Undocumented Patients and Rehabilitation Services

Abstract

Limited options for undocumented patients can create ethical dilemmas and moral distress for health care providers working in rehabilitation. Compared with other low-income patients, patients who are undocumented have less access to financial, social, and medical services. For example, uninsured patients who are citizens or permanent residents may be eligible for public aid, charity care, or have access to philanthropic resources. For most undocumented patients, this is not the case, although some states and local communities have made provisions. Furthermore, the U.S. safety-net health care system is geared towards emergency and acute inpatient services. The Emergency Medical Treatment and Labor Act (EMTALA), enacted in 1986, requires that any patient who comes to an emergency department must be screened and, if needed, stabilized. They cannot be turned away from the emergency department based on inability to pay. There is no such requirement for rehabilitation providers, although patients with various conditions and injuries initially treated in emergency departments and acute care hospitals could often benefit from rehabilitation. As a clinical medical ethics fellow from 2000 to 2002, I attended case conferences in which we discussed and analyzed the details of cases—medical indications, patient preferences, quality of life and contextual factors 1. We debated the complexities, options, and recommendations. Often, when issues of social justice were brought up, a faculty member cautioned that resource allocation or justice issues should not be adjudicated at the bedside. I understood the caution—clinicians and clinical ethicists should work with the facts that they can gather and know and make decisions based on the best set of options practically available to them. Yet, as a bicultural daughter of immigrants, keenly aware of social justice issues from my training in clinical/community psychology and affinity with disability rights, I struggled with how we balance and address the principle of social justice in practice. I continue to struggle with this tension. This column is one attempt to explore social justice and rehabilitation using a current issue. In this column, we will explore the controversies and complexities of providing rehabilitation services for undocumented patients. The ethical issues have been explored in other venues, most notably by a working group at the bioethics think tank The Hasting Center in a project entitled, “Undocumented Patients: Human Rights, Access to Health Care & the Ethics of the Safety Net” 2. This topic of health care for undocumented patients certainly is timely. It became heated when the Affordable Care Act was being debated, came to the forefront during our recent U.S. presidential election, and has been raised again in the first weeks of the current administration. Is health care a right or a privilege? How should payer status impact rehabilitation services received? Do we have a responsibility to treat patients regardless of immigration status? And beyond our personal or political leanings, what do we do at the bedside when a patient who is undocumented needs our services? I have asked 4 columnists to share their perspectives. Michelle Gittler, MD, Medical Director, Chairperson of PM&R and Residency Program Director at Schwab Rehabilitation Hospital in Chicago, uses 2 different rehabilitation cases to address the utility of rehabilitation, reminding us that the medical indications are in fact, very relevant. Our second columnist, Judy L. Thomas, MD, a clinical assistant professor in the department of PM&R at UT Health Houston Medical School, and the Chief of PM&R at LBJ General Hospital, describes her practice in Texas, serving a large population of undocumented patients. Michael Bozza, an immigration lawyer practicing in Boston, describes his experiences with undocumented clients and reminds us that many patients who need our services will never try to access them. Finally, Nancy Berlinger, research scholar at The Hastings Center, based in Garrison, New York, explores the ethical issues raised by occupational injuries and the role of charity care in providing services. As always, I welcome your reactions and ideas for columns. As of March 25th, I can be reached at [email protected] (formerly ric.org). Michelle Gittler, MD Schwab Rehabilitation Hospital It is estimated that in 2016 there were more than 5 million undocumented immigrants in the United States who are uninsured 1. There is a fairly strong likelihood that some of these individuals will sustain disabling conditions that require rehabilitation services. Although the EMTALA requires that individuals are treated in emergency departments regardless of their ability to pay, there is no requirement for the provision of postacute care. I will present 2 cases of undocumented, uninsured individuals that illustrate some of the complexities of this issue. José (pseudonym) is a 27-year-old, soon-to-be new father, who sustained a midthoracic spinal cord injury during a carjacking. While delivering food in an unfamiliar neighborhood, he was pulled out of his car, robbed of his money, and he was shot and left down. He was taken to a