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An undocumented Jamaican woman arrived in February at the Broward General Hospital emergency room in Fort Lauderdale, Fla., complaining of kidney problems. She was admitted for treatment. Within two months, her condition stabilized. For more than 30 days, she’s been ready to go home. But Broward General can’t discharge her. Because of an ongoing kidney problem, she requires dialysis treatment two or three times a week for the rest of her life. The hospital isn’t authorized to perform dialysis on an outpatient basis, and none of the local outpatient clinics will take her because she doesn’t have health insurance and her illegal status makes her ineligible for federal funding. She refuses to return to Jamaica because she’s lived in South Florida for more than 20 years. So far, her unpaid hospital bill totals more than $200,000. “The reality is that we’re backed into a corner,” said Chris Lloyd, chief financial officer for North Broward Hospital District, a public agency that owns five tax-assisted general hospitals and 35 clinics in and around Fort Lauderdale. Last week, the U.S. House of Representatives rejected a bill that would have required hospitals to ask patients coming to their ERs for proof that they are U.S. citizens or legal residents. For those without proof, hospitals would have been required to report them to the U.S. Department of Homeland Security for possible deportation. And earlier this month, the state’s 4th District Court of Appeal ruled out allowing hospitals to use state courts as a way to ship undocumented patients back to their home countries. In July, a Martin County Circuit Court probate judge had authorized Martin Memorial Medical Center in the city of Stuart, Fla., to airlift a brain-damaged patient who was an illegal immigrant from Guatemala back to his native country. The patient had run up unpaid medical bills of more than $1 million. But the 4th District Court of Appeals unanimously overturned that ruling, holding that a state judge has no legal authority to send an illegal immigrant back to his country. That was the sole jurisdiction of federal immigration authorities, the court said. The appellate panel also said Martin Memorial failed to comply with federal regulations that require hospitals receiving Medicaid funding to have an appropriate discharge plan for all patients, regardless of whether they are uninsured or undocumented. “The message is that because people who come here are going to need medical care, we must have a health care system that treats all people decently, regardless of where they’re from or why they’re here,” said Joseph Zumpano, a health care lawyer and partner at Zumpano Patricios & Winker in Coral Gables. Zumpano was not involved in the Martin Memorial case. Hospitals in South Florida and across the country are facing major financial strains from caring for a growing number of uninsured patients, including many undocumented aliens. Health care experts attribute the increase to job layoffs and cutbacks in employer-provided health coverage, as well as the many undocumented aliens who work in jobs with no health coverage. Last month, Nashville-based HCA Inc., the largest hospital operator in the country, reported that the number of uninsured patients coming to its emergency rooms increased 18 percent during the first quarter this year, compared with he first quarter last year. Partly as a result, HCA’s first quarter net income dropped 26 percent from the year before. In 2002, Florida hospitals spent an estimated $40.2 million caring for undocumented immigrants, according to a study by the Florida Hospital Association. Nationwide, Florida ranks second after California on health care spending for illegal immigrants, with Texas third. Last year, Jackson Memorial Hospital in Miami spent $400 million providing free care to illegal immigrants and uninsured patients, including U.S. citizens. Of that, the hospital estimates that $41 million was spent on undocumented aliens. The North Broward Hospital District spent $217 million in 2003 for the undocumented and uninsured. Baptist Health, which owns five hospitals in Miami-Dade and Monroe counties, spent $57 million providing free care to uninsured and undocumented patients. “We struggle with this problem all the time because of the kinds of patients we get in this area,” said Conchita Ruiz-Topinka, spokeswoman for Jackson Memorial, which handles the largest number of uninsured and illegal immigrants in Miami-Dade. Because of the problem, U.S. Rep. Mark Foley, R-Palm Beach Gardens, has asked the General Accounting Office to study how much hospitals spend on care for undocumented immigrants. He requested the study after complaints from Martin Memorial and other hospitals in his district. All claimed they were struggling under the financial