Deporting Hospital Patients

Illegal immigration is now the buzz of the political ball. Candidates are talking about building a wall, rounding up and deporting undocumented immigrants, and its economic ramifications.

What happens when undocumented workers are injured and need long term medical care? What must hospitals do? What do hospitals do?

Hospitals sometimes medically repatriate patients.

Huh?

Medical repatriation is the process by which uninsured aliens who suffer from long-term medical care needs are transferred from a United States hospital to a medical care facility in their country of origin.

It’s not an uncommon practice.

The Center for Social Justice in collaboration with the Seton Hall Law School Immigration Rights/International Human Rights Clinic found that from 2006–2012, there had been over 800 documented attempted or completed medical repatriations across 15 states

The driving force behind medical repatriation is simple – lack of money. Most undocumented aliens have no access to health insurance, Medicare, or Medicaid.

When patients come to the ER in extremis, EMTALA mandates a hospital cannot deny such a patient care because of their inability to pay.

Moe specifically, in hospitals that receive federal funds, EMTALA mandates such patients receive an appropriate screening to determine whether an emergency medical condition exists. Once performed and confirmed, the hospital must then stabilize the emergency medical condition. The hospital may transfer the patient to another facility if the physician determines the other facility would provide better medical care.

EMTALA only requires that hospitals stabilize the patient or transfer the patient to another facility if the original institution cannot provide adequate care.

In discharging a patient, there are additional federal requirements. The federal discharge standards require that there is a discharge plan for the patient, that the hospital carries out the discharge plan, and that the patient be transferred to any necessary additional medical facilities to follow up on needed medical care. Patients are to be informed of their options and work with physicians to create the best discharge plan for the patient.

For patients with long term needs, the hospital must either keep the patient or find a place for them to be legally discharged. Medical repatriation to the patient’s home country solves this conundrum for hospitals that want to end the financial bleeding. In that model, the hospital transfers the patient to a facility in another country.

Let’s see how this has played out in the courts.

There are two leading cases –   Montejo v. Martin Memorial Medical Center (Florida) and Cruz v. Central Iowa Hospital Corp (Iowa).

In Montejo, Luis Jimenez, an undocumented gardener, suffered horrific orthopaedic and brain injuries when his car was struck by a drunk driver in 2000. He was hospitalized at Martin Memorial Medical Center. The hospital saved his life twice. He was hospitalized as its ward for several years, at a cost of over $1.5M. The hospital failed to find a rehabilitation center willing to take an uninsured patient. The hospital did actually collect $80k from Medicaid for emergency care. The hospital elected to terminate its care. It secured a state court order declaring Jimenez an invalid. They leased an air ambulance for $30k and transported him to National Hospital for Orthopaedics and Rehabilitation in Guatemala. He now lives in a remote hill-top one room house.

Now for the court case. And who the hell is Montejo? At the time of the deportation, guardianship proceedings were initiated by Montejo Gaspar Montejo, a relative of Mr. Jimenez. The hospital was determined to be an “interested party” in the court proceedings, successfully intervened, and obtained the court’s approval to transport Jimenez back to Guatemala. Jimenez was transported back before the trial court ruled on the guardian’s motion.

The appeals court noted that although the case regarding Jimenez was moot (he was long gone in Guatemala), such cases involving medical care of undocumented aliens were likely to recur. The appeals court agreed that the hospital was an interested party and had rights. They also noted that the hospital presented insufficient evidence supporting its decision to discharge and transport the patient. The only evidence which had been supplied to the lower court as to whether appropriate medical care would be available in Guatemala was the testimony of an “expert” on the Guatemalan public health system. So, in the future, such a hospital might have to buff up its documentation supporting that appropriate care can be rendered abroad.

In Cruz v. Central Iowa Hospital Corp, two undocumented aliens were hit by a truck. They were ejected from their vehicle. Both needed long term care and, after being treated, the hospital in Iowa wanted to discharge them to a facility in Vera Cruz, Mexico. Their conditions were stable at the time of the transfer. But, both men were “semi-comatose.” In Mexico, the two men (or their representatives) brought suit against the hospital alleging violation of EMTALA and false imprisonment. Given that the patients were “medically stable” at the time of transfer, there was no EMTALA violation. The remaining charge was false imprisonment – the argument being the hospital inappropriately “detained” the patients when they were deported to Mexico. The lower court concluded any detention was a result of the patients’ medical condition, not a detention by the hospital.

The case was appealed. False imprisonment is an unlawful restraint against the person’s will. The hospital asserted the patients’ families consented to the transfer. The families stated they did no such thing. The court still found consent noting that because the families did not adamantly object to the transfer, they effectively did consent. Further, the appellate court stated that if their condition deteriorated in Mexico, it was not the hospital’s fault. The problem was caused by the Mexican facility.

While there is limited case law on the topic, medical deportation appears to comport with federal law.

One company has taken notice. MexCare. From its website:

AN ALTERNATIVE CHOICE FOR THE CARE OF THE UNFUNDED LATIN AMERICAN NATIONAL.
We ensure impressive results for our patients through our unique service: arranging high-quality acute medical treatment in Latin American countries.
Since 2001 we have prided ourselves on our ability to design and develop customized healthcare programs that meet the needs of both hospital administrators and Latin American patients alike.

I wonder just how “impressive” the results are.