One day last January, Ariel Gonzalez was picking oranges in Okeechobee. The next, the 35-year old Mexican laborer was overcome by lower back pain from what would later be diagnosed as Stage 5 kidney disease.
Medicaid usually doesn’t cover the health needs of undocumented workers like Gonzalez, but it can — and it did — in his case. But apparently no one knew of the potential exception — not the hospital staff, outpatient dialysis clinic or even the Florida Department of Children & Families that administers Medicaid — until University of Miami law students stepped in and got Gonzalez the treatment he needed.
“We unearthed a policy that was figuratively locked in a drawer. Even the DCF workers who created it weren’t aware of it,” said Kanchi Doshi, 26, one of four law student volunteers at UM’s Health Rights Clinic who worked on the case. UM law students like Doshi have handled over 1,500 benefits cases for disabled and indigent clients since the clinic opened in 2005.
Federal law requires only that hospitals treat and stabilize undocumented workers who experience a health emergency. But a DCF policy published in a 2010 internal memo also allows patients like Gonzalez to qualify for 12 months of Emergency Medicaid for ongoing treatments needed to keep them alive. The application process for approval can take as long as 90 days.
A DCF spokeswoman, Ana Valdés, said local medical providers generally are aware of the policy. “In Miami-Dade County, we have a centralized process in which one eligibility specialist processes all the Emergency Medicaid determinations for dialysis,” Valdés said.
Valdés would not comment further about Gonzalez’s case, saying, “Any information pertaining to public assistance benefits recipients, including recipients of Medicaid, is confidential.”
Gonzalez was admitted to Lawnwood Hospital in Fort Pierce as a charity case rather than as a Medicaid applicant, according to Health Rights Clinic Director JoNel Newman. She said nonprofit hospitals receive tax exemptions for providing a “community benefit” such as charity care.
A Lawnwood spokeswoman would not discuss the case because of patient-privacy issues, and refused to comment on the hospital’s admissions protocol for Emergency Medicaid cases.
In 2011, Florida spent $214 million on 31,000 charity cases, and Lawnwood claimed $24,813,000 in charity-care costs in its 2011 Community Report.
For Gonzalez, being a charity case meant having to wait for the poisons to build up in his blood to life-threatening levels until he was sick enough to receive dialysis in Lawnwood’s emergency room. Without Emergency Medicaid, he could not have received the weekly outpatient dialysis he needed.
“Sometimes the pain was so bad I thought I would have a heart attack,” the farmer said in Spanish, explaining he returned to Lawnwood at least twice more for emergency treatments, and was turned away as many times because his blood “wasn’t bad enough.”
Robert Varno of Patient Pathways, a subsidiary of DaVita HealthCare Partners providing discharge planning for the hospital’s renal patients, was in charge of Gonzalez’s follow-up care after each emergency room admission. Varno said he had not realized Emergency Medicaid was an option until the Health Rights Clinic got involved.
He and other Pathways outpatient dialysis liaisons were trained that medical repatriation programs like MexCare were the only way for undocumented patients to obtain care beyond the ER.
But MexCare, which arranges for Latin American patients to return to their home countries for treatment at no cost to them, could have been a death sentence for Gonzalez, who is from rural Mexico, where dialysis facilities are distant.
“I thought, ‘I need to get this guy care.’ It was heartbreaking to watch what he was going through,” Varno said.
Meanwhile, the UM team raced to get Gonzalez’s Emergency Medicaid application in play. With no previous experience in filing such an application, the students called DCF repeatedly until they determined what steps they needed to take.
The students said the hardest part was assembling the required medical and financial documents.
“Healthcare administrative procedures are supposed to be designed for individuals to navigate the system, but the agencies are impenetrable,” UM’s Newman said.
It took the four law students, along with two attorneys and a paralegal, 20 days to secure outpatient dialysis for Gonzalez.
“It’s called Emergency Medicaid, but the fact that it has a 90-day time-frame makes it a misnomer,” said Jenna Feldman, 24, a second-year UM law student who worked on the case. “DCF can approve emergency food stamps in seven days. I think the agency just didn’t think through the implications of someone needing emergency dialysis.”
In the end, the students said, securing help for Gonzalez involved 16 steps, five administrative functions, multiple locations and documents.
They said they would use their experience to develop a toolkit for use by providers to standardize the process.
Varno’s organization, Patient Pathways, will use the toolkit to inform all contractors at its 33 client hospitals across Florida. An official with the Mexican Consulate in Miami met with Newman about creating “know your rights” cards that the uninsured can hand to practitioners, asking them to apply for Emergency Medicaid on their behalf.
“We’re getting calls almost every day from people wanting help with similar cases,” the clinic director said.
Most recently the students — Kanchi Doshi, Jenna Feldman, Becky Greenfield and Niki Velazquez — received UM law school’s Innovative Service in Public Interest Award.
Gonzalez calls them “My angels.”
This story was produced in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.