On Wednesday March 14, 2018 I was taking the bus to campus. The bus contained the usual mix of students and workers heading to start their early mornings. However, there was one exception. A man was doubled over in pain, wrapped in a tattered sleeping bag. I was unable to see his face, he was sitting with his stomach lying flat against his thighs. Every so often he would try to sit up before slumping back down. His hands were dry and cracked, wrapped with dirty bandages. I started talking to the man next to me, asking if he thought we should try to get him to the hospital, located at the end of the bus line. He replied that he worked at the hospital and planned on trying to get the homeless man seen. It raised the question though, how is someone whose sole possession is a torn up sleeping bag going to afford medical treatment when medical debt is the number one cause of bankruptcy in the United States?
In 2017 the National Alliance to End Homelessness recorded around 550,000 men and women living on the streets. While shelters can help, many people fall through the cracks due to overcrowding. There’s too much strain on the system and the unfortunate fact is that there isn’t enough money to spread around. Even places that are suppose to care and protect it’s charges are attempting to lighten their load by the practice known as “dumping”. In January of 2018 Andrea McDaniels, a reporter for the Baltimore Sun, wrote about the practice. When hospitals receive homeless patients, protocol dictates that they treat the patient before connecting them with social services. Instead some hospitals have taken to treating the bare minimum and then dropping patients off at the nearest bus stop. At first it seemed like this had to be some kind of an exaggeration, but the reported cases were shocking. McDaniels article went on to tell the story of an unidentified homeless woman. A concerned bystander recorded the incident and later posted it to social media. The video depicts a young woman dressed in only a hospital gown and pair of socks being escorted in a wheelchair by four security guards to the bus stop. Upon their arrival they leave her at the stop and simply walk away with the wheelchair, leaving a disoriented woman alone with no clothes, on a cold night when the temperature was barely over thirty degrees.. It was later found out that she was a patient from the University of Maryland Hospital who had recently been discharged. Fortunately, the man recording the video was a psychotherapist names Imamu Baraka who was leaving his job from the same hospital. Baraka reportedly called an ambulance and spent the next few hours at the hospital making sure she wasn’t just dumped back on the streets. Dr. Mohan Suntha is the President and CEO of the hospital and claims full responsibility for the act, but claims that it was an isolated incident. So just how common is hospital dumping?
After the incident McDaniels wrote another article published in the Baltimore Sun about the history of hospital dumping. The phrase originated in the late 1800’s and has grown to be a major issue. In 1986 congress passed the Emergency Medical Treatment and Labor Act, which prohibits emergency rooms from casting patients out who are unable to pay. As the 21st century began, the problem continued, especially in California. Reports concerning “dumping” have been filed, that range from a homeless man being left on the street after being treated for a minor foot wound, to a paraplegic man being dumped in an alleyway without a wheelchair. In Las Vegas a psychiatric institute was caught dumping groups of patients at a bus terminal with a ticket to California and few days of food and water, in Washington three campus police officers were fired after they brought a barefoot woman to a bus stop before knocking her out of the chair and leaving her on the ground. These incidents all happened multiple years ago, but don’t think the problems stopped. In an eight day time frame, two major dumping stories were reported in cities only hours away from each other. Beckers Hospital Review recently released a statement about the Dignity Health Dominican Hospital in Santa Cruz, California. The report states that the hospital wheeled a man in an undersized hospital gown to a bus station. The man was found at 11 pm by the bus driver who contacted local authorities. The police proceeded to care for the man until Brent Adams, a local shelter administrator, arrived. He was told the man had been found practically naked and alone. The hospital declined to comments on the mans treatment due to patient privacy. Less than a week previously a Sacramento newspaper wrote an article about Arlan Lewis, a 78 year old man who recently became homeless, after he could no longer afford his rent. He had spent over a week at the Woodland Memorial Hospital, however when he was discharged the staff stuck him in a cab with paperwork stating they had called and made arrangements for Lewis to stay at a shelter around 20 miles away. After Lewis was dropped off, he made his way to the shelter and showed the paper to the attendant. As it turned out, the shelter was never contacted and had no open beds. The next day he was taken to another shelter. Thanks to local support programs in California he’s now living in a new building where he can afford the rent. Workers and volunteers at both shelters were interviewed and reported that this happens at least once a week.
