Khullar D, Chokshi DA. Immigrant Health, Value-Based Care, and Emergency Medicaid Reform. JAMA Health Forum. Published online January 23, 2019. doi:10.1001/jamahealthforum.2019.0004
The politicization of immigration has highlighted the unique challenges many immigrants face to accessing stable, high-quality health care, particularly those who have lower incomes or are undocumented. Barriers related to language, stigma, and difficulty navigating the health system aside, immigrants in the United States have more limited access to commercial health insurance through employers and to public insurance through Medicaid and the Children’s Health Insurance Program (CHIP).
Lack of regular health coverage and uncertain access to care creates an environment favoring catastrophic and hospital-based care over ambulatory and primary care, at a time when health systems and policy makers hope to shift in the reverse direction and reduce unnecessary emergency department visits and hospitalizations. Indeed, value-based care is among the few remaining bipartisan health care initiatives, and Alex Azar, JD, Secretary of the Department of Health and Human Services, recently identified “value-based transformation” as one of his 4 overarching priorities.
At the intersection of 2 policy goals—better health for immigrants and value-based care delivery—lies a little-discussed policy known as Emergency Medicaid (EM). The EM program accounts for about $2 billion in spending annually and offers reimbursement to hospitals providing emergency services to approximately 100 000 individuals who would otherwise qualify for Medicaid but for their immigration status. (Undocumented immigrants are not eligible for full Medicaid coverage, and legal immigrants must generally wait 5 years after entry into the United States before they become eligible.) California hospitals receive about half of all EM reimbursement, followed by New York, Texas, Florida, Arizona, and North Carolina.
Through the EM program, the federal government requires treatment of an emergency medical condition, one in which the absence of immediate medical attention could place a patient’s health in serious jeopardy. However, states have considerable latitude around how they define emergency and the scope of services they choose to provide. New York, for example, covers chemotherapy and radiation; Illinois covers kidney transplants. Florida changed its policy to pay for services only until a condition is stabilized, but not until it is relieved or eliminated. Most states provide emergency-only hemodialysis, but a growing subset now offers routine dialysis. (Some cover routine hemodialysis but not associated medications or procedures).
The majority of EM spending is for pregnancy-related care, which is estimated to account for more than 80% of EM costs in some states. States are required to provide emergency labor and delivery services to pregnant women, but 2 policies have allowed them to cover a broader set of prenatal services using matching federal funds. First, the 2002 CHIP created the “unborn child” option, by which a fetus may be designated as a low-income child and its mother can access prenatal services on its behalf, regardless of legal or immigration status. Second, a provision in the 2009 CHIP Reauthorization Act (CHIPRA) allows states to waive the 5-year waiting period for pregnant women during the first years of legal residency. As of 2015, 33 states had used some combination of state funds and these 2 policy options to expand access to at least some prenatal services for low-income immigrant women. These changes were motivated in part by a recognition that poor prenatal care may lead to higher uncompensated care costs for hospitals and higher education-related costs for local schools.
Evidence suggests there are medical, economic, and public health reasons for states to consider extending comprehensive prenatal care to all immigrant women—and that doing so is an important step toward higher-value care and long-term population health outcomes. Oregon’s expansion of prenatal care (Emergency Medicaid Plus) to low-income legal and undocumented immigrant women offers an illuminating case study. In 2008, Oregon began piloting the Emergency Medicaid Plus program in several counties, and it was introduced in a stepwise fashion to all counties by 2013. Research suggests the program has had a positive effect on both maternal and fetal health. Emergency Medicaid Plus increased diagnoses for diabetes mellitus, hypertension, and high-risk pregnancies among immigrant mothers, potentially offering a path to better management of these conditions before they progress. It also substantially increased receipt of prenatal care, reduced infant mortality, lowered rates of extremely low-birth-weight births, and increased rates of recommended screenings and vaccinations.
Dialysis-related care for individuals with end-stage renal disease represents another major area of spending for EM. An estimated 6500 undocumented immigrants with kidney failure lack reliable access to hemodialysis. Some states and cities have developed regular funding strategies for routine hemodialysis, but many undocumented immigrants must wait until they develop life-threatening complications before hospitals can access federal EM funds.
Research has consistently demonstrated that emergency-only hemodialysis (EOHD) is inferior to routine thrice-weekly hemodialysis—leading to more hospitalizations, higher mortality, and higher overall costs. The risk of death for individuals receiving EOHD is 14 times higher than for those receiving routine hemodialysis, and costs are about 4 times higher. In Houston and Denver, for example, EOHD cost local health systems an average of $300 000 to $400 000 per patient per year compared with $90 000 for Medicare patients receiving routine hemodialysis. Another recent study found that compared with patients receiving EOHD, those receiving standard hemodialysis experienced 6 fewer ED visits per month and spent 10 fewer days in the hospital per 6 months.
Clinicians in safety-net health systems who provide EOHD also report experiencing moral distress and professional burnout due to witnessing needless suffering and jeopardizing patient trust. No evidence suggests that providing standard dialysis increases illegal immigration, and most undocumented immigrants who develop ESRD do so years after immigrating to the United States. Emergency-only hemodialysis is associated with higher costs, higher mortality, and greater moral distress—and yet it remains the only option for undocumented patients in 40 states.
The EM program requires more rigorous academic study. More research is needed to fully understand the costs of failing to provide routine outpatient clinical care while simultaneously requiring hospitals to treat emergent conditions under federal law, as well as the lost productivity and wages for immigrant populations due to uncertain access to needed care. Questions also remain regarding the extent of potentially preventable disease burden and long-term spending for US-born children—who are eligible for Medicaid and other public benefits—of immigrant mothers.
Nevertheless, policy makers hoping to transition to a higher-value health system—one that improves quality and reduces costs by preventing and managing illness—should not ignore mounting evidence of the perverse incentives created by the current structure of the EM program. Comprehensive prenatal services for pregnant women and routine hemodialysis for individuals with ESRD represent 2 critical areas for improvement.
In the current political environment, it is likely that states are better positioned to act than the federal government. States should avail themselves of existing policy options, particularly through CHIP and CHIPRA, and consider applying for Section 1115 demonstration waivers to use EM and state-only funds to provide limited, value-oriented coverage for at-risk populations. Eventually, the federal government could also make funds more readily available, perhaps through block grants, to allow health systems to manage these conditions in a more ethically, medically, and financially responsible way.
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Dave A. Chokshi, MD, MSc Dave A. Chokshi, MD, MSc, is Chief Population Health Officer at New York City Health + Hospitals, clinical associate professor at NYU School of Medicine, and primary care physician at Bellevue Hospital. Previously, Dr Chokshi served as a White House...