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Sunday, Apr 22, 2018
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Hospitals sue over cut in state reimbursement for noncitizens

Immigration is more than a political firestorm for people running some of Florida’s hospital emergency rooms. For them, it’s about business. Poor and sick pregnant women, children and disabled noncitizens have come to symbolize yet another financial challenge to an already-stressed bottom line. More than two dozen hospitals, including several in the Tampa area, are suing the state for reducing reimbursements for patients who, had they not arrived in this country illegally, would be eligible for Medicaid. The hospitals say the state arbitrarily changed the amount it would give them specifically to pay for this emergency medical treatment, which the hospitals are obligated to provide. An administrative court agreed, but the state’s Agency for Health Care Administration recently filed a challenge in the First District Court of Appeal.
“We’re certainly not trying to make a political statement about immigration,” said Tommy Inzina, chief financial officer at BayCare Health System, which has several hospitals involved in the lawsuit. “For us, it is purely that they (the state) did not follow the rules.” Nearly every hospital in the United States is legally required to treat anyone – citizen or noncitizen – who shows up in the emergency room. Questions about ability to pay or citizenship are irrelevant, says the 1986 Emergency Medical Treatment and Labor Act, known as EMTALA. Those questions are asked only after the emergency room team has assessed a patient’s medical condition, said Lou Ann Watson, manager of BayCare’s financial assistance department. Her team helps uninsured citizens and noncitizens find financial and medical resources they may qualify for, such as community health centers or private groups. “We in no way make decisions that go back to the clinical team,” she said. “Their care in the ER continues regardless of their financial status.” National studies estimate that anywhere between 25 and 40 percent of all hospital emergency room patients – citizens and noncitizens – won’t be able pay for their care. As a result, hospitals across the country expect a percentage of their costs each year will be unpaid, and they budget for that. A vast majority of those patients are American citizens who don’t have insurance or don’t have the ability to pay. Immigrants without legal status are a small portion. Still, any cuts made to an already strained budget hurt. Exactly how much money is at stake in this immigration issue is not clear. Hospitals attorney Joanne Erde said over time, it could add up to hundreds of millions of dollars. Inzina estimates BayCare is fighting over maybe $1 million a year, a fraction of the $189 million reported in 2012 as charitable or unpaid care. “The federal government and state … are constantly looking for ways to decrease what they are paying,” he said. “As an industry, we are constantly trying to deal with it.” Medical emergencies – such as labor and delivery for poor, pregnant noncitizens – are now partially paid for through an “Emergency Medicaid” fund. That care won’t stop because the state has changed its payment formulas, Erde said. But without some government assistance, expenses will essentially shift to patients with insurance, she said. “The cost of operating a hospital will go to the people who can afford to repay,” said Erde, who is now drafting the hospitals’ argument for appellate judges. An Agency for Health Care Administration spokeswoman declined comment on the pending lawsuit. But in the recent brief, the agency maintained the change was only a clarification of a rule in place since 2003. The state recognizes that the emergency medical treatment law places a financial burden on hospitals, but says a line has to be drawn. “Congress did not intend EMTALA to be a cure-all or to solve the larger problem of providing medical services to the growing number of uninsured patients,” wrote Tracy Cooper George, an attorney for the agency. Florida is not the first state arguing over health care for poor, undocumented residents, said Leighton Ku, a professor of health policy at George Washington University. So far, however, the Sunshine State has been able to avoid the tensions that mark many immigration debates. “In some states, it has taken on an element of politics,” he said. And while this now 2-year-old lawsuit won’t be resolved anytime soon, Ku said theimmigration reform bill now being debated in Washington, D.C., could add a dramatic wrinkle to the case. Last week, a Senate version of the bill passed through its Judiciary Committee, but it didn’t address the specific issue of noncitizens and emergency medical treatment. Immigrants seeking the 10-year “path to citizenship,” however, would not qualify for any government health care support, according to the latest version of the Senate bill. Ku said that language could endanger the emergency Medicaid funding. Another potential problem, Ku said, is that there still isn’t a bill from the more conservative, Republican-led House. He said that could be because politicians are still trying to hammer out these politically controversial health care issues behind the scenes. “You have potentially something that is explosive in nature,” he said of the debate over caring for immigrants in the country illegally. “I think this is why the negotiators have tried to keep health care issues off the table.” Inzina acknowledges that this lawsuit also comes at a time when hospitals are being roundly criticized for charges that appear hyperinflated. He said that condemnation overlooks the complexities of health care, specifically the nearly 50-year old financial push and pull between hospitals, insurance companies and the government’s Medicare and Medicaid programs. It’s not easy to untangle this mess, and that is, in part, why BayCare and other hospitals are fighting over seemingly small financial issues involving undocumented immigrants, Inzina said. The bottom line is that hospitals have to make sure they can afford to provide care for all patients, he said. “Unfortunately sometimes, because it is a business, we get dragged into talking about money.”

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