When a patient enters an emergency room, a hospital is required by law to treat the patient until the patient is stable for transfer, no questions asked. That’s right. No questions about health plan coverage or ability to pay.  This also includes asking whether or not the patient is a citizen of the United States.

Unfortunately for hospitals, this is a one-way street when it comes time to discharge a patient who is in the country illegally and has no means of payment. Hospitals are legally obligated to find an appropriate place to discharge the patient. This discharge direction is largely dictated by the patient’s insurance status, and it makes all the difference.

All hospitals have a transfer policy, which outlines the transfer process for all situations involving a patient.  A patient cannot be transferred to another hospital for any non-medical reasons, such as inability to pay, unless all of the following conditions are met:

1. Patient is examined and evaluated by a doctor and surgeon.
2. Patient has been provided with appropriate emergency medical services to ensure there will be no harm to the patient by a transfer.
3. The treating physician and surgeon have arranged with the new hospital for the appropriate resources and doctors to treat the patient.
4. The patient’s medical records (including a “transfer summary” signed by the transferring physician) are transferred with the patient.
5. The hospital complies with all relevant state regulations related to transferring the patient.

Federal law adds the following requirements for the transferring and receiving hospitals that accept Medicare patients:

1. The transferring hospital must provide the Medicare patient with medical treatment that minimizes risk to the patient’s health.
2. The receiving hospital must have adequate space and staff to attend to the patient.
3. The receiving hospital must have agreed to accept the transfer.
4. The transfer is done with qualified medical staff and transportation equipment, including the use of necessary and appropriate life support measures.
5. The transferring hospital must send all the Medicare patient’s medical records related to the emergency condition with the patient.

What happens when an uninsured, non-US resident patient is severely injured and hospitalized with months of rehabilitation facing said patient? Normally, a hospital would discharge this patient from the hospital to a rehabilitation facility. There, the patient would continue physical therapy, which, over time, would allow for the patient to eventually be discharged.

But when a patient from another country lacks healthcare coverage, it is next to impossible for a hospital to find another facility to accept the patient. Since this patient has an immigration status with no coverage eligibility, the hospital would be hard-pressed to find any outside charity that would cover the costs of care or pay for insurance coverage.

The U.S. Border Patrol often delivers to California hospitals undocumented patients who need emergent health care. Since these immigrants have not been arrested, the Border Patrol is not obligated to pay for their medical care. Earlier in this century, the Medicare Modernization Act included a provision known as Section 1011, which authorized $250 million per year from the federal government to reimburse hospitals, physicians and ambulance services for the cost of care associated with the treatment and transportation of undocumented immigrants. However, California exhausted its funds rather quickly.

In 2015, the number of California counties committed to providing low-cost, government-run medical care to such residents increased from 11 to 48. And in June of last year, California Governor Jerry Brown signed a state budget that for the first time funds healthcare for undocumented children. But many states do not offer such coverage, and there is fiscal concern about the effect the total cost (estimated at $1 billion per year) will have on the state. Even with that coverage, it is difficult to find places to transfer the patient, given the extremely low reimbursement the hospital receives from the state for the care.

So a hospital has no choice but to hold and continue treating the patient with very little to no compensation. As highlighted in a 2008 New York Times article, these inpatient admissions can last for years, if not longer.

While medical air transportation to another country is far from cheap (in the neighborhood of $50,000-plus), it is often a cost benefit in order for the facility to halt the indefinite, uncompensated costs of continued hospitalization.