local trauma unit, where he was found to have intra-abdominal injuries that required emergent laparotomy with primary repair of bowel injuries. He had complete paraplegia and was evaluated by neurosurgery and did not require surgical intervention. He also had a neurogenic bowel and bladder, and, all of the other potential secondary risk factors, attendant to a spinal cord injury. Rehabilitation medicine was consulted, and recommendations were made to prevent secondary complications. His wife, who was 9 months pregnant, was at the bedside daily. We had multiple meetings with the patient and family. It was clear he needed interdisciplinary rehabilitation to learn how to manage his spinal cord injury and all of the secondary conditions; however, he was uninsurable secondary to being undocumented. His wife was a U.S. citizen, and the family planned to stay in the United States and raise their children. They lived in a second-floor apartment. We agreed that we would engage in a short, intensive inpatient rehabilitation program at the rehabilitation hospital within the health system. The patient was taught clean catheterization techniques, and all red rubber catheters that were used during his rehabilitation stay were collected in anticipation of discharge. The patient and wife were taught to clean the catheters with soap and water and to store each catheter in a baggie with a few drops of rubbing alcohol (or to microwave them for several minutes). We were able to obtain a secondhand wheelchair for him and taught him transfers including in and out of a car. Family and friends were taught how to get him up and down stairs in his wheelchair, and, he was also taught how to bump up and down stairs. He was discharged home successfully after 2 weeks of inpatient rehabilitation. Although the rehabilitation hospital was not reimbursed, the cost savings to the acute care hospital was estimated at 60,000 dollars, an approximation for staying on the medical-surgical unit for 3-4 weeks with limited therapies. In addition, this individual did not require emergency department or rehospitalization services for 2 years after discharge from the rehabilitation setting. Juan (pseudonym) is a 40- or 50-year-old individual who was found down outside of the boarding house in which he shared a room with multiple other people. He was found to have massive subarachnoid and intraventricular bleed necessitating craniectomy, with implantation of the skull in his abdomen, to keep it nourished for when it would be reimplanted. Although he did appear to have identification (documents), it was later determined that these were fake. The individuals in the rooming house were unaware of his family name or where he was from. He was reported to speak Spanish, although we could not prove his country of origin. He remained unresponsive. A tracheostomy and a gastrostomy tube were placed. He was weaned successfully from a ventilator. After 6 months, a guardian from the state was appointed. When it came time to plan for the next level of care, there was heated debate between physicians from the rehabilitation hospital and administrators at the acute care hospital. The physiatrists noted Juan's limited rehabilitation goals and were concerned that this was an inappropriate transfer. Furthermore, there was no discharge plan in place after rehabilitation. Juan ultimately was transferred to the skilled unit at the rehabilitation facility within the same system as the trauma unit, with the assumption that this would be less expensive than staying in the acute care hospital. Because we could not prove his nationality, we did not have the option of petitioning a consulate to try to get him repatriated. Once he came to the rehabilitation hospital, his tracheostomy tube was downsized, capped and, he was decannulated. He continued to receive tube feeds. The staff provided routine nursing care. We contacted the surgeon, who refused to perform a cranioplasty, stating that it was not a life or death situation but an elective procedure. We appealed to the chair of surgery, who stated that he could not force his attendings to do a procedure. Juan continued to wear a helmet when gotten out of bed by staff. Juan has now been living at our rehabilitation center for more than 7 years. The therapeutic recreation team brings him downstairs from time to time so that he can participate in social events. His state-appointed guardian has not seen him in many years, nor does she call to ask about him. We were able to get his guardian to agree to a DO NOT RESUSCITATE order. He has been to the emergency department once; he developed tachypnea and shortness of breath and was diagnosed with pneumonia. He returned to our skilled unit, where he received intravenous antibiotic therapy. He has had no pressure injuries. He remains nonverbal. He has no visitors. These 2 stories showcase different aspects of having an undocumented individual in a rehabilitation facility. José had clearly defined rehabilitation goals, an identified discharge destination, and had support at home. He was able to learn how to do his own care. In fact, the primary obstacle in rehabilitation for José was that the staff wanted his length of stay to be the same as all of the other patients with