The future of American health care remains uncertain. It was only a few weeks ago that the Affordable Care Act (ACA) narrowly evaded the congressional guillotine a mere seven years after its installation. On March 25, millions of Americans learned they would retain the coverage they have had since the ACA was signed into law in 2010. Yet, despite the wide-reaching ACA and its individual mandate, our ever-increasing undocumented immigrant population continues to slip through the cracks of health care policy. Undocumented individuals present a complex issue for the American health care system, placing a sizable economic burden on the institution that treats them. To make matters worse, this group resides in the intersection of two highly contested and controversial policy realms: health care and immigration. The resulting lack of flexibility for bipartisan governmental action places the impetus for a working solution on nonprofit community organizations.
But nonprofits should not have to bear this burden alone. This is where we come in — a generation of aspiring physicians in need of understanding the reality and inadequacies of health care distribution and creating pragmatic, equitable solutions that empower a new reality. The United States Department of Homeland Security has estimated that as many as 11.1 million undocumented immigrants lived in the United States in 2014. A large majority of these immigrants come from countries in Latin America. Even among naturalized citizens, Hispanics represent the second highest percentage of any uninsured ethnic group in America at a staggering 21.1%, nearly double that of African Americans (11.2%) and triple that of White Americans (7.5%). While cost is the primary barrier to care, language differences further accentuate the difficulties in navigating the complex American health care system.
Roughly 57 million Hispanic people live in the United States, a number that has increased sharply since the early 2000s. American medical schools recognize the rapid increase in the Hispanic population, and some have incorporated Spanish-speaking recommendations into the admissions process. Stanford, UCLA and Florida State are among this group. Proficiency in Spanish widens the scope of a physician’s practice and increases the accessibility to care for patients with poor English-speaking skills.
Increasing the number of Spanish-speaking physicians will undoubtedly mitigate barriers to care for Hispanic residents. But this does not change the underlying issue that certain sectors of the health care industry are disproportionately financially impacted by caring for uninsured undocumented Hispanic immigrants. The Emergency Medical Treatment and Labor Act (EMTALA) passed in 1985 mandates that hospitals offer treatment to all patients in need of emergency care, regardless of their ability to pay. An article released from Kellogg School of Management at Northwestern University in 2015 highlighted how nonprofit hospitals bear the largest cost from uninsured patients, facing roughly $900 of expenses for each additional uninsured patient treated per year. Without an insurance company to cover these expenses, non-profit hospitals serve as “insurers of last resort,” absorbing treatment as a sunk cost. As the demand for care remains constant, so too do the losses incurred by this system. This method of providing health care as a last resort to those who cannot afford their bills is known as the health care safety net.
The health care safety net consists of all services available to uninsured members of society who otherwise cannot afford care, including community health centers, nonprofit hospitals and other charitable alternatives. The future of American health care in our lifetime will revolve around the strategic utilization of this safety net, focusing on the role of nonprofit and non-governmental agencies in providing care. It is imperative we lessen the impact on local hospitals and turn towards an emphasis on burgeoning local clinics.
While the onus on nonprofit hospitals does stem from treating uninsured patients, there exists a fundamental misconception regarding the way undocumented immigrants choose to seek care. The UCLA Center for Health Policy and Research released a study in 2012 to combat the assumption that undocumented immigrants disproportionately utilize emergency room care relative to the native born and naturalized population. In fact, it reported that undocumented individuals are less likely than naturalized and U.S. born citizens to visit the emergency department, typically resulting from a fear of being asked for some form of identification. This study implies that in the absence of other care options, an undocumented immigrant often chooses to avoid seeking treatment initially, prolonging the onset of a more serious condition that may ultimately land him/her in a lengthier and more expensive hospital stay. This reticence to obtain care at the hospital level provides still stronger evidence of the need for community-level nonprofit clinics that work with and for the patient. Ultimately, local clinics prevent the necessity of visiting the hospital for routine care and help manage symptoms as they arise, not after they worsen.
These clinics are gaining traction across the country. Casa de Salud in St. Louis, MO is an example of a successful community nonprofit clinic. Casa de Salud provides care to local Spanish-speaking immigrants in St. Louis for a flat rate of $25 per visit, providing a staff of volunteer physicians with multiple specialties to avoid the complexity and cost of referrals. If a referral is necessary, Casa de Salud has developed a program called Guia (meaning “guide” in Spanish), wherein a bilingual employee accompanies the patient to his/her specialty visit, with each referral overseen and monitored by a case manager. This type of developmental approach to care for uninsured patients emphasizes the importance of empowering the patient to seek continued care, guiding him/her through the complex health care process and demonstrating the value in the community-level primary care-centered model. Imagine this model of care spread throughout the country — hospitals would face less financial hardship by treating fewer patients who can’t afford their care. More importantly, hospitals could devote more time and energy to serious emergencies.
Health care is shifting in the United States. While a governmental policy is needed to expand coverage to undocumented immigrants and increase funding to the health care safety net, progress regarding these controversial issues is stagnated in a gridlocked congress. More than ever, our generation needs to understand and reshape the importance of nonprofit health care centers in hubs where undocumented and uninsured patients live. If there is to be a sustainable future for America’s health care industry, medical students must get involved early on in volunteering at small, local nonprofit clinics. They need to be entrepreneurial by starting their own clinics in areas in need and help develop a vision and proliferate this model across the entire country. Moreover, medical schools must continue to increase Spanish-speaking recommendations nationwide to grow the number of physicians with the necessary skill set to treat and advocate for this population. It is with this collective, compassionate understanding that we can work to simultaneously increase quality access to care for uninsured patients and lessen the burden on our already financially exhausted health care industry.
Photo credit: Photograph by Paul Beaty of the Associated Press.