So why is the practice of dumping becoming more common? The Department of Health and Human Services provides instructions for how Medicaid can be used to help the homeless gain access to medical and behavioural services. One of the statutes for eligibility for Medicaid is based on income, which guarantees the homeless treatment. Each State sets its’ own threshold, but surely people with next to nothing would qualify, right? The simple answer is I don’t know, upon researching access to quality care for the homeless I found a lack of useful information. Another possible problem is that States determine what the minimum of care is. The Emergency Medical Treatment and Labor Act only specifies that hospitals must stabilize patients. States determine what that means.
Of the private organizations, the site for the National Health Care for the Homeless Council stood out. This is an organization of over ten thousand doctors, nurses, and other healthcare professionals dedicated to eliminating homelessness. Across the US there are 200 health care facilities sponsored by the council that focus on providing treatment to the homeless. In addition to providing medical support, they also work on healthcare reform. The main focus is Medicaid expansion. In March of 2013 they released a policy statement that laid out their goals. Their first goal is to get all 50 states to provide Medicaid to those with an income level that is 133% of the poverty level. Second, they believe States should have targeted outreach programs to inform homeless and at risk individuals about their options. Lastly, they want to make applying to Medicaid easier. Medicaid was born from bureaucracy and bureaucracies run on paperwork. The NHCHC believes that Medicaid applications should be condensed into a single application. So how close are they to their goal? Well, they last reported on it in 2015. As of that time only 28 states had started Medicaid expansion. Unfortunately, that’s barely half the nation working towards only the first of three goals.
This brings us to the crux of the article. Early we mentioned that there just isn’t enough money to go around, and later on that Medicaid covers the homeless. The only disconnect was how do the hospitals actually get paid? The Kaiser Family Foundation was extremely enlightening. In an article written by Peter Cunningham in 2016, the details of how hospitals are paid back was revealed. Hospitals are reimbursed by the government in two steps. The first is the base payment. The base payment is a lump sum of money given to a hospital for pre arranged treatments covered by Medicaid. However, as we’ll discuss in a moment, these payments are not reflective of the prices charged. The second step is supplemental payments. The base payment isn’t enough to cover expenses, so the government tries save them further money by provider taxes, waivers, and direct payments. Hospitals in areas with a greater percentage of low income patients receive more money, to compensate the added costs. Due to each state gathering its’ own data and way of doing things, it’s hard to estimate the actual amount hospitals are paid. The American Hospital Association reports that Medicaid will actually pay 90% of the cost, Medicare will pay 88% of the cost, and private insurers (the everyday people) will pay 144% of the cost. In effect, hospitals can expect to be short 10% of what they’re due from Medicaid, 12% short for Medicare, and make a 44% off everyone else. Don’t you just love the little quirks of capitalism? Overall, congress estimates that on average hospitals make back 107% of their costs. However, the low point is 81% in low paying states and 130% in high paying states. There’s one more point I’d like to make regarding a Kaiser article. It showed that States that have expanded their Medicaid program have saved 35% in uncompensated care. That’s nearly six billion dollars. Now the NHCHC reports that’s for 28 states, imagine what it would be like if it were all fifty. Imagine what six billion dollars could do for the 550,000 homeless. That’s roughly $10,000 per person that can be set aside for medical care.
We’ve examined the facts behind accessibility to quality care, but one thing I believe still needs to be addressed is the social stigma surrounding our homeless population. This part of the article will purely be an opet, but I believe it’s integral to the larger issue. At the beginning of the article I described the inspiration for this article, but I didn’t paint the full picture. The bus is always crowded, people have places to go. Yet out of all the people on the bus no one asked the homeless man if he was ok, myself included. If he had been wearing a suit and tie with a briefcase rather than a large coat and sleeping bag, I have no doubt that someone would have checked on him. When I look back on it, I want to say that I don’t know why I didn’t ask if he was ok. Truthfully though I know why. It’s simple and born from a bias that society has instilled into all of us. He was homeless. When we’re growing up, the homeless are portrayed as a real life boogeyman. Our parents tell us that if you don’t work hard and have a job, you’ll end up homeless. Somewhere in our heads this gets twisted into homeless people are homeless because they don’t work hard. Now is this actually true? What facts or evidence are we basing this off of? We’ve allowed our prejudice to turn into a poor justification for something we’ve misinterpreted as the truth. So how does this connect back to the article overall? If we won’t even ask a suffering man if he’s ok, what makes us think we’ll put in the time, money, and work to make sure everyone has quality healthcare despite their socioeconomic status?