the same level of spinal cord injury; however, they grudgingly understood the reasoning behind an accelerated course of rehabilitation. I am proud of how they advocated for this patient: saving and cleaning catheters, teaching bathroom transfers with suboptimal adaptive equipment, and their jerry-rigging of other equipment to meet his needs. At the opposite end of the spectrum, Juan, who was unresponsive, actually had no rehabilitation goals and no family for training. We knew that once he was transferred, he would live in the rehabilitation center. In our system of care, that decision was made at the highest level. I am also proud of how staff continues to advocate for Juan. He is well taken care of. They get him out of bed into a reclining wheelchair at least weekly and decorate his room for the holidays. They insist that he have the bed by the window so he has something to look at. The fact that he had only one visit to the emergency department in many years is nothing short of miraculous. The care for an undocumented individual becomes an unfunded mandate for hospitals, yet they still have to balance their ethical and legal obligations to patients with their fiduciary duties to manage their assets and survive. By creating a mandate for emergency treatment, it seems that we should acknowledge a corollary mandate for ongoing care, if only to avoid further visits to the emergency department. In many ways, the provision of rehabilitation services for an individual with a newly acquired disability is no different than the treatment of an individual with newly diagnosed heart failure, or newly diagnosed diabetes. For individuals with well-defined rehabilitation goals and a defined discharge destination, it seems that the ethical obligation for a hospital or health care system would be to ensure that a patient has access to high-quality rehabilitation services. With excellent care coordination, hospitals would save money by identifying individuals who can go home by aligning with the rehabilitation service early on. Interdisciplinary rehabilitation can teach individuals to prevent secondary complications related to their disability, which will diminish the necessity for further visits to the emergency department. Some consideration would be needed for the physicians who follow these patients in rehabilitation (acknowledging the relative value units (RVUs) if they are employed, or, some other stipend if they are private). For hospitals that are not a part of our health care system, we have been able to negotiate a per-diem rate for rehabilitation services. This has proven to be a win-win situation. Acute care hospitals are able to move individuals who require rehabilitation services in a timely fashion, avoiding prolonged length of stay, and often successfully returning individuals to the community with their family. Less straightforward is what to do with the individual who does not have a discharge plan. If the undocumented individual would benefit from an interdisciplinary rehabilitation program, thus improving their quality of life, it should be available to him or her in some form. Before transfer to rehabilitation, case management should initiate repatriation discussions with the patient, family, and consulate. There are no easy solutions to the issues raised by undocumented patients. Perhaps one conversation that needs to occur is whether hospitals, particularly in those states that have a large percentage of undocumented individuals, participate in a modified provider assessment tax that could be used to provide rehabilitation services or postacute services. Further discussion about options would benefit our patients, clinicians, hospital systems and communities. Judy L. Thomas, MD UT Health Houston Medical School There are more than 1.6 million undocumented immigrants in my home state of Texas. Proximity to the U.S.-Mexico border, favorable growth in the Texas economy, and creation of low-wage jobs predicts a continued increase along this path during the next decade 1. Addressing the health care needs of undocumented immigrants and their families in Texas constitutes an increasing problem that currently is being managed by a patchwork of clinics, safety net hospital systems, and charity care. I work at Lyndon B. Johnson (LBJ) Hospital, which is part of Harris Health System, a community-owned health care system that serves as a safety net for the underserved population of greater Houston and Harris County, which has more than 500,000 uninsured patients and 600,000 patients on Medicaid. I work in both the inpatient setting, providing physical medicine and rehabilitation consults as well as the outpatient setting in a musculoskeletal specialty clinic. I have taken care of many undocumented patients while working at LBJ and have experienced several challenges in providing comprehensive health care to this population. As a safety net hospital in Houston, LBJ Hospital has an extremely high volume of uninsured patients, many who present initially to the emergency department. In fact, LBJ has one of the busiest Level III emergency departments in the entire nation. (Emergency departments are categorized into 5 levels of care, with Level I being the highest level with the capacity to handle