When the Ward is Your Mooring: The Human and Economic Costs of Long-Term Acute Care for Undocumented Immigrants in the U.S. – Nora Kenworthy
A recent New York Times article by John Leland recounted the lengthy medical history of Raymond Fok, an uninsured and undocumented immigrant who ended up marooned at New York City’s Downtown Hospital for 19 months after surviving a stroke. Although suffering from chronic health problems, including kidney failure, and initially in need of acute care, Mr. Fok remained in the hospital long after his initial emergency because he had no other place to go.
Without insurance or public benefits, numerous immigrants in the U.S. find similar fates in public hospitals, learning that without chronic or community-based services to assist them in recovery, they cannot be discharged. Rather than qualifying for a home health aide, or getting transferred to a nursing home, Mr. Fok’s status left him in the expensive care of an already cash-strapped public hospital. As Leland writes: “Mr. Fok’s immigration status never kept him from receiving treatment, but it helped make sure that his care would be delivered in the most expensive setting possible and in a place no one wants to spend more time than necessary.”
Mr. Fok was a “prisoner” by default, held captive only for lack of other options. Ultimately, he was transferred to the care of his family, who had been difficult to locate (many undocumented patients will not disclose family contacts for fear that the information will be shared with immigration authorities), and were poorly equipped to care for him. He had no benefits or assistance to help him with his long-term recovery. Back at home, with little or no support, he appeared to lose much of the mobility and verbal skills he had rebuilt in the hospital after his stroke.
In my last post, I discussed the research I have conducted with undocumented immigrants residing in psychiatric hospitals who, like Mr. Fok, remain hospitalized for lack of less restrictive and more community-based options. They too are “prisoners” by default, often eager to leave these isolated residences, but lacking other places willing to provide for their care. Particularly for those with mental health problems, long-term hospitalization in a state psychiatric institution can be more damaging than recuperative, and community-based services provide a crucial gateway towards full recovery.
Many patients I have interviewed show sufficient improvement by clinical measures, but transfer to further community-based services is all but impossible without qualifying for additional institutional supports such as Medicaid, supportive housing, and disability pensions. Others cycle through episodes of acute illness but, without a vision or a hope of future discharge, seem unable to claim a foothold in recovery. Some individuals have remained hospitalized for decades even as family members have gained citizenship and carried on with their lives. Hospital staff and administrators often bear witness to the damage caused by long-term institutionalization, yet remain unable to facilitate discharge.
The costs of confinement—either to public hospitals or to state psychiatric institutions—are enormous and excessively wasteful of public resources. Just last week, the New York Times released another report on the costs of unnecessary acute care for undocumented patients at New York City’s overburdened public hospitals. Although comparing costs is always difficult, it is much more expensive to treat mental health issues within a state psychiatric hospital than to provide community-based care and services. Without a change in immigration laws, in Medicaid and Medicare eligibility criteria, or both, we can expect these expenses to continue rising for public hospitals. With Congress enacting laws to reign in the costs of Medicaid and Medicare, and with state budgets badly strapped for cash, hospitals are tightening the belt on already slim budget margins. Under these circumstances, it is imperative that we face facts: improving access to community services will not only facilitate better recovery for many undocumented immigrants, but also dramatically reduce wasteful spending on costly acute care services.
For now, few clear alternatives exist for patients like Mr. Fok. Although no one would advocate for the unnecessary waste of resource-intensive care, the current system leaves undocumented immigrants with few other options. Discharging a patient to less restrictive and more supportive care is wonderful, but only if that person also has a place to live and a means of making a living. As cases like this one illustrate, the situation for immigrants confined to institutions is embedded, by default, within the overlapping (and seemingly insurmountable) crises in the U.S. health care and immigration systems.
If immigrants with chronic health concerns received the benefits available to citizens, then they would be better supported in managing their illnesses (mental or physical) and charting their paths to recovery. And, crucially, this would be accomplished at much lower cost to states and healthcare facilities. Continued penalization of the most vulnerable immigrants not only lays the groundwork for gross rights violations, but also bars their access to the tools of their own recovery—recovery, it is worth noting, that would save our health systems millions of dollars a year.
Nora Kenworthy is a PhD student in Sociomedical Sciences at Columbia University, where she is also a fellow with the Columbia Population Research Center. Her work focuses on political determinants of health, and how health systems and health-seeking impact citizenship, political participation, and social belonging. She recently completed a research project on undocumented immigrants in psychiatric institutions in the U.S., with funding from the Center to Study Recovery in Social Contexts.
Kenworthy, Nora. 2012. “When the Ward is Your Mooring: The Human and Economic Costs of Long-Term Acute Care for Undocumented Immigrants in the U.S.” Accessed [date] at https://accessdeniedblog.wordpress.com/2012/01/12/when-the-ward-…nora-kenworthy/.