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Unwanted Patients

On May 24th 2007 a small tragedy took place inside the Haarlem courthouse. Against the advice of her physician and the wishes of her family, Fatima (the child's name has been changed to conceal her true identity), a five-year-old Afghan refugee, was denied treatment by Kennemer Gasthuis Hospital. Despite the fact that both Rozita’s GP and her ENT physician considered the operation necessary, the hospital refused to operate on Rozita due to her inability to pay. 

Financial considerations trumped medical ethics for Kennemer Gasthuis, despite various international codes of medical ethics, such as Article 3 of the World Health Organizations (WHO) Statement on Access to Health Care  which states clearly that “no one who needs care should be denied it because of inability to pay.”

Unfortunately, Fatima is not the only undocumented immigrant refused treatment.  Between January and March 2007 31 similar cases were reported by MEDOC, a project of Médecins du Monde The Netherlands advocating access to health care for undocumented migrants in The Netherlands. Similar research conducted in 2006 revealed that in 94% of these cases, financial considerations were the decisive factor. Furthermore, studies show that not only the Kennemer Gasthuis refuses to treat undocumented immigrants—Dutch GPs, dentists and physicians too often request payments up-front, a nearly impossible feat for the undocumented or the uninsured. 

Extensive international treaties and codes of conduct attempt to protect the rights of individuals like Rozita. In her defence, Mr. Jelle Klaas of Fischer Advocaten detailed the various international laws securing health care for all people regardless of their ability to pay. Prime among these is the WHO preamble to their Statement on Access to Health Care, asserting that every human being has the “right to the highest attainable standard of health.”

Ever since World War II, this available level of care has been very high in The Netherlands. Due to the virtual absence of private clinics and lack of income barriers to insurance, the Dutch welfare system provided its citizens with excellent and accessible health care. However, increased international competition, growing immigration in Europe and the aging of the European population caused many European countries to re-examine their long-touted social security and health system, which were becoming a costly welfare burden in drastic need of reform. 

A New System

In response to these concerns, Holland revamped its health insurance system at the turn of the century.  The rationale was simple: competition leads to better quality and lower prices as consumers shop for the best deal. However, human rights health organizations such as Médecins du Monde The Netherlands, Johannes de Wier and Lampion report an increasing number of cases similar to Rozita’s, highlighting the pitfalls of the new system. Some even claim that the change in policy intentionally targeted undocumented immigrants in an attempt to control high levels of immigration. Dr. Reyis Kurt, a family physician, thinks that “Some politicians believe immigrants are not welcome in this country and so should not receive proper health care.” 

Other concerns with the new health insurance system extend far beyond the state of undocumented immigrants. Dr. Koning, the head of the radiotherapy department at the Amsterdam Medical Center, explains that the problems facing illegal immigrants highlight larger problems with the new health system.  In an ominous tone she says, “Our biggest fear is that we’re moving to the American system.”  

In scrutiny of the private model of care, Dr. Koning asks aloud whether healthcare is even an appropriate subject for the free market. “It will never be a real free market—there are so many constraints,” she muses.  When the goods being traded are human lives, rather than profit margins or net revenues, the picture becomes ever more complicated.  While it is still too early to determine just how the Dutch system will compare with the privatized American system, such concerns are highly relevant. Even the strongest advocates of health care reform want to avoid such a system. Hans Hoogervorst, the previous minister of Health, wrote in Europe’s Welfare Burden that “it must be possible, somewhere between the US and Europe, to let the ship steer a middle course.”

Gerd Beckers, director of the MEDOC project of Médecins du Monde The Netherlands, puts it another way. “This way, populations who cannot fend for themselves—the poor underclass, undocumented migrants or asylum seekers like Rozita’s family—are in a way excluded from the health system, whereas it was in particular this ‘weak’ population that the social system was once designed for.” 

A Weak Population

Complicating matters further, the health needs of undocumented immigrants differ from the population at large. Klaas indicates that in particular their psychological needs are often understated, though these are a vital component of care for many immigrants. Asylum seekers, for example, have very high rates of post-traumatic stress disorder (PTSD) as a result of mass violence or from living in a culture of fear in their native states.  Since psychological treatment is limited to seven sessions under the new system, those who require long-term care must pay out of pocket for further sessions or forgo the treatment altogether.  

Moreover, diagnose such issues is difficult due to language and cultural barriers.  Globally, the psychological needs of refugees and asylum seekers lie undetected and untreated.  The World Health Organization estimates that the majority of individuals suffering from depression or PTSD as a result of mass trauma seek treatment from their primary care provider (PCP).  Tragically, only 2.9% of such cases are detected by PCPs today, leading to a vast under-provision of care.  These kinds of psychological disorders make acclimating to a new culture, acquiring a job or caring for one’s family even more difficult.