the most severe and complicated injuries. Level III ERs may not have on-call surgeons at all times, but can usually handle surgical problems within 24 hours.) One of the challenges we face with undocumented patients is that they often present to the emergency department with more advanced disease due to lack of primary medical care, early diagnosis, or treatment. As a result, the admissions tend to be more complicated, prolonged, and expensive. There often is greater morbidity in conditions such as strokes in patients with undiagnosed or untreated hypertension. The treatments tend to be more extreme such as wounds in patients with undiagnosed or poorly treated diabetes so severe and even life threatening as to not uncommonly require emergent lower extremity amputation. The chronic conditions often lead to multiple visits to the emergency department, such as patients with end-stage renal disease coming routinely to the emergency department for compassionate dialysis. Another challenge I face, particularly as a rehabilitation physician, is ensuring patients receive appropriate postacute care. Because of the lack of funding for these patients, postacute options are limited. The Harris Health System is fortunate to have an inpatient rehabilitation unit and skilled nursing unit for postacute rehabilitation, but beds are limited and waiting times to get these beds often very long. Primary teams feel pressured to discharge patients as soon as possible to reduce acute lengths of stay. Oftentimes I have had to advocate on behalf of patients who I feel are unsafe to return home to keep them in the acute setting to wait for a bed to open on the rehabilitation unit. For patients whose only option is to go home with functional deficits, I work closely with the therapists to try to get patients and their families trained to manage at home and have many times directed patients and their families to charitable organizations to obtain durable medical equipment that cannot be provided at discharge due to lack of funding. Determining whether a patient has an ultimate stable final disposition, including family support and housing, plays an integral role in discharge planning. As such, there is a heavy reliance on our social workers and case managers to help find appropriate postacute accommodations. The majority of undocumented patients are discharged home with family, with some of these patients going first to the county inpatient rehabilitation unit as self-pay status before returning home. There have been situations in which patients who no longer had acute care needs stayed at the hospital in a step-down unit for several months because they were unsafe to discharge home independently, they had no family to support them, and they had no funding for postacute long-term care. Some of these patients have had to return to their native countries, some were taken in by charity nursing homes, and some eventually were able to establish residency and get Medicaid funding for long-term care. In the ambulatory setting at LBJ, nonemergency care is provided in more than 35 medical specialties. We do not see as many undocumented patients in the ambulatory setting; I suspect many of them are not able to access outpatient care due to lack of funding. Many undocumented immigrants may avoid coming because of the fear of deportation or exposure to the law. Language and cultural barriers also exist, with people experiencing difficulty navigating the system. I have found that many patients who do come to me present with severely neglected injuries, end-stage conditions, or with comorbid diseases often exacerbating or complicating their conditions. Long wait times to see specialty care exists due to an overwhelmed and under-resourced system that causes frustration to both patients and providers. Despite long waiting times to get into the clinic, another challenge I face is patients not showing up for scheduled appointments because of irregular work schedules, transportation issues, lack of contact information, language barriers, and miscommunication. Managing undocumented immigrants is time consuming. Patient encounters often take more time because of language and cultural barriers. Family members often need to be approached to help clarify social situations. Time is spent collaborating with therapists, social workers, case managers, other physicians, and family to try to find creative solutions to limited treatment and discharge options. Providing quality health care to undocumented immigrants in a safety net hospital is challenging. We are working with limited resources, and there is certainly no glamor or great compensation for the work we do. I believe that many health care workers, me included, choose to work in this system because we believe in a mission to help people who otherwise have no access to health care. The undocumented immigrant population is continuing to grow and access to health care for this growing population will continue to be an issue. Hopefully, there will come a day when legislation exists to improve the health and welfare of undocumented immigrants including their access to health care, and their reintegration into mainstream society. Michael N. Bozza, Esq. Village Law, PC In the practice of