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Back in 2019, California became the first state in the country to offer government-subsidized health benefits to low-income, undocumented young adults age 25 and younger living in the U.S. This was an expansion from the California law that has allowed children under 18 to receive taxpayer-backed health care despite immigration status.

As a doctor who took an oath when graduating medical school to always use all measures required to benefit the sick, this change allows us to ease pain and suffering in more patients who need help. However, there’s a large demographic remaining throughout the entire United States that is not able to receive needed care.

One very late Thursday night, a 45-year-old patient came to the emergency department with excruciating abdominal pain. The ER physicians caring for her ordered imaging to diagnose what could be causing her symptoms. As the ER Radiologist for the evening, I interpreted the CT scan of her abdomen and was taken aback: she had the largest liver cyst that I had ever seen in my life. The cyst was so bulky that it was taking up the majority of the entire right lobe of her liver.

Medicaid can cover emergency services for undocumented immigrants, but there are no safety nets for urgent procedures such as this very intervention the patient needed.

The patient was then transferred to an inpatient hospital team when she told her physicians that she had been living in Canada. The rest of her back story was less clear with some murmuring that she was visiting family in Southern California for an indefinite amount of time. She said she had known about her liver cyst for the last two years, but she had not felt such agonizing pain before her visit, only some right upper quadrant aches every now and then. 

To cure the patient of her symptoms, she would need an image-guided drainage of her large liver cyst. However, for the patient to get this procedure performed by the Interventional Radiologists, she would have to first get discharged from the hospital and then return to get it done as an outpatient procedure. For the drainage to even be scheduled, the patient’s insurance would have to be approved.

But the glaring problem was that the patient simply did not have any medical insurance to authorize the procedure. So there was no choice but to discharge her from the hospital with pain medication (that she would have to pay for out of pocket) to get her through until she could have the procedure done elsewhere.

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It’s true that Medicaid can cover emergency services for undocumented immigrants, but there are no safety nets for urgent procedures such as this very intervention the patient needed.

If the patient was able to obtain the procedure during her hospital visit, it would have taken care of the source of her pain. She would not have to be discharged in immense discomfort with opiate drugs that do have potential for abuse. Since the patient’s pain will only continue as the cyst is so large, she may need increasing amounts of pain medication to ease her discomfort over time. And although rare, bleeding or infection of hepatic cysts do arise, which can lead to significant complications. If her condition were to become an emergency, it could potentially cost the patient and the healthcare system significantly more money.

Yes, the option to apply for PRUCOL (Permanently Residing in the U.S. Under Color Of Law) in order to have access to Medi-Cal does exist. However, the immigrant may only claim to be PRUCOL when they have a strong belief that U.S. Citizenship & Immigration Services will not pursue deporting them. So, for some people living in fear after escaping their home countries for a number of reasons, they have to choose between deportation or significant morbidity and possible death.

For some people living in fear after escaping their home countries for a number of reasons, they have to choose between deportation or significant morbidity and possible death.

A month later, a patient with a history of breast cancer presented to our hospital with unrelenting right upper quadrant pain. Her CT scan showed a 2 cm lesion in her liver and the major concern was that the lesion may have been from a metastasis, or cancer spread to her liver. In order for the patient to be treated for this possible cancer metastasis, the diagnosis had to be proven. This patient would need a liver biopsy that could only be performed on an outpatient basis after insurance approval. But the patient admitted that she was in fact an undocumented immigrant from Mexico, lacked health insurance and was just too frightened to apply for PRUCOL. The health care providers, despite doing all they could to take care of her, were again at a loss.

I want to tell you that these cases are extremely rare, but they happen more often than you want to believe. And although many do support a health care system for undocumented immigrants, it is understandably an extremely complex issue with no clear present solution. But all doctors made a pledge to always remember we are treating a human being whose illness may affect the person's family and economic stability with sympathy and understanding. So it’s difficult as a physician to be prevented from intervening when a patient struggles with pain or a health problem that can be treated.

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And in this situation and many others across the country, there was nothing for the physicians to do but to stand aside even though we promised to treat pain and suffering, no matter a person’s immigration status.

Karen Tran-Harding
How the Other Side Thinks