The course that Ms. X’s case has taken is non-reassuring in that she has not regained any of her lost function and now receives IVIG a treatment that has not shown efficacy in SPMS, her presumptive diagnosis. However, what has further complicated her care is her citizenship status: she is undocumented, and currently receives care under emergency Medicaid. My understanding of Medicaid is quite limited so I wanted to expand on this subject and attempt a greater understanding of the legal complications to her care.
Medicaid, enacted in 1965, is a federally funded program that provides assistance to acquiring healthcare to those individuals with low incomes1. The program assumes the cost of medical care by reimbursing on a state level certain medical expenses that fall within its sphere. The burden of cost shared by each state varies; those states with higher per capital incomes are less well reimbursed for the cost of the care they provide, and poorer states with less per capital income are federally reimbursed more substantially. Currently New York States federal medicaid match rate is 50%2, shifting the burden of health care onto state coffers. Guidelines for states to administer entitlements vary, but most states do not offer benefits for adult men and non-pregnant women who are not disabled. In fact beneficiary populations are normally subdivided into categorically needy, medically needy, special groups, waiver populations, and children1.
Categorically needy are pregnant women, women with children less than 6, income below 133% of poverty level ($29,326.50 for family of four)3, those living in medical institutions, and the impoverished elderly who are eligible for supplemental security income (SSI). The medically needy are individuals who may have limited financial resources and states may chose to expand and widely vary in what they cover. Certain individuals who variably qualify may nonetheless be unable to get care, and so Medicaid reserves the following special groups, those who lose Medicaid coverage because of work but are still below 200% of federal poverty line, those with TB, women with breast/cervical cancer not otherwise eligible for Medicaid but who have no insurance. Many states engage in cost experimentation and pilot studies and in these circumstances a “waiver” may be acquired to access care. Centers for Medicaid and Medicare Services (CMS) regularly reviews these waivers. Finally there is SCHIP, the state children’s health insurance program designed to provide care for children whose parents do not meet income criteria for Medicaid. Benefits provided by Medicaid include hospital services and long term nursing care. “The bulk of long term care is provided by medicaid4.”
However, what about Ms. X? How is she able to access care? Immigrants and undocumented individuals are generally ineligible for Medicaid, however Ms. X is eligible for emergency treatment under Emergency Medicaid and Emergency Medical Treatment and Labor Act (EMTALA)5. These laws require anyone who shows up on the doorstep of the emergency room the right to receive care and be stabilized. However what about Ms. X’s case, she is overall medically stable and being treated for a chronic neurodegenerative disease. How was her care able to be arranged? The New York City Health and Hospitals Corporation has a program called HHC Options which has the ability to provide care for everyone regardless of legal status and ability to pay6. This would include access to city hospitals, including her current residence where she is receiving long term care at the skilled nursing facility XYZ. Although it is not clear how her care is arranged I believe this program may in fact be her lifeline. As the social burden in New York and America continually increases, tax funded city programs like this will face mounting financial stressors. But it is critical that they be maintained so that the rare cases like Ms. X do not end in tragedy. Currently Ms. X is getting by with very little help and is not a great burden on taxpayes, and she has no good options. First she is unfortunately afflicted with a crippling and unremitting neurodegenerative disease. Second, she has little support from family members, only a sister that has been a regular caretaker. And third, she is undocumented, a status that severely limits her access to care, keeping her the institutionalized. But although the system where she subsides may at times be inefficient she is nevertheless receiving some standard of care (more than if she were in her home country).
References:
1. Baldor R. Medicaid. http://www.uptodate.com/
2. Comparison of State Medicaid Costs. 2002. http://www.leg.state.vt.us
4. Baldor, RA. Managed Care Made Simple, 2nd ed, Blackwell Science, Cambridge, MA 1998.
5. Kaiser Family Foundation: Kaiser Commission Medicaid and the Uninsured: Medicaid and SCHIP eligibility for immigrants. 2006
6. http://www.nyc.gov/html/hhc/downloads/pdf/hhc-options-06-2009-eng.pdf
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