immigration law in the United States, you must first define the immigrant. The starting point and overarching guidelines of how to make this definition is found in the Immigration and Naturalization Act (the INA) 1 and its various amendments and interpretations. Broadly speaking, the INA dictates your identity as an immigrant. Each type of immigrant has varying rights and expectations with respect to the justice and health care systems of the United States. Furthermore, each state has their own systems of local laws, some codified, some based primarily on precedent, that are technically subordinate to the overarching federal law, but in practice often serve as the vehicle and prism through which an individual encounters the regulatory framework of federal immigration law. For reference, I am an immigration attorney practicing in Boston, and I specialize in family-based immigration in both affirmative and defensive matters. Approximately one half of my clients are undocumented; this means that they entered this country without permission or have overstayed their authorized period of stay. They are outside of the system, unable to access any means into the maze of state and federal laws that can provide some level of subsidized or standardized care for other immigrants or citizens. Undocumented patients have a dramatically different experience navigating the existing framework of health care law, starting with the lack of identification needed to initiate the most basic encounters with medical professionals. The undocumented immigrant's health care treatment, whether rehabilitative or on an emergency basis alone, is an individualized experience. The general state of things is that you will get no care without paying, just as any other citizen or resident of this country would view services such as home improvement, car repair, or any other good or service available for commercial consumption. As such, most undocumented immigrants are forced to make choices on their health care, including rehabilitation, the same way the rest of us would make choices when shopping for household items at a store—What can I afford? What has the best value? But their choices are shaded by a more sinister and portentous angle—Who can I trust to give me these services? Who will provide these services without asking specific questions? What recourse will I have if something goes wrong? The EMTALA of 1986 2 charges emergency departments with the duty to stabilize anyone that happens on them in an emergency, which is heralded by some as an act of American compassion, and others as a fatal weakness in our national identity, as most states emphatically deny routine access to any kind of subsidized benefits beyond the aforementioned emergency care. In most cases, medical emergencies highlight a tension of putting patients in positions of exposure with groups of professionals that may or may not refer them to state or federal law enforcement and the immigration courts, the ultimate arbiter of a one's immigration status. Emergency care often raises an uncomfortable confrontation between first responders, medical providers, and law enforcement, who must weigh their immediate duty to render services against the duty to identify an undocumented immigrant. Some states have specific prohibitions on inquiring or reporting on a person's immigration status as a matter of privacy, whereas others do not. In the states that do have these prohibitions, and in sanctuary cities within these states, it is ultimately up to the law enforcement officer, first responder, or health care provider themselves to make a decision about whether to report a person's immigration status. For undocumented immigrants, this lurking fear informs their daily life, most drastically when it comes to questions of whether to call the police to report criminal activity or to go to the hospital to seek medical treatment. A very brutal cost benefit analysis in the face of criminal and medical emergencies is an unfortunate reality. I have many clients who have made unfortunate and frankly unthinkable choices when faced with what I would consider medical emergencies. Take, for example, a client who was a passenger in a car accident (her vehicle was struck by a U-Haul truck), whose 2 front teeth were cracked in half. She was given emergency medical treatment to stop the bleeding but was discharged without restorative dental care. Without the ability to access subsidized insurance, she sought care where others in her predicament had gone before, namely, a somewhat unscrupulous dentist from her immigrant community, who may or may not have pursued a license in his home country, and most certainly did not in the United States. After paying up front, in cash (as demanded by the so-called dentist), the client emerged with what she called “Bugs Bunny” teeth, and was forced again, in shame, to find a more reputable dentist, who was able to fix the cosmetic blunder, for a significant sum, paid entirely out of pocket. At the very least, with the second dentist, she was able to enter into a more standard payment plan. Another example is an undocumented client who suffered an accident while riding a motorized scooter. There was no one at fault besides this individual, and with