Undocumented individuals make hospital discharge difficult

Working in the hospital this month, my team has been caring for Mr. M. He was here when we started on service at the beginning of the month, and unless his planned transfer to another facility goes through, he’ll be here when we sign off to the next team at the end of the month.

Mr. M is in his fifties. He speaks Spanish. He is an undocumented immigrant from Central America. He came to the U.S. to seek employment, and send money home to his family. He has no family here that can help care for him when he’s ready to be discharged from the hospital.

Unfortunately, three months ago, he had a big stroke. He was paralyzed on his right side. He couldn’t swallow, walk, or use his hand. He could barely speak.

He’s been in the hospital all that time. This won’t surprise you, but he doesn’t have health insurance.

Even before he had his stroke, his situation was fairly complex, in that he’d developed kidney failure due to his longstanding and poorly treated high blood pressure. Luckily for him, he lives in the dialysis era. Three times per week, he’s hooked up to a machine that filters the waste from his blood.

He’d been getting dialysis at a local center before his stroke, because even without insurance there are federal subsidies for people with End Stage Renal Disease (ESRD). This has been in place since 1973.

We continued dialysis for him here at the hospital. He’s received physical, occupational, and speech therapy. He needed a stomach tube to help feed him, and we provided it for him. Due to these tube feedings and the great work of our therapists, his overall condition has improved significantly.

He’s now able to eat by mouth, and no longer needs to use the feeding tube (“G-tube,” we call it, for gastrotomy–it’s in his stomach). Also, he can walk without any assistance.

Several weeks ago, we’d have transferred Mr. M to a rehabilitation facility to hasten his return of function. But no facility would accept him without insurance.

Hospitals work feverishly to discharge patients to the appropriate level of care. We want good outcomes for our patients. It suits no one to have patients “bounce back” if we’ve discharged them too hastily or sent them home when they’re not yet ready to care for themselves or there isn’t a solid enough plan in place.

Mr. M doesn’t have family here that can look after him. His original home is in Central America. Even though he’s clinically improved, he’s still not ‘employable.’

We can’t keep him in the hospital forever, though it feels like that to the intern on my team (the one whose job it is to round on Mr. M every day, examining him and formulating his ‘daily plan’). There has to be somewhere he can go, right?

If he had a home or family nearby, of course we’d send him there. But he doesn’t.

So, our discharge planners have investigated doing the ultimate: sending him home–to his native country.

I will admit, when I read the article linked at the beginning of this post, it made me very skeptical of the practice of sending undocumented immigrants home. After all, we are not the INS. We are the medical establishment. It’s our job to care for people, regardless of who they are or where they come from.

But in Mr. M’s case, there really doesn’t seem to be any alternative. We’ve provided him with months of first-world, outstanding medical care for free. And given his social situation, there isn’t any other reasonable discharge plan for him, as no other facility will take him. Home truly seems to be the only reasonable option.

And before you accuse us of ‘dumping’ him back home, consider the cost of doing so: for a ‘regularly insured’ patient, it costs next to nothing (there might be a transport fee, but even that is paid usually by insurance) to transfer to a facility.

How much do you think it costs to send someone home, using a ‘medical escort service?’

If you guessed fifty thousand dollars, you’d be on the mark. And that’s just flying commercial, with a medical escort. If he were sick enough to merit an air ambulance, you can add another $25 k to the bill.

Only in America! Our entrepreneurial spirit is truly amazing. Where there’s a need, the market rises up to meet the demand. For example, this company.

Surely the Health Care Reform legislation that just passed will help future patients like Mr. M, right?

Incorrect. There is no coverage scheme for undocumented individuals in the plan.

John Schumann is an internal medicine physician at the University of Chicago who blogs at GlassHospital.

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