These issues are echoed by a variety of experts.  A 2004 report in Global Migration Perspectives depicts the challenges faced by undocumented migrants, stating that “illegals receive limited access to health systems despite high risk of segregated urbanization, labour, economic and sexual exploitation, and physical, psychological and sexual abuse.”  Coupled with a higher exposure to contagious infections and diseases, immigrants face severe health barriers with drastic consequences.  

The plight of undocumented pregnant women provides a particularly poignant study of this issue. An estimated 25-50,000 undocumented women live in The Netherlands, giving birth to about 500-1,200 children annually. Although they have the right to gynaecological care, some of these women hesitate to ask for it, afraid to be caught by officials. Some even do not dare to register their child. The fact that more precise figures are impossible to determine indicate the severity of the problem.  Hanneke Bontenbal-Pleizier works as a midwife in Charlois, a socially deprived neighbourhood in the south of Rotterdam. When asked about this situation she says: “Undocumented women are a very significant percentage of my patients. As we have our medical code of conduct, I do not pass on any addresses or names to the authorities and I always tell this to my patients up front, in order to create a relation of trust. Of course there is a language barrier and sometimes also cultural differences, but I do not see why I should not provide care to these women! Also, from a financial perspective there is not much difference –rather than filling in the papers of an insurance company, we fill in a request for financial reimbursement from the Koppelingsfonds, a financial fund available for first line medical care.” 

The Koppelingsfonds have been hotly debated a over the past years. Established in 1998, the 5.9 million EUR fund is available to providers of primary health care such as dentists and GPs. The fund is often considered as an administrative burden, requiring too much paperwork. Conversely, midwife Hanneke Bontenbal-Pleizier is one of many who perceive it as a source of vital financial support allowing her to deliver health care to women in need. “The amount of paperwork is about the same as with the insurance forms.  When you are familiar with the documents, the administrative work is not very difficult.”

Little Empathy

Despite the clear need for adequate and accessible health care, there currently appears to be strikingly little empathy for undocumented immigrants within Dutch society. As it is estimated that there are about 120-150,000 undocumented immigrants in The Netherlands, their presence in society cannot be denied. Though some may wish otherwise, most undocumented immigrants are here to stay, with or without legal recognition. 

The negative attitude towards immigrants in Holland today causes politicians to be unenthusiastic about developing solutions that might inadvertently encourage more immigration. The rationale behind this reluctance is straightforward: if The Netherlands would offer social benefits and health care to undocumented immigrants this would result in an enormous influx of migrants from all over the world. Up until this moment however, not a single study proves this relation to be true. In fact, studies like the B & A report in 2001 show that migrants coming to The Netherlands are eager for jobs and to reunite with their families, rather than the social benefits. Jeroen van Doomernik, a researcher at the Institute for Migration and Ethnic Studies, explains the causes of migration by classifying them according to a push -and pull mechanism: “As global inequality intensifies, people from the developing world are pushed abroad to earn a liveable wage in an attempt to escape from political and social insecurity, while at the same time the developed world pulls in low-skilled labour to do the jobs they prefer not to do themselves.” A recent article in the New York Times confirms Doomernik’s findings: “Despite current alarm, migration is likely to grow. Rich economies with aging work forces need labour. Workers in poor countries need jobs. Border crossings are hard to prevent, and the rewards of moving have never been greater. We asked for workers, but we got people.” 

This analysis shows the general misconception of the economic value of the undocumented immigrant. Numerous jobs that Dutch are loathe to take are completed by immigrants at very low wages. Although such workers generally do not pay taxes, their employers benefit directly from these low cost services. Since undocumented workers provide such valuable services, a recent article in The Nation therefore stated that rather than having illegals pay a $5000 fee to the US government in order to receive citizenship, they should actually collect well in excess of $5000 in order to compensate for the low wages they recieve. Though such measures may value their economic contribution in an adequate way, it may inadvertently increase the pull effects of migration. In the light of the lack of empathy towards undocumented migrants in The Netherlands, a fair valuation of immigrant workers’ economic contribution is unfortunately unthinkable. 

Perspectives on Access to Healthcare

There are many reasons why immigrants should be provided the same level of healthcare as Dutch citizens. “The trouble starts where ‘luxury medicine’ comes in,” says Dr. Koning. Currently, some hospitals do not treat uninsured patients with fatal but non-acute and non-communicable diseases such as cancer.  There is no public health need, the argument goes, so why cover the cost? Most would consider cancer to merit treatment, regardless of one’s ability to pay. But what about fertility treatment? Cosmetic surgery? What about reconstructive cosmetic surgery after a tragic accident?  More importantly, who gets to make decisions about what is “luxury” and “necessary” medicine? “It’s not clear cut. No doubt about it,” concludes Dr. Koning. 