no plausible way to afford anything other than subsidized insurance, he was forced to pay his way through any health care he could find. By luck, or mistake, the hospital found a record of a health insurance policy in his name from a previous employer over a decade prior, and proceeded with a surgery. It was only after the surgery was completed that the insurance flagged the error, and he was left with a hefty bill, but also a surgically repaired knee. He turned to a local social services agency, which provides some subsidized services paid for by private charities, local hospitals, and volunteer medical students. They could not, however, provide any financial aid towards rehabilitation equipment or medications, and so he turned to YouTube for suggestions of how to “Do It Yourself” his recuperation. The legal and ethical question of whether or not we, as a country, have a duty to provide medical and rehabilitation care to undocumented immigrants eventually comes down to the same questions at issue with the debate over the Affordable Care Act, which are primarily economic in nature. Without a program of aid for the least among us, they are on their own to scrape together any kind of questionable care and services that they can find. Reasonable minds can disagree on whether heath care is a right or a privilege, and who is responsible to pay for this care, but for the undocumented patient, for the time being and the foreseeable future, they are left completely on their own. Nancy Berlinger, PhD The Hastings Center The nation's 11 million undocumented immigrants constitute a low-income population that is often uninsured or underinsured as the result of a lack of access to jobs providing health insurance and the formal exclusion of people who are not “legally present” from federal benefits. These benefits include Medicare, Medicaid, the Child Health Insurance Program, and Affordable Care Act insurance subsidies 1. Medicaid is the major insurer of rehabilitation and long-term care services for low-income people; Medicare provides some coverage for acute rehabilitation, among other health care services, for people with disabilities and for people age 65 and older (On Medicaid and Medicare provisions for acute and postacute rehabilitation services, see http://kff.org/medicaid/report/medicaid-and-long-term-services-and-supports-a-primer/; http://kff.org/report-section/medicaid-financing-the-basics-issue-brief/; and http://kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing/). Because undocumented immigrants are locked out of these benefits—despite contributing to them through payroll deductions 2—their access to rehabilitation services is extremely limited. Add to these policy constraints the fact that undocumented immigrants are at significant risk for occupational injuries occurring in construction, farm work, or other dangerous or physically demanding jobs 3, and the professional challenges in providing medically appropriate treatment and care become evident. Consider, for example, the situation of a fictional undocumented immigrant, Mr Ramos, a 28-year-old construction worker who was born in Mexico and has lived in the United States for 8 years. His wife also is undocumented; their 2 young children are U.S. citizens. On the non-union job sites where he works, Mr Ramos and his coworkers are reluctant to draw attention to safety problems because of their undocumented status. When Mr Ramos suffers a fall from scaffolding, first responders transport him to the nearest trauma center. Every hospital with a community emergency department has a mandate, under the federal EMTALA of 1986, to provide appropriate medical screening to all patients presenting in the emergency department and to treat patients experiencing a medical emergency (or in active labor) until stable. Mr Ramos is admitted for emergency treatment of traumatic injuries to his pelvis, left hip, left leg, and internal organs. A medical social worker's review concludes that Mr Ramos is uninsured and uninsurable. (A hospitalized patient's undocumented status may be confirmed or presumed when determining whether or not the patient has, or is eligible for, Medicaid or other insurance.) The hospital applies to the state-funded Emergency Medicaid program to receive reimbursement for treatments and services provided to Mr Ramos that are covered in that state. The hospital absorbs some unreimbursed costs as part of its charity care and community benefit obligations as a tax-exempt institution. As Mr Ramos's condition stabilizes and his eligibility for Emergency Medicaid ends, his bedside team consults with the hospital's complex case management service to figure out how to meet this patient's continuing medical needs. Although his internal injuries have been repaired and his potential for a full recovery after a course of rehabilitation is excellent, Mr Ramos cannot yet walk unaided, needs help with activities of daily living, and needs medical and postsurgical follow-up. A medically appropriate discharge plan would include transfer to an inpatient rehabilitation facility for intensive inpatient physical therapy (PT) and occupational therapy (OT) evaluation, and eventual discharge home, with continuing outpatient therapy, plus supplies