 years (Nam, 2012) • Emergency Medical Treatment and Labor Act EMTALA (1986) • Any patient regardless of citizenship arriving in ED must be given appropriate medical screen to determine emergent health needs (Campbell, Sanoff, and Rosner, 2010).

  8. Realities of the Problem • University Medical Center (2010)- 80 undocumented immigrants with ESRD requiring $2 million/month in dialysis services (Harasin, 2012). • Experienced a deficit of $70 million for FY 2010 • 8 UI arrive each day hoping to receive dialysis care • Grady Hospital (2009) – closed outpatient dialysis center after losing $2-4 million annually (Faden, 2009) • 2/3 of patients remaining were UI (50) • Undocumented citizens filed a lawsuit to receive care • Harborview Medical Center (2011) – contracted to pay NWKC $400/treatment to provide outpatient dialysis services to keep patients out of the ED.

  9. Estimated Undocumented Immigrant Population by State, 2008. (Campbell, Sanoff, and Rosner 2010)

  10. Unauthorized Immigrant Population and Origins

  11. Analysis (Con) • Overburdened health systems with uncompensated care for uninsured population • Unemployment rate 7.9% October 2012 (bls.gov) • Uninsured rate 17.2% June 2012 (gallup.com) • Runaway health care costs- resulting in unsustainable Medicare and Medicaid spending • Increasing burden on citizen taxpayer • Increasing burden on safety net hospitals • Unrelenting supply of UI requiring health care without ability to pay

  12. Issues related to Nursing Goals • Nurses MUST remain consistent with the American Nurses Association Code of Ethics • “The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of the health problem” • “The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.” • “The nurse participates in … improving healthcare environments … conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.” (American Nurses Association, 2001)

  13. Advanced Practice Nursing Goals • Promote awareness and dialogue with policy makers at both the State and Federal levels. • Seek alternate solutions to promote healthy communities including public education • Seek safe alternative care options for UI ( sponsorship from country of origin, transportation home) • Provide educational opportunities to support movement to citizenship status

  14. Stakeholders Patients, undocumented workers, families Citizen taxpayers Healthcare community : Safety net hospitals Emergency departments MD’s, Nurses, SW, others Public Health department Dialysis clinics Law enforcement Politicians

  15. Applicable Moral Theories • Non-maleficence- We should act in ways that do not cause evil or harm to others ( Beauchamp and Childress, 2009). • Beneficence- We have an obligation to act and promote good( Beauchamp and Childress, 2009). • In health care we have an implied duty to help by virtue of our relationship with the patient. • The duty is both legally and morally grounded: patients expect a professional to act in ways that will promote their health (Munson, 2004). • We generally recognize a limit to the level of service and sacrifice owed to a patient by any health care professional (Munson, 2004).

  16. Applicable Moral Theories • Utilitarianism- defines a moral act solely in terms of the outcome of the consequences of that act. • In any given situation, consider a range of goods and preferences to determine the greatest overall balance of good. • Should produce the greatest benefit at the least unhappiness. • An action is right that produces the greatest benefit for the greatest number of people. Stanford encyclopedia of Philosophy. Utilitarianism. http://plato.stanford.edu/entries/utilitarianism.

  17. Religious/Cultural Values • Catholic Moral Tradition- emphasizes an abiding commitment to the promotion and defense of human dignity from conception to death. • Each human life is considered sacred and deserving of a right to life (US Bishops 2009) • Justice- To act in ways that treat people equitably and fairly (Munson, 2004).

  18. Alternatives • Salud Migrante (2008): Health insurance initiative that would cover uninsured Mexican immigrants residing in the U.S. (Viladrich, 2011) • Evidence-based • Developed by Mexican institute of Health • Pilot in WA and NC – 3000 workers/ $30/mo. • Provides ambulatory and emergency services • Education • Work with County Public Health to provide preventative healthcare • Cost effective strategy to reduce emergency room visits • Transport to country of origin

  19. Course of Action Develop policy and strategy with federal and foreign governmental leaders to create programs for guest workers (cross-boarder) health insurance. Create policies for governing dialysis care to reduce demands place on safety net institutions and providers of care. Determine viability of treatment in country of origin when possible.

  20. Ethical Justification • Principle of utility – actions are right if they produce the greatest balance of happiness over unhappiness (Mill, 1861, Beauchamp and Childress, 2009) • Determine what will constitute the greatest overall balance of good. • Produces the greatest benefit for the greatest number of people. • Promoting utility • Distributive Justice- Refers to an equitable balance of benefits and burdens with particular attention to situation involving allocation of resources (Munson, 2004)

  21. Summary • Health care reform will only tighten reimbursements to safety net hospitals and providers putting more pressure on the already overtaxed healthcare system. • Health care will only become more expensive. • No foreseeable solution to immigration reform. • In the absence of change in social policy and adequate funding for undocumented workers, the taxpayers will continue to bear the burden of paying for UI. • The advanced practice nurse has a role in creating policy and searching for viable alternatives to support both Citizens and UI alike.