To the consternation of some, human rights are being questioned in the most developed countries, with international law complicating an issue already fraught with subtlety.  Klaas points to international law, which he finds uniformly in favour of undocumented immigrants.  A nation has an undisputable responsibility to its citizens and unreasonable demands on the nation’s coffers for non-citizens should understandably be avoided.  But part of that responsibility to its citizens involves the nation’s credibility on an international playing field.  To protect this, international law, including laws that protect a patient’s right to medical care, must be stringently upheld.  The ethical reasons for adopting such laws in the first place must guide subsequent interpretations of that law in novel circumstances.

Others argue that undocumented migrants should receive care in their home country.  However, the WHO clearly speaks of the “right to the highest attainable standard of healthcare.”  The Dutch health system is arguably one of the best in the world; sending patients to their home country for treatment therefore becomes impossible due to this guideline. Does this however mean that The Netherlands has the responsibility of providing treatment to all individuals –even to undocumented immigrants?  

Beckers points to four different perspectives on why accessible healthcare should be granted to undocumented migrants: medical, financial, ethical and aesthetical perspectives. From a medical point of view, creating barriers to healthcare will deter patients from seeking care until conditions become serious.  Such barriers not only decrease the effectiveness of health care but are also a threat to public health in general. In addition, effective health care also has a financial component in which prevention is a lot cheaper than curative medicine.  From an ethical perspective, Beckers continues, the notion that all people are equal makes it unethical to deny treatment to anyone, regardless of their ability to pay. An unexpected but quite powerful argument is that from an aesthetic point of view, sick people are considered unsightly in the developed Western world. In several cities in The Netherlands, there are laws against begging on the streets, showing that indeed aesthetic considerations are taken into account.  

The Burden of Proof Lies…Where?

With a government failing to take proper action, the pressure to address the health needs of patients like Rozita is falling on hospitals rather than policy makers. As a result of the significant financial consequences implicit to this issue, hospitals like the Kennemer Gasthuis are vilified in the process of their attempt to find an adequate solution to the severe financial strain of providing for uninsured and often undocumented patients.  The Erasmus MC in Rotterdam estimated that in 2005 alone, the costs of providing health care to uninsured patients totalled about 2.4 million EUR. 

Some means for recouping losses do exist for hospitals. Once a hospital discovers that a patient is unable to pay, the costs of their treatment is added to an allowance for bad debt. At the end of the year, this money is compensated by insurance companies in order for the hospital to avoid losses.  In other words, insurance companies pay for everyone’s care, even the the uninsured, either up-front or during end-of-year accounting. 

This is a far from a satisfactory solution, however. Bob van de Brand, associate professor of accountancy at the RSM Erasmus University in Rotterdam, believes it is even unjustified in the case of undocumented migrants. “Apart from the personal tragedies involved, the hospital knows in advance that the undocumented patient is unable to pay. In such a case it should not consider it as a ‘bad debt’ that could possibly be repaid one day, but written off as a direct loss.” 

In addition, reimbursements from insurance companies rarely cover all losses incurred by hospitals in the treatment of uninsured individuals. In the Annual Report of Erasmus MC it is stated that the annual difference between actual costs and reimbursements is about 700,000 EUR. 

In Rozita’s case, the lawyers for Kennemer Gasthuis defined the issue very clearly.  “We agree on the facts.... [but] the question is who should pay for health care? It is a ‘bridge too far’ to demand our hospital provide both the healthcare and pay for it.”  Most hospitals recognize the burden this policy places on the uninsured.  Kennemer Gasthuis’ lawyers continue “For years already, several hospitals and other parties have demanded the state to provide a proper solution to this situation. Although we regret the current situation, we cannot do anything for Fatima and recommend that she go with this case to the government or insurance companies.”  

Nevertheless, the pressure to act currently rests squarely on those whom it affects the most—hospitals, doctors, and their patients. Dr. Henk Vergunst, urologist at the Canisius-Wilhelmina Hospital in Nijmegen, understands the position of the hospital. “To a certain extent it indeed goes too far to demand a hospital treat patients without providing financial reimbursements. From a medical perspective this issue highlights the very real and serious tension between the (moral) obligation of a doctor and his practical capability to fulfil these obligations. Of course a doctor can choose to work pro bono, but not all the time. In the case of Rozita, the doctor did his work properly by stressing the medical necessity of the operation. At all times, a doctor is responsible for treating his patients in the best possible way – without being influenced by personal profit or unfair discrimination – as the International Code of Medical Ethics puts it.” 