burden. Foley said he plans to use the report, due out next month, to argue that Congress should provide additional financial help to hospitals that treat many illegal immigrants. “The federal government should step up to the plate to fund the especially egregious cases in which hospitals are absorbing the costs and facing potential bankruptcy,” Foley said in an interview. In some cases, hospitals have sought relief from the high cost of treating illegal immigrants through the courts, as Martin Memorial did. To do so, a hospital must file a motion for declaratory relief asking the court to order the patient removed from the hospital because he or she no longer requires acute medical care. Hospitals also have filed motions challenging the treatment plan of the appointed guardian or surrogate. But to win injunctive relief, a hospital must prove it has stabilized the patient, as required by federal law, and has a safe discharge plan that will ensure the patient will be properly cared for. It’s often a Catch-22. Under the federal Emergency Medical Treatment and Active Labor Act, hospitals that receive Medicare and Medicaid payments are required to provide emergency care to all patients, regardless of ability to pay or immigration status. To offset this burden, the federal government provides some funding for emergency care for undocumented aliens. But it doesn’t pay for those who need long-term care for disabilities. On the other hand, federal regulations known as anti-patient dumping rules require hospitals receiving federal money to ensure that patients in need of additional care are transferred to rehabilitation or long-term care facilities. But many of these facilities won’t take the patients because they have no payment source. Officials at the Department of Homeland Security in Miami said it’s up to the patient and the hospital to determine how long medical care is needed. Officials were vague when asked under what circumstances the department’s Immigration and Customs Enforcement unit would intervene in cases involving undocumented patients with nowhere to go. As a result, hospitals are stuck. They must try to devise appropriate discharge plans for indigent patients who don’t qualify for public money. “We’re put in the position of having to treat these patients, stabilize them and transfer them out,” said Rich Rasmussen, spokesman for the Florida Hospital Association. “But if they can’t be transferred, we have to absorb the cost.” POOR MEDICAL OPTIONS Last year, Martin Memorial tried to get out of absorbing further cost by seeking permission from a probate judge to ship Luis Jimenez back to his native Guatemala. Jimenez was admitted in February 2000 following a car accident involving a drunken driver. More than two years later, Jimenez was still in the hospital — in stable condition but in need of long-term care. Martin Memorial officials claimed they tried to place Jimenez in a local facility that could provide the aftercare he needed. But no facility would take him because he was ineligible for public funding. Martin Memorial filed a petition claiming that Jimenez’s legal guardian wasn’t acting in his best interest by recommending that he stay in the hospital, where he was receiving 24-hour medical supervision. The hospital said it already had spent more than $1 million caring for Jimenez and could do nothing more for him. Martin Memorial presented a letter from the vice minister of public health in Guatemala providing assurances that he would personally see to it that Jimenez was admitted to an appropriate hospital. The hospital presented that letter to Circuit Judge John Fennelly, asking him to allow them to transport Jimenez back home. Under federal regulations, hospitals must ensure that patients are transferred to another facility that will provide the next level of appropriate care. Jimenez’s guardian objected to having him returned to Guatemala, because the country did not have a facility that could provide rehabilitation for his brain injury. But Judge Fennelly granted the hospital approval to transport Jimenez back to Guatemala, ruling that Jimenez had reached a “therapeutic plateau” and that remaining in the hospital would not improve his condition. On July 10, the day after Fennelly’s order became final, the hospital airlifted Jimenez to Guatemala. Just as his guardian feared, Jimenez was admitted to a hospital in Guatemala City for a month, then was discharged to live with his mother in a one-bedroom house. He lives there in impoverished conditions with little medical or custodial care. On May 5, nearly a year after Jimenez had been returned to Guatemala, the 4th District Court of Appeals overturned Fennelly’s decision, ruling that Martin Memorial failed to provide Jimenez with a discharge plan that included a thorough investigation of whether the Guatemalan facility could