  22. References • ANA Code of ethics for nurses with interpretive statements (2001 ed.). Silver Spring, Maryland: Nursebooks.org. • Beauchamp, T. and Childress, J. (2009) Principles of Biomedical Ethics. 6th ed. New York, NY. Oxford university Press • Bureau of Labor Statistics (2012). Labor force statistics from the current population survey. Retrieved from www.bls.gov/cps • Campbell, G. A., Sanoff, S., & Rosner, M. H. (2010, January). Care of the undocumented immigrant in the United States with ESRD. American Journal of Kidney Diseases, 55(1), 181-191. • Faden, R. (2009). Denying care to illegal immigrants raises ethical concerns. Retrieved from www.kaiserhealthnews.org • Gallup wellbeing (2012). In U.S. uninsured rate stable across states so far in 2012. Retrieved from www.gallup.com/poll/156851/uninsured-rate-stable-across-states-far-2012.aspx • Gusmano, M. K. (2012). Undocumented Immigrants in the United States: U.S. health policy and access to care. Retrieved from www.undocumentedpatients.org

  23. References cont’d • Harasim, P. (2012). More illegal immigrants getting emergency treatment at UMC. Retrieved from www.lvrj.com/news/more-illegal-immigrants-getting-emergency-treatment-at-umc-82579442.html • Hoefer, M., Rytina, N., & Baker, B. (2012). Estimates of the unauthorized immigrant population residing in the United States: January 2011. Retrieved from www..dhs.gov/estimates-unauthorized-immigrant-population-residing-united-states-january-2011 • Labor force statistics from the current population survey. (2012). Retrieved from www.bls.gov/cps • Munson, R. (2004). Intervention and reflection: Basic issues in medical ethics (7th ed. ed.). Belmont, CA: Wadsworth. • Nam, Y. (2012). Welfare reform and older immigrant adults’ Medicaid and health insurance coverage: Changes caused by chilling effects of welfare reform, protective citizenship, or distinct effects of labor market condition by citizenship? Journal of Aging and Health, 24(4), 616-640. • Stanford encyclopedia of Philosophy. Utilitarianism. http://plato.stanford.edu/entries/utilitarianism. • United States conference of Catholic Bishops (2009) Ethical and Religious directives for Catholic Health Services. 5th ed. • Viladrich, A. (2012). Beyond welfare reform: Reframing undocumented immigrants’ entitlement to health cre in the United States. A critical review. Social Science medicine 74. 822-829.

  24. Image Sources • MidDayInformedia Ltd. 2010 [Dialysis patient] Retrieved from http://www.mid-day.com/news/2011/mar/130311-goregaon-dialysis-patients-facebook-group-news-mumbai.htm • The Red Phoenix. 2012. [Immigrant family]. Retrieved from http://theredphoenixapl.org/2011/05/07/undocumented-immigrants-paid-11-2-billion-in-taxes-last-year-general-electric-paid-zero/ • AP/Catholic Health Association. ND. [Immigrant woman and child with doctor]. Retrieved from http://www.americanprogress.org/issues/immigration/news/2009/09/11/6693/fact-check-health-care-and-undocumented-immigrants/ • Dr. Akilah El-Celestial Healing Wellness Center. ND [Health care professionals.] Retrieved from http://docakilah.wordpress.com/2011/11/14/health-care-workers-now-choose-alternative-medicine/

  25. Image Sources • Marion County, Ore. ND [Police Badge]. Retrieved from http://www.businessinsurance.com/article/20111120/NEWS08/311209980 • PKL Healthcare ND [Interior of dialysis center]. Retrieved from http://www.healthcarehire.co.uk/renal_dialysis_clinic.asp • U.S. Immigration Visa & Travel. ND [United States citizen with flag] Retrieved from http://usa.immigrationvisaforms.com/us-citizenship • Pew Hispanic Center. ND [Immigrant population by state]. Retrieved from http://pewresearch.org/databank/dailynumber/?NumberID=778 • New York Law School.2011 [Gavel and Stethascope]. Retrieved from http://www.lasisblog.com/2011/03/page/2/

  26. Image Sources • DistractionAssassins. ND. [Statue of liberty-illegal aliens cartoon] Retrieved from http://www.distractionassassins.com/wp-content/uploads/podcasts//2012/04/illegal-aliens.jpg

  27. Questions ?

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