Medical providers to be required to ask patients about residency status

By SHERRY JACOBSON / The Dallas Morning News

When a Grand Prairie teenager broke his collarbone playing football three years ago, his mother feared that the emergency room staff at Parkland Memorial Hospital would learn his secret: 15-year-old Jose had been living illegally in the United States most of his life.

"I thank God they didn't ask him" his immigration status, said Rosalea, 41, who asked that the family's last name not be published. "They just focused on his injury."

Such unquestioned access to medical care may end soon for illegal residents who use the hospital's emergency room. New federal rules for Medicare payments to health care providers are expected to take effect Oct. 1, requiring medical workers "to make a good faith effort to obtain citizenship information" from patients who receive emergency care in hospitals or doctors' offices.

Civil rights advocates warn that the attempt to identify undocumented patients will have a chilling effect – either by scaring illegal residents away from necessary medical care or by denying needed federal aid to hospitals that refuse to act as an arm of the U.S. immigration service. Federal authorities say the information will be used only to make sure that health care providers are reimbursed for the costs of caring for undocumented patients.

"We're looking at a public health crisis in the making," said Marcela Urrutia, senior health policy analyst for the National Council of La Raza, a national Latino civil rights group. "It will create an enormous amount of fear in the immigrant community."

$1 billion program
The new rules were issued in July after Congress voted last year to establish a $1 billion immigrant health program under the 2003 Medicare law. The money will be distributed over four years to hundreds of hospitals, physicians and ambulance companies around the country. Those in Texas are expected to share in the state's $47 million cut, second only to California's expected $72 million.

Parkland – Dallas County's lone public hospital – expects to receive about $1 million under the new law, based on an estimate of the number of undocumented patients the hospital may be serving.

While Congress did not specify how illegal residents were to be identified, the proposed guidelines require asking patients directly whether they are in the country legally.

Dallas County Commissioner Jim Jackson said he favored such queries at Parkland. In fact, he has been pushing the hospital's officials – unsuccessfully – for years to get an estimate of the number of illegal residents receiving care and how much it's costing.

"Dallas County taxpayers can't afford to give nonemergency care to all the people in the world," Mr. Jackson said recently. "We're going to have to face reality."

About 7 million illegal immigrants were estimated to be living in the United States in 2000 – slightly more than 1 million of them in Texas, according to the U.S. Immigration and Naturalization Service.

The federal government has struggled for years to determine their financial effects on the health care system.

"Determining the number of undocumented aliens treated at a hospital is challenging," the General Accounting Office said in a May report. "Hospitals generally do not collect information on patients' immigration status because undocumented aliens are reluctant to identify themselves."

Dr. Ron Anderson, Parkland's president and chief executive officer, has declined to estimate how many of the facility's 257,200 current patients might lack legal status. But there are indications that the number could be significant. For example, about 80 percent of the women who gave birth at Parkland last year qualified for Medicaid funding reserved for undocumented mothers.

'Are you a U.S. citizen?'
Under the new rules, citizenship information would be sent to the U.S. Centers for Medicare and Medicaid Services, where a "designated contractor" would verify that each patient qualified for coverage. Hospitals would also have to share the information with doctors and ambulance providers.

Each patient would be asked questions such as, "Are you a United States citizen?" and "Are you a lawful permanent resident, an alien with a valid and current Employment Authorization Card or other qualified alien?"

The patient's name would be recorded, along with photocopies of identifying documents and any questions not answered.

The new rules were to have taken effect Sept. 1. But Mary Kahn, a spokeswoman for Medicare and Medicaid Services, said the agency decided to take more time to consider the 100-plus comments about the policy that came in over the summer.

Although final guidelines on obtaining patient identification won't be decided for several weeks, hospitals began enrolling in the voluntary program Sept. 1.

The National Association of Public Hospitals and Health Systems, which represents more than 100 public hospitals serving a large share of the nation's illegal population, has asked Washington to stipulate that a patient's immigration status would be "protected information" that could never be used for deportation.

"On one hand, the law requires that we protect our patients' privacy, and yet the government now wants us to document those who are undocumented," Dr. Anderson said. He said the federal government should have to acknowledge why it wants the lists.

"Does the government want to pay for illegal immigrant care or does it just want to know who these patients are for some other purpose?" he asked. "I don't know what the motives really are in doing this."

Rather than confronting patients and drawing up lists of those who failed to document their legal status in the United States, Dr. Anderson suggested that hospitals use an indirect measure, such as counting as undocumented any patient who has no Social Security number.

Nonetheless, he said, Parkland is willing to implement the rules to get the much-needed money.

Fallout feared
Several Parkland patients, interviewed recently as they sought assistance at Catholic Charities Immigration and Counseling Services in Dallas, worried that the new law would keep potential patients from seeking medical care.

Paula Elizondo, a 31-year-old domestic worker who has been a legal Dallas resident since March, said no one asked her status when she gave birth at Parkland three years ago.

"This will be bad," she said. "People will be afraid to go to the hospital, and they are going to get sicker at home."

Rosalea, the Grand Prairie mother, said medical providers who ask questions about citizenship would drive undocumented patients to unlicensed practitioners in Dallas' poor neighborhoods.

"Sometimes people end up having worse problems," she said of the quality of care such an alternative might force.

A man, who spoke on condition he not be named, added, "Some people would rather die than go to a hospital that asks questions about their immigration status."

Immigrant advocates said that posing questions about immigration status would effectively turn hospitals into an extension of the former INS, now part of the Department of Homeland Security.

"The immigrant community talks to each other, and once you start asking questions, they will tell their families and their neighbors," Ms. Urrutia of La Raza said. "They will be afraid to seek medical services. And that is a frightening thing for all of us."

Driving large numbers of patients out of the U.S. health care system also would pose a community health risk, said Jacobo Kupersztoch, director of Centro Comunitario Mexicano, an immigrant advocacy organization that helps Mexican immigrants deal with social and health care problems in Dallas.

"A bacterial infection doesn't ask if you are legal or not," said the former associate professor of microbiology at the University of Texas Southwestern Medical Center at Dallas. "If many people are not allowed to go to the doctor because of fear, how are you going to stop that infection?"

Other uses for info?
Federal authorities have said they want identifying information only to assure that health care providers are reimbursed for the medical costs of illegal residents. Such care, guaranteed under the 1986 Emergency Medical Treatment and Labor Act, cannot be denied to anyone who needs it, according to the law.

It was not clear, however, whether the information could be put to other uses.

U.S. Rep. Dana Rohrabacher, R-Calif., suggested in an Aug. 11 interview on National Public Radio that the government should take action when patients are found to be in the United States illegally.

"That information should be made available to the Immigration and Naturalization Service," he said. "We should find out where the illegal immigrant is working, and the [medical] bill should be paid by the employer."

In Texas, Attorney General Greg Abbott has advised local governments that they may decline to spend money on medical care for illegal immigrants, even when they prove they are living in a certain jurisdiction and fall within the income standards for receiving free health care there.

Staff writer Frank Trejo contributed to this report.