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By Benjamin Nanes, HealthSTAT

HealthSTAT previously reported concerns from students and health professionals that it is becoming more difficult for immigrants to access care in the Grady Health System, which includes Grady Memorial Hospital and its eight neighborhood health centers. Though this issue has not been widely reported, there have been similar worries in the community at large as well. Yolanda Hallas, Executive Director of the Hispanic Health Coalition of Georgia, has collected reports from immigrants who have been denied discounted care at Grady due to apparent changes in how the health system enforces its policies. Among them are unemployed patients and family members of Medicaid-eligible children, people who clearly cannot afford health care anywhere else. In order to understand what is happening, it is important to look at the big picture: how the Grady system delivers care to those who are unable to pay, and the financial and political pressures that system faces.

How Grady Gets Paid

Like other hospitals, Grady requires money to run. Also like other hospitals, Grady raises money by charging patients for the services it provides. In fact, for patients with health insurance, be it Medicare, Medicaid, or a private plan, Grady bills the insurance company for any charges it will cover and the patient for any co-pay, deductible, or other uncovered charges – just as any other hospital in the Atlanta area would.

Where Grady differs from most other hospitals, however, is in how it deals with patients who lack health insurance. Nearly all hospitals treat at least some uninsured patients. Regardless of whether or not they bill and try to collect from uninsured patients, they are usually able to cover their costs through higher charges to patients with health insurance, a practice known as cost-shifting. However, treating patients irrespective of their ability to pay is an integral part of Grady’s mission, and an unusually high proportion of its patients lack health insurance. This makes cost-shifting impossible.

Instead, Grady receives government contributions which are intended to support its mission of providing health care to those who could not afford it elsewhere. The federal government contributes some money through the Disproportionate Share Hospital program.  Fulton and DeKalb counties also contribute money from their annual budgets, about $80 million and $20 million, respectively. The state and other counties in the metro Atlanta area do not contribute.

The Grady Card

The county payments are specifically intended to fund the care of uninsured patients who are residents of Fulton and DeKalb, and the counties expect the residency of patients treated with their funds to be documented. Grady does this through something called the Grady Card, which, from the patient’s perspective, functions much like a health insurance card, though it can only be used within the Grady system. Patients with a Grady card are charged fees, similar to insurance co-pays, on a sliding scale based on their income.

In order to obtain a Grady Card, patients must prove that they are residents of Fulton or DeKalb, that their income is not above a level at which they should be able to pay for their care, and that they are not eligible for another government-funded healthcare program, such as Medicaid. In most cases, this process must be completed before uninsured patients can access non-emergent care in the Grady system.  Obtaining a Grady Card can be quite a cumbersome process, and it sometimes leads to delays in accessing care.

Challenges for Immigrants

Grady’s policies on obtaining a Grady Card and accessing care do not directly discriminate against immigrants. However, for a variety of reasons, the procedural barriers that these policies create may affect immigrants disproportionately. As with any bureaucracy, non-native English speakers trying to navigate the Grady system are at a distinct disadvantage. The documentation requirements for obtaining a Grady Card are complex, and even though Grady has interpreters available, a non-native English speaker is much more likely to have difficulty identifying and collecting the necessary documents.

Some of the specific documentation requirements may also be more difficult for immigrants. Those who live with relatives, and therefore do not have their name on rent or utility bills, may have trouble documenting their residency, and those who work irregularly may have trouble documenting their income. Immigrants are more likely to be in both of those situations than the general population. As a result, immigrants may face greater difficulty than others when Grady enforces its policies more stringently.

Undocumented immigrants face an especially difficult situation. It is not clear that Fulton and DeKalb have specifically refused to pay for the care of undocumented immigrants, and Grady will accept consular identification cards, used almost exclusively by undocumented immigrants, as proof of identity.  However, undocumented immigrants are ineligible for government programs such as food stamps and unemployment benefits; these programs generate documentation that Grady often requires in order to issue a Grady Card. Furthermore, undocumented immigrants who are employed are generally paid in cash and have no way to document their income.

Why Is It So Difficult?

Grady has made a commitment to providing care for patients who cannot afford it elsewhere, but its resources are limited. Financially, Grady simply cannot afford to provide free medical care to all of the uninsured patients in the Atlanta area, or even just those who live in Fulton and DeKalb. Since Grady has a limited ability to care for patients who are uninsured, the process of obtaining a Grady Card serves as a way to decide how that care is distributed, for example, by allowing for an income-based sliding scale of payments. When the requirements for obtaining a Grady Card are narrowed, the system is better able to cover the cost, but fewer uninsured patients are able to get the care that they need.

In addition to financial limitations, Grady is also restricted by its agreements with Fulton and DeKalb. The counties want Grady to use their contributions only for the care of their residents.  The process of obtaining a Grady Card is the main way in which Grady compiles the documentation to show the counties that their demands are being met. The more detailed the reporting Fulton and DeKalb require, the more stringent the requirements for obtaining a Grady Card will be, and the more trouble uninsured patients will have accessing care.

What Has Changed?

The recently reported increase in difficulty faced by immigrants seeking care at Grady coincides with worsening financial and political pressures on the health system. Though Grady has received donations to cover some capital expenses after its financial crisis two years ago, it has continued to have an operating budget deficit of approximately $40 million per year.  To make matters worse, this past summer, the state demanded that Grady repay $20 million in Medicaid overpayments that occurred over the past decade, and Fulton has delayed payment of most of the $60 million allocated for the hospital’s operating costs in the county budget.

Grady’s financial difficulties have been compounded by political pressure from Fulton County. The county claims that Grady has not provided it with the proper documentation of how its contribution is being spent, and has delayed payment; Grady says that the county is merely stalling.  A concern about spending county money on undocumented immigrants does not seem to be driving the disagreement. Instead, Fulton’s demand that Grady increase the documentation it provides probably stems from a desire to reassert greater control over the health system after its governance structure changed from a bi-county agency to an independent non-profit corporation, and from a determination not to let other counties benefit from their contribution. In addition, as with many local governments, Fulton has faced a decline in tax revenue, and the commissioners may be searching for ways to decrease county expenditures.

The financial and political pressures on Grady may well have led it to more rigorously enforce its policies on who can obtain a Grady Card and what documentation they must present in order to do so. Stricter requirements for obtaining a Grady Card create procedural barriers that limit access to care for all uninsured patients. However, it should not be surprising that immigrants, who are more likely to have difficulty navigating Grady’s bureaucracy, have been affected more than others.

Benjamin Nanes is a medical student at the Emory University School of Medicine and is also a HealthSTAT member.

HealthSTAT is a nonprofit, member organization run by health professional students in Georgia, engaging them in service, education, and advocacy.  By mobilizing students to take action on health issues confronting Georgia, we foster a civic ethic in future leaders that will benefit our state for years to come.  Learn more at www.healthstatgeorgia.org.