In Search of Answers

Undocumented migrants currently living in The Netherlands are desperately in need of specialized health care. At the same time, the general public and the current political climate perceive the presence of the approximately 150,000 undocumented immigrants in Holland to be a burden.  It could therefore very well be that more than a change in policy is required; rather, a change of public perception could be the fulcrum on which the success of this debate rests. 

Rozita was finally treated by the Kennemer Gasthuis.  The court decided that she would pay a €5-10 monthly payment, until the total cost of €1,138 was paid in full. This arrangement was chosen as the hospital considered the intention to pay via a symbolic monthly amount to be an important signal to society.

Unfortunately, Rozita’s case is not unique. The Kennemer Gasthuis alone is currently facing twelve similar cases of undocumented patients demanding treatment. 

“I have no adequate solutions,” says Dr. Kurt.  Hampered by administrative red tape and inadequate funds, many more individuals must forgo care before this issue is successfully resolved in the eyes of both the Dutch majority and undocumented migrants.

“The current situation is that access to health care for undocumented immigrants is clearly a medical vs. political issue. Where do they converge? In my opinion on juridical treaties, on fundamental human rights,” says Klaas.  In his defense of Rozita, Klaas therefore chose to extensively discuss international medical codes of conducts and treaties. In addition to international law, the Amsterdam disciplinary tribunal stated already in 1934 that “a medical doctor should – under all circumstances – be willing to provide medical care, and have financial considerations come second.” 

In the debate on access to health care for undocumented immigrants, the most prominent argument against free access are financial considerations. Some believe that immigration should be curbed, or that the length of stay should be capped after a worker’s most productive years are over.  Nevertheless, the current number of undocumented immigrants makes these goals unrealistic. There are 120-150,000 undocumented immigrants in the country and they are here to stay as active participants in our society and economy. Though uninsured, they will likely end up in one of The Netherland’s many hospitals or clinics one day. Should it be left to the individual doctor’s or hospital’s decision to care for this patient – and are there sufficient financial funds available to treat these uninsured patients? Despite the Koppelingsfonds and the reimbursements to the hospitals, Rozita’s case highlights the pitfalls of the Dutch healthcare system. Rozita’s case raises many questions: should health care be available to everyone on an equal basis –like electricity or drinking water –or is this causing an unsolvable welfare burden? Is the Kennemer Gasthuis to blame for not taking responsibility when politicians also do not speak out? Is international law violated if health care is denied to undocumented immigrants and if so, what are the consequences of this violation?  Who has the right to enforce such consequences?

With the number of uninsured growing and immigration on every policy maker’s table, these questions are never more timely.

References

Interviews

Mr. Jelle Klaas / lawyer at Fischer Advocaten in Haarlem (June 20, 2007)

Dr. Koning / head of radiotherapy department AMC  (June 22, 2007)

Hanneke Bontenbal-Pleizier, midwife in Charlois (June 23, 2007)

Dr. H.Vergunst / urologist at the Canisius-Wilhelmina Hospital in Nijmegen (June 23, 2007) 

Dr. Reyis Kurt / family physician (June 24, 2007)

Rob / GP in Amsterdam (June 25, 2007)

Gerd Beckers / coordinator MEDOC and medical doctor (June 27, 2007)

Articles 

Carlso, Benny et al, Europe’s Welfare Burden: The case for Reform, Civitas, 2002

DeParle, Jason, ‘Border crossings’, in New York Times, June 24, 2007

Ehrenreich, Barbara, ‘What America owes its “illegals”’, in: The Nation, June 12, 2007

Jans, G. ‘Als de kwaal erger is dan het middel’, in: Tegen de tuberculose, nr. 2, 2004, p.48-50

Kraus, Sabine, ‘Koppelingswet werkt niet, maar mag toch blijven’, in: Equality Matters, 12, 2001, p. 15-16

MacPherson, Douglas W. and Gushulak, Brian D., ‘Irregular migration and health, in: GCIM Global Migration Perspectives, no. 7, 2004, p. 1-14

Nourhussen, Seada, ‘Illegale patienten – ongezond en onzichtbaar, in Trouw, August 13, 2005

Otter, Joost den and Tavenier, Daniel, ‘Gelijke rechten op gezondheidszorg’, in: Medisch Contact, nr.33/34, Augst 2006, p.1316-1318

Stratmann, H. van, ‘Gezondheidszorg voor illegalen – hoe nu verder? Tien vragen aan Joost den Otter’, in Mensenrechten en Gezondheidszorg, June 2006, p.13-15

Stouwe, Relinde van der and Annegarn, Anne, ‘Verloskundige zorg aan onverzekerde zwangere vrouwen’, in: Tijdschrift voor Verloskundigen, January 2007

Waard, Ellen de, ‘Apartheid in de gezondheidszorg’, in Fabