Immigrants Cling to Fragile Lifeline at Safety-Net Hospital

September 24, 2009
Immigrants Cling to Fragile Lifeline at Safety-Net Hospital

By KEVIN SACK
NEW YORK TIMES

ATLANTA — If Grady Memorial Hospital succeeds in closing its outpatient dialysis clinic, Tadesse A. Amdago, a 69-year-old immigrant from Ethiopia, said he would begin “counting the days until I die.” Rosa Lira, 78, a permanent resident from Mexico, said she also assumed she “would just die.” Another woman, a 32-year-old illegal immigrant from Honduras, said she could only hope to make it “back to my country to die.”

The patients, who have relied for years on Grady’s free provision of dialysis to people without means, said they had no other options to obtain the care that is essential to their survival. But the safety-net hospital, after years of failed efforts to drain its red ink, is not backing away from what its chairman, A. D. Correll, calls a “gut-wrenching decision”: closing the clinic this month.

The sides confronted each other in state court on Wednesday morning as lawyers for the patients sought to keep the clinic open until other arrangements for dialysis could be secured. Dialysis patients and their families packed the benches and 60-year-old Nelson Tabares, a seriously ill illegal immigrant from Honduras, was wheeled into court in a portable bed.

Despite a judge’s urging that the two sides negotiate a solution Wednesday, there was no agreement by the end of the day on how to go forward. For the time being, a restraining order keeping the clinic open stands. The judge is considering whether to extend it.

The dialysis unit on Grady’s ninth floor might as well be ground zero for the national health care debate. It is there that many of the ills afflicting American health care intersect: the struggle of the uninsured, the strain of providing uncompensated care, the inadequacy of government support, and the dilemma posed by treating illegal immigrants.

Grady is one of many public hospitals that have been battered by the recession as the number of uninsured has mounted. New York City’s public hospital system is eliminating 400 positions and closing some children’s mental health programs, pharmacies and clinics. University Medical Center in Las Vegas has closed its mammography center and outpatient oncology clinic.

“It comes down to which service do you need to keep open,” said Larry S. Gage, president of the National Association of Public Hospitals. “You try your hardest to cut back on services that are going to be available elsewhere in the community.”

Public hospital officials are concerned that the health care legislation being negotiated in Washington could worsen their plight before making it better. Under bills traveling through both houses of Congress, as the number of uninsured declines there would be commensurate reductions in Medicaid subsidies to hospitals that provide large amounts of uncompensated care.

At Grady, about four in 10 patients are uninsured, and an additional 25 percent are insured by Medicaid, which reimburses at rates so low they often do not cover actual costs. As a result, the hospital lost $33.5 million last year, with the dialysis clinic accounting for about $2 million of that total, said Denise R. Williams, the hospital’s executive vice president.

Nonetheless, as a taxpayer-supported hospital with the mission of serving the indigent, Grady is expected to take all comers in need of emergency care, like dialysis. Treatment there does not depend on a patient’s insurance or immigration status.

The hospital has been encouraging some of the dialysis patients to move to other states or back to their home countries, offering to defray some costs.

Hospital officials estimate that two-thirds of the outpatient clinic’s roughly 90 patients are illegal immigrants. They do not qualify for Medicare, which covers dialysis regardless of a patient’s age, and they are excluded in Georgia from Medicaid and other government insurance programs. Legal immigrants face a five-year waiting period before becoming eligible. That leaves Grady to absorb costs of up to $50,000 a year per dialysis patient, some of whom have availed themselves of the thrice-weekly treatments for years.

After years of fiscal desperation and management turmoil at Grady, Atlanta business leaders stepped in last year to force a restructuring, from a quasi-governmental authority to a nonprofit corporate board. In response, the Robert W. Woodruff Foundation pledged $200 million over four years to replace dilapidated beds and modernize computers. A $20 million gift from Bernie Marcus, a founder of Home Depot, is helping to update the emergency department, which provides regional trauma services.

But the hospital’s operating deficits have continued. Grady’s senior vice president, Matt Gove, estimated that its uncompensated care would grow by $50 million this year, up 25 percent. The new nonprofit board eliminated 150 jobs this year, closed an underused primary care clinic and began charging higher fees to patients who live outside of the two counties that support Grady with direct appropriations.

The closing of the outpatient dialysis clinic was recommended by consultants in 2007, who said that equipment was outmoded, that most hospitals did not provide outpatient dialysis and that Atlanta had scores of commercial dialysis centers. When the hospital’s chief executive at the time tried to shut it down, the resulting firestorm helped prompt his dismissal.

This July, the new board voted to try again. The hospital gave patients a month’s notice of the scheduled Sept. 19 closing, and vowed to assist them in finding local dialysis providers, relocating elsewhere and qualifying for public insurance. “We committed that not a single person would be left behind,” Mr. Correll wrote in a newspaper advertisement published on Sunday.

About a third of the patients have been successfully moved, including several illegal immigrants who returned to Mexico with the hospital’s financial help, Mr. Gove said. But others have said they have no place to go, have no means to pay for dialysis or are too ill to travel.

The female illegal immigrant from Honduras, who has a 7-year-old son, said her parents live more than a four-hour drive from the nearest dialysis center, in Tegucigalpa. She is mindful that her sister died from a stroke while being driven to a hospital there. She said she had no money to pay for dialysis because she was too weary from her kidney condition to hold down a job.

“I feel like they are trying to get rid of me because I don’t work,” she said, her eyes tearing. “But being sick is not my fault.”

Samuel Tabares, who rolled his father into court in his bed, said his father, who was paralyzed by a stroke, would probably not survive the strain of relocation or repeated trips to the emergency room in search of treatment.

“They’re treating the closing of this clinic like it’s the closing of a dental clinic,” Mr. Tabares said, “as if people’s lives don’t depend on it.”

http://www.nytimes.com/2009/09/24/health/policy/24grady.html?hp