such as a walker or cane. There is no financing mechanism to cover these services for an uninsured and uninsurable patient. Mr Ramos remains stuck in the hospital, which is now fully covering the costs of “boarding” him on a medical ward. Organizational pressure on the complex case manager to “clear the bed,” and mounting uncertainty and stress among bedside staff, reflected in remarks about whether Mr Ramos “deserves” the care of a short-staffed unit, prompts the hospitalist (a staff internist responsible for patient care in medical wards) to request help from the hospital's clinical ethics consultation (CEC) service. The CEC team confers with Mr Ramos's bedside team, with the complex case manager, and with Mr Ramos in his preferred language (Spanish), through a certified interpreter. The consultation identifies the following ethical and practical questions relevant to meeting the “safe and effective” standard for discharge: Retaining Mr Ramos as a charity-care patient on the medical ward raises questions of justice: is it fair to other current and future uninsured patients to expend considerable resources on one patient who no longer needs hospitalization? The hospitalist explains: “Sometimes, the best or only option is to retain an uninsured patient in the hospital—for example, when Emergency Medicaid covers a life-sustaining treatment as an inpatient service but not in clinic. But emergency provisions aren't a good fit for rehabilitation. And our inpatient therapy services are focused on getting patients back on their feet after surgery so they can go home. Would Mr Ramos get the intensive PT and OT he needs if he stays here?” Transferring Mr Ramos to a nonprofit rehabilitation hospital for several weeks of PT and OT, with the hospital where he originally was admitted paying for his care, is the most appropriate option medically. The complex case manager reports that administrators are wary about this arrangement: “The hospital is worried we'll become a ‘magnet’ for transfers if word gets out that we've paid for an undocumented patient's rehabilitation. And they ask me, so what about the charity-care obligations of the rehabilitation hospital? Is it all on us because we get these patients through the emergency department, or is there a shared obligation?” Looking for a bed in the public health system's rehabilitation hospital is another option that is medically appropriate, but it raises its own justice questions. A nurse practitioner on the CEC team says, “Say tomorrow we get a patient with a gunshot injury to his spine. Who should get that scarce public-hospital bed? The patient who needs a short course of PT and OT, or the patient who needs long-term services?” Discharging Mr Ramos home is ruled out by the complex care manager as an option: “Discharge to home would not meet the ‘safe and effective’ standard. Mr Ramos can't walk, and he lives in a walk-up. He's the primary wage-earner and gets paid in cash. There's no money coming in now, so his wife won't be able to afford medical transport to get him to clinic for follow-up. And he needs intensive inpatient PT and OT to fully rehabilitate. Even if we could persuade a nonprofit home care agency to take him on as charity care so he could get some therapeutic services at home, the orthopedic surgeon says that wouldn't be enough. It's not right to kick this problem to a low-income family and risk a preventable disability.” Medical repatriating Mr Ramos to Mexico is also ruled out. The clinical ethics consultant explains: “Medical repatriation requires informed consent. The patient has decision-making capacity and he's clear that he wants to stay in this country with his wife and children. Even when the country of origin offers the needed services and there is family support back home, you can see why a patient who is likely to recover would refuse this option. His kids are citizens. His community ties are here now.” This fictional account of Mr Ramos and the health care professionals who are grappling with how to provide good care amid severe resource constraints plays out in reality across the United States. Beyond clinical collaboration to identify medically appropriate, ethically sound, and financially sustainable options when a patient is undocumented and uninsured, the medical-legal partnership model of direct legal services to hospitalized patients may, in some cases, identify a legal remedy offering a pathway to paying for needed care 4. These remedies may include changing a patient's immigration status or pursuing a workers' compensation claim. Institutions should be clear about their charity care provisions for uninsured patients, so professionals responsible for the care of these patients during care transitions know what internal resources may be available. State-level reforms, such as using Emergency Medicaid to cover certain chronic care services after a qualifying diagnosis without requiring subsequent “emergency” admissions, may benefit some patients with posthospitalization medical needs. Beyond these remedies is a crucial question for social ethics: what does a society that benefits from labor and economic contributions of undocumented immigrants owe to these members of our society when they are sick or injured?