provide appropriate care. Based on the ruling, Jimenez’s lawyers are conferring with his family to determine whether they will try to have him readmitted to the United States on a special visa. Martin Memorial plans to file a motion for rehearing before the 4th District Court of Appeals and possibly appeal the case to the Florida Supreme Court. At Martin Memorial, Jimenez spent his days in a wheelchair, said his attorney, Michael Banks, a solo Stuart practitioner, “but it was a lot better than where he got sent. At least he was being fed, bathed and given medication.” “It’s really tough to discharge a person from a U.S. hospital into another country, because oftentimes the smaller country doesn’t have the same level of medical care that we do,” said William Spratt Jr., a health care lawyer at Kirkpatrick & Lockhart in Miami who was not involved in the case. “This case illustrates the need for public policy review and intervention on how our society cares for and funds the health costs for undocumented aliens,” Martin Memorial spokesman Miguel Coty said in a written statement. “It’s unrealistic to expect local hospitals and its communities to bear these type of costs.” Valerie Larcombe, a health care lawyer and shareholder at Akerman Senterfitt in West Palm Beach, agreed that federal and state law lack clear guidelines on how far a hospital must go to ensure follow-up care for undocumented immigrants. “There’s no black-and-white rule for determining when a hospital’s obligation ends,” said Larcombe, whose firm represents the public South Broward Hospital District and other area hospital operators. “Most hospitals look at it on a case-by-case basis.” ‘EXERCISE IN FUTILITY’ U.S. Rep. Dana Rohrabacher, R-Calif., thought he had a solution to the hospitals’ problem. His bill would have required hospitals to ask patients coming to their ERs for proof that they are U.S. citizens or legal residents. Those without proof would be photographed or fingerprinted. The information would be forwarded to federal immigration officials, who could initiate deportation proceedings. Hospitals that failed to comply would risk losing federal subsidies. But immigration advocacy organizations and medical groups, such as the American Hospital Association, opposed the bill, arguing that it would turn hospital employees into border control agents. The bill was defeated by a 331-88 vote. Even without the bill, hospitals remain free to notify immigration officials about illegal immigrants who come to them. But officials at South Florida hospitals say they rarely call immigration officials for help, not only because it’s a punitive approach but because they get the runaround. “We’ve tried contacting federal immigration authorities on occasion, but it’s typically an exercise in futility,” said Lloyd of the North Broward Hospital District. Ruiz-Topinka said Jackson Memorial in Miami does not contact federal immigration officials. If it did, many illegal immigrants would refuse to come in for needed care for fear of being deported. That would heighten the risk of spreading untreated communicable diseases, she said. As an alternative to contacting authorities, many hospitals say they try to work with the consular offices of the patients’ native countries to make voluntary arrangements for transportation home. “On occasion, we’ve been able to line up services for a patient in their homeland,” Lloyd said. “But in order for that to work, patients have to want to do it.” Cases involving countries that don’t have facilities adequate for transfer, such as Jimenez’s, pose a major problem. In those situations, Jackson Memorial keeps the patient, Ruiz-Topinka said, often transferring them to one of Jackson’s two nursing homes for indigent patients who have been stabilized but need additional care. While Rep. Foley said the federal government needs to provide more financial help to hospitals caring for illegal immigrants, help is on the way. The Medicare prescription drug legislation passed by Congress in December provides an additional $1 billion to hospitals that provide emergency care for undocumented immigrants. Much of the money, which will be allocated over four years starting on Oct. 1, will be given to hospitals in states that have the largest number of undocumented immigrants, such as Florida. About one-third of the money, however, is tied to state efforts to help the federal government with border control. But Anne Dunkelberg, a senior health care analyst at the Center for Public Policy Priorities in Austin, Texas, said the $1 billion allocated under the new Medicare law is just a “drop in the bucket” and fails to address the lack of federal funding for long-term and aftercare. “Every day, hospitals have to discharge people into situations that are inadequate,” she said.

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