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The New York Times
U.S. Rule Limits
Emergency Care for Immigrants
By SARAH KERSHAW,
nytimes.com on the Web, September 22, 2007
The federal government has told New
York State health officials that chemotherapy, which had been covered for
illegal immigrants under a government-financed program for emergency medical
care, does not qualify for coverage. The decision sets the stage for a
battle between the state and federal governments over how medical emergencies
are defined.
The change comes amid a fierce national debate on providing medical care to
immigrants, with New York State officials and critics saying this latest move is
one more indication of the Bush administration’s efforts to exclude the
uninsured from public health services.
State officials in New York and other states have found themselves caught in the
middle. The New York dispute, focusing on illegal immigrants with cancer —
a marginal group of unknown size among the more than 500,000 people living in
New York illegally — has become a flash point for health officials and advocates
for immigrants in recent weeks.
Under a limited provision of Medicaid, the national health program for the poor,
the federal government permits emergency coverage for illegal immigrants and
other noncitizens. But the Bush administration has been more closely
scrutinizing and increasingly denying state claims for federal payment for some
emergency services, Medicaid experts said.
Last month, federal officials, concluding an audit that began in 2004 and was
not challenged by the state until now, told New York State that they would no
longer provide matching funds for chemotherapy under the emergency program.
Yesterday, state officials sent a letter to the federal Medicaid agency
protesting the change, saying that doctors, not the federal government, should
determine when chemotherapy is needed.
Federal health officials declined to discuss chemotherapy or the New York
claims. But Dennis Smith, director of the Center for Medicaid and State
Operations at the federal Centers for Medicare and Medicaid Services, said in a
statement, “Longstanding interpretations by the agency have been that emergency
Medicaid benefits are to cover emergencies.”
The federal statute that defines an emergency under Medicaid makes it clear that
routine care for illegal immigrants and nonresidents, including foreign students
and visitors, is not covered. But the only procedures it specifically
excludes from reimbursement are organ transplants, leaving to the states the
task of further defining an emergency. States and courts have grappled
with the question for years, yielding no clear definition.
Some states have maintained that any time a patient is able to schedule an
appointment — as opposed to showing up at an emergency room — the condition
would not be considered an emergency. Others, including New York, have
defined an emergency as any condition that could become an emergency or lead to
death without treatment.
“There are clearly situations that we consider emergencies where we need to give
people chemotherapy,” Richard F. Daines, the New York State health commissioner,
said in an interview late yesterday. “To say they don’t qualify is
self-defeating in that those situations will eventually become emergencies.”
Dr. Daines said that for every effort in the state to use Medicaid “creatively”
to cover the uninsured, “the Bush administration, at every chance, is pushing it
back.”
The state estimated that the federal government denied $60 million in matching
funds for emergency Medicaid from 2001 to 2006, including $11.1 million for
chemotherapy. Medicaid costs are typically split evenly between the state
and the federal government.
It is unclear how many other states are providing chemotherapy to illegal
immigrants, because all emergency services are generally lumped together in
state Medicaid reports. But others have also been challenged on emergency
Medicaid claims.
In Washington State, where illegal immigrants are entitled to Medicaid coverage
for a month or more after treatment in an emergency, officials said a federal
audit of their emergency Medicaid claims was under way, and the state has asked
the federal government to provide a definition of emergency services.
“The awkward position state Medicaid programs are in is trying to figure out
what kinds of medical care should be available for emergency conditions,” said
Douglas Porter, assistant secretary for the Washington Health and Recovery
Services Administration.
Washington and other states have also fought the federal government over
Medicaid for infants born to illegal immigrants, an issue reflected in the
ferocious debate over the national children’s health insurance program.
In the wake of stricter federal rules, New York, New Jersey, Connecticut and 20
other states have extended full Medicaid coverage, using only state money, to
some immigrants who do not qualify for federal aid. Under federal law,
proof of citizenship is required for full Medicaid coverage, but not for
emergency coverage.
But some states with growing immigrant populations, like Georgia and Arizona,
have themselves moved to limit coverage under emergency Medicaid, leading to
intense opposition from immigrant health advocates.
Advocates for breast cancer patients said they were particularly concerned about
the denial of coverage after lobbying the federal government for years to
provide breast cancer screening to uninsured women. Under a program
offered to underinsured and uninsured women, the Centers for Disease Control and
Prevention provides free or low-cost screening.
“To allow women to be diagnosed with breast cancer and then create an obstacle
for them to get treatment is a horrendous policy,” said Donna Lawrence,
executive director of Susan G. Komen for the Cure in New York.
In New York City, cancer kills 15,000 residents a year. It is the second
leading cause of death among both the native- and the foreign-born, according to
a 2006 survey by the city’s health department, with lung, breast and colon
cancer the top killers.
The state had initially accepted the federal finding that New York was not
entitled to federal reimbursement for chemotherapy under the emergency Medicaid
program. But until last month, state health officials had not informed
medical providers that the treatment would no longer be covered by either state
or federal funds.
That provoked a pitched outcry from immigrant health advocates over the last few
weeks, and state health officials reversed their position this week, saying
Medicaid should cover the treatment.
State officials said they were challenging the federal decision on the grounds
that chemotherapy treatment qualifies as an emergency under the federal
government’s own rules. Certain conditions, including diseases of the
brain, spinal cord and bone marrow disease, could require immediate
chemotherapy.
The state’s letter also said that chemotherapy can be used to “cure cancer,
control cancer and/or ease cancer symptoms,” and that if that the measures
typically used to treat cancer were not available to patients, their health
could be in serious jeopardy — one of the federal criteria in determining an
emergency.
The cost of emergency Medicaid is still a relatively small portion of state
Medicaid budgets, experts said, and a majority of the money is spent on care for
pregnant women, labor and delivery. But the demand for it rising quickly
as the immigrant population balloons.
Health advocates say that many illegal immigrants who need and qualify for
emergency care are afraid to seek help, and that emergency Medicaid is
underused.
A recent study of emergency Medicaid services in North Carolina found that
spending, largely devoted to pregnant women, increased by 28 percent from 2001
to 2004; still, the emergency costs accounted for less than 1 percent of total
Medicaid expenditures.
New York City public hospitals, which serve 400,000 uninsured patients a year,
among them illegal immigrants, would continue to provide the cancer treatment no
matter what, said officials from the Health and Hospitals Corporation. But
if there is no reimbursement from Medicaid, they said, they will have to look
elsewhere for financial support.
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