Home > Recent Post > Defects in the Safety Net: When the Emergency Option is the Only Option – Sural Shah

Defects in the Safety Net: When the Emergency Option is the Only Option – Sural Shah

Sural Shah
Cambridge Health Alliance & Harvard School of Public Health

Ana, age 29, came to the clinic for a sore throat, her two energetic children in tow. While her kids darted around the clinic space, which was donated by a local academic medical center, I introduced myself as a volunteer physician and began asking about her medical history. As Ana moved from her chair to the exam table, she told me she had traveled from Mexico to the United States as a teenager and now was living here illegally, a familiar story among patients in the largely Latino and impoverished Philadelphia community our non-profit clinic[1] serves. Moving my stethoscope around her chest, I was surprised to hear a harsh murmur suggesting problems with the blood flow through her heart. 

Ana told me she had been feeling tired even before the sore throat, and that even as a little girl she would tire out more easily than other kids. Concerned, I looked into her medical record. It turned out Ana’s heart murmur had been noted during a prior pregnancy, and an ultrasound had shown two significant congenital heart defects requiring surgery. Although her case had been reviewed by cardiologists and surgeons, Ana was unable to continue seeing the specialists or receive surgery because her medical coverage had run out once she had delivered her baby. Her return to the clinic for the unrelated sore throat was an opportunity to bring Ana back to care and patch the holes in her heart.

Since Ana was undocumented, poor, and uninsured, her only option was to apply for Emergency Medicaid. In Pennsylvania, recipients of Emergency Medicaid receive an insurance card valid for all care typically covered by Medicaid over an approved time period. For Ana, this would include surgery and post-operative care. The process seemed straightforward, yet we couldn’t be certain. Our clinic’s history was full of stories demonstrating potential challenges.

To obtain Emergency Medicaid in Pennsylvania, an applicant must meet a number of criteria: (1) state residence, (2) an “emergency” medical condition, and (3) traditional Medicaid-eligible status, including its income/asset requirements, in every way except the citizenship/legal status requirement. The definition of “emergency” applied in this context does not require that the applicant be admitted to the emergency room. Rather, an eligible applicant must have a medical condition with symptoms that, if left untreated, would put his or her life in serious jeopardy or result in serious impairment to bodily function or serious dysfunction of any body organ or part.[2]

Typically, a patient or an advocate completes the regular Medicaid application but does not check the box confirming one’s legal status. A provider submits a letter on the patient’s behalf detailing his or her medical condition, findings from the medical examination, and relevant laboratory or radiographic results. The letter must also explain the need for immediate treatment, the anticipated duration of treatment, and a detailed treatment plan including specific dates (usually less than six months). Resources exist to facilitate this process, such as Pennsylvania Health Law Project.[3] When providers are unaware of Emergency Medicaid, or when they fail to understand how closely their letter must follow Department of Public Welfare (DPW) guidelines, the physician’s letter can become a stumbling block.

For Ana, an ultrasound of her heart was donated by hospital providers, and her case was again discussed with surgeons, who provided background information and a detailed plan. Our nurse, the clinic’s de facto social worker, completed the paperwork on Ana’s behalf, including the necessary supporting information. We submitted these materials to the DPW along with her regular Medicaid application.

Then, we waited. Despite attempts to reach out to DPW, we waited for months with increasing concern for Ana’s health. Ultimately, Ana developed worsening symptoms and ended up in the emergency room. At that point, the hospital was able to use its clout to push her paperwork through, and Ana underwent surgery just before Christmas, approximately six months after her application was initially filed, but not before her health had been compromised. The next month, I saw her on a follow-up visit. She had a healing scar on her chest, but also the smile of a young mother now able to keep up with her two rambunctious children.

Despite the positive outcome, this experience left me concerned about what delays in paperwork might have meant for Ana’s health and what they mean for others in her situation. Nationally, Emergency Medicaid represents less than one percent of Medicaid spending. Yet for undocumented immigrants, who are otherwise summarily excluded from most other forms of health coverage and access, it can be a matter of life and death.[4],[5]

As the Affordable Care Act is implemented and we see resultant cuts in federal funds to hospitals that serve the uninsured, Emergency Medicaid may rise in importance as a means of reimbursing inpatient services.[6] For undocumented immigrants, who are projected to comprise up to 25 percent of the uninsured population once the ACA is fully in effect,[7] I worry about the impact on Emergency Medicaid and, at the same time, on the undocumented community’s more visible isolation in the shrinking uninsured pool. Will these changes encourage policy-makers to further complicate the process of obtaining even this limited catastrophic coverage, which is often our only option as providers striving to save our patients’ lives? Or will they propose legislation, like that in California,[8] that would extend coverage to this population and recognize not only their contribution to our society, but also their value as fellow human beings?

For the sake of patients like Ana and her young family, and for my own sake as a physician bearing witness to the consequences of our restrictive system, I can only hope it is the latter.

Sural Shah, MD is an adult and pediatric primary care provider at Cambridge Health Alliance and a Masters in Public Health candidate at Harvard School of Public Health focusing on immigrant health and healthcare access. She graduated from Penn State College of Medicine and completed her Internal Medicine and Pediatrics Residency at the University of Pennsylvania, where she has provided care as a staff physician at Puentes de Salud, a non-profit clinic providing health and social services for a largely Latino and unauthorized community in Philadelphia, Pennsylvania. She has also been a Fogarty International Clinical Research Scholar and Thomas J. Watson Fellow. She is currently a Kraft Fellow in Community Health Leadership through Partners HealthCare.

Shah, Sural. 2014. “Defects in the Safety Net: When the Emergency Option is the Only Option.” Accessed [date] at https://accessdeniedblog.wordpress.com/2014/02/27/defects-in-the-safety-net-when-the-emergency-option-is-the-only-option-sural-shah-2/.

  1. June 29, 2017 at 9:50 pm

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