‘He's just awaiting the social worker for homelessness resources, but is medically cleared,” my colleague told me at the beginning of a night shift. “He has a wound infection and needs to keep the area clean and dry, change the dressings daily, and take the antibiotics as prescribed.”
I glanced outside the sliding doors of the ED ambulance bay. It was miserable outside. It had been raining for four straight days in LA; there was no way this patient could accomplish these things in this weather. No shelter would be open or have space at this time of night.
This man faced another barrier to health care—he was an undocumented immigrant. He worked as a day laborer after emigrating from El Salvador to escape violence. He did not earn enough to secure stable housing. He was terrified of being deported to a country where his family's lives were still under threat. He told me he needed a two-drink-minimum beer jacket to be able to handle sleeping outside. He would probably need many more if he were sent back out into this relentless rain.
California law began mandating in January that hospitals provide certain basic needs before discharging homeless patients, including food and water, clothing, medication, and transportation to a social services agency if requested. (“California Law Setting Discharge Rules for Homeless Patients Creates Tough Task for EDs,” EMN. 2019;41:1; http://bit.ly/2Jf2mLa; Loma Linda University. June 2018; http://bit.ly/2EWdjft.) The law aims to address patient dumping concerns because many shelters reported patients arriving at their facilities still in hospital gowns without prior arrangement, including during times they were closed or at capacity and without reasonable plans for medical follow-up.
More than a quarter of the nation's homeless population resides in California. (New York Times. Dec. 21, 2017; https://nyti.ms/2EQDynA.) Homelessness increased by 23 percent from 2016 to 2017 in Los Angeles County. That rise was in almost every demographic group, with a notable 63 percent increase in Latino homelessness. (Los Angeles Times. June 18, 2017; https://lat.ms/2ERAcRb.) Latinos made up 35 percent of all homeless individuals in LA County in 2017. It is challenging to have a truly accurate number of how many of them were undocumented, but anecdotally, it was likely a high proportion. Their only options for health care are safety net clinics and emergency departments.
Given the current political climate, a constant fear of deportation means that undocumented immigrants are less able to find work, seek public assistance, and access health care. Many of these individuals work in low-wage jobs that are important for society, often without any health benefits, and they are unlikely to break out of the poverty and homelessness cycle. (KQED. Sept. 23, 2016; http://bit.ly/2EQSemC.) Laws like the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 made it more challenging for undocumented residents to access health and social resources, meaning the social worker for whom my patient was waiting would have limited options to offer him. (UCLA Center for Health Policy Research. Aug. 31, 2012; http://bit.ly/2EWpQzD.)
Immigrants tend to be healthier, younger, and less costly to the health care system, but maintaining their good health requires preventive services. EMTALA dictates that anyone who comes to an emergency department seeking care must be stabilized and treated for life- and limb-threatening conditions regardless of insurance or financial status. Combine that with the fact that EDs never close, and they become the last resort for the most marginalized of society not only when they have medical need but also when hungry or in danger.
The cost of treating patients is borne by society because these disproportionate-share safety net hospitals are financed by taxes and private funding. There is nowhere else for homeless immigrants to turn when they are critically ill. Addressing the proximate causes of poor health in this vulnerable population, including poor nutrition, lack of stable housing, inadequate transportation, and inability to obtain medications or follow-up, will reduce long-term health care costs.
This legislation is an unfunded mandate that places a burden on hospitals for services that are largely dependent on community resources and outside the scope of medical care. The California chapter of the American College of Emergency Physicians, the California Hospital Association, and the California Medical Association opposed the bill because it will contribute to crowding in hospitals and emergency departments without adequate community resources.
Solving homelessness is likely not a part of a hospital's direct mission, but hospitals can play a vital role in public health and community capacity-building for overall health care and human rights. Good evidence shows that providing housing helps patients stabilize their medical conditions. (Scand J Public Health. 2017;45:686; http://bit.ly/2ESmVrx.) California has already been a champion of immigrant health, for example, by providing Medi-Cal coverage for undocumented children despite the federal political climate. (USC Dornsife. August 7, 2017; http://bit.ly/2EVsfdw.) This legislation serves an important role in bridging gaps in care, especially for vulnerable populations like this one.
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Dr. Acharyais a fellow in the International and Domestic Health Equity and Leadership program in the department of emergency medicine at Olive-View UCLA/Ronald Reagan UCLA Medical Center. He thanks Breena Taira, MD, and Steven Wallace, PhD, for their assistance with this article.