So where are we now in conclusion? This article is a lot of information and it just seems… wrong. How did we get to the place where old men and young women are just thrown to street? If it happens this often why don’t we hear about it more often? The good news is that we’re making progress, albeit slowly. The bad news is we’re not making enough progress and we’re being held back by all the wrong things. There’s also still a disconnect in why hospitals don’t treat low income patients properly. If the government reimburses them then why not? It’s actually quite simple. State governments will pay them around 90% of what they spend on a Medicaid patient. That patient takes up a bed, resources, and staff time. If they give that to an independent insurer they can make a 44% profit. It poses a unique dilema you’ll have to reflect on. Is it moral to make a profit at the expense of some people, in order to better help the majority? Is it acceptable to let a few suffer, so that the majority can prosper? Hopefully those who read this will consider their answer carefully. While we don’t have to live by our answers 550,000 others do.
- McDaniels, A. K. (2018, January 12). What is patient dumping? Incident with woman at Baltimore hospital is hardly new. Retrieved from http://www.baltimoresun.com/health/bs-hs-what-is-patient-dumping-20180111-story.html
- McDaniels, A. K., & Cohn, M. (2018, January 12). University of Maryland hospital apologizes for its failure to discharged patient found on street in hospital gown. Retrieved from http://www.baltimoresun.com/health/bs-hs-hospital-video-follow-20180111-story.html
- Rege, A. (2018, January 16). Second nationwide instance of alleged ‘patient dumping’ of a homeless man at California hospital stirs debate. Retrieved from https://www.beckershospitalreview.com/hospital-physician-relationships/second-nationwide-instance-of-alleged-patient-dumping-of-a-homeless-man-at-california-hospital-stirs-debate.html
- Hubert, C. (2018, January 08). ‘It was a scary thing.’ Hospital dumps senior at homeless shelter. He’s not the first. Retrieved from http://www.sacbee.com/news/local/homeless/article193308479.html Note: The article was updated on January 9, 2018.
- Cunningham, P., Rudowitz, R., Young, K., Garfield, R., & Foutz, J. (2016, October 27). Understanding Medicaid Hospital Payments and the Impact of Recent Policy Changes – Issue Brief. Retrieved from https://www.kff.org/report-section/understanding-medicaid-hospital-payments-and-the-impact-of-recent-policy-changes-issue-brief/
- National Alliance to End Homelessness. (2018). FAQs. Retrieved from https://endhomelessness.org/homelessness-in-america/homelessness-statistics/faqs/
- HHS Office. (2007, September 26). How to Use Medicaid to Assist Homeless Persons. Retrieved from https://www.hhs.gov/programs/social-services/homelessness/research/how-to-use-medicaid-to-assist-homeless-persons/index.html
- Medicaid.gov. (n.d.). Homelessness Initiatives. Retrieved from https://www.medicaid.gov/medicaid/ltss/balancing/homelessness/index.html
- NHCHC. (2013, March). Health Reform and Homelessness: Twelve Key Advocacy Areas for the HCH Community. Retrieved from http://www.nhchc.org/wp-content/uploads/2011/09/Health-Reform-Policy-Statement-2013.pdf
- NHCHC. (2017, November 06). Policy Statements. Retrieved from https://www.nhchc.org/policy-advocacy/policy-statements/
- NHCHC. (2015, June 05). State Medicaid Expansion Advocacy. Retrieved from https://www.nhchc.org/policy-advocacy/reform/state-medicaid-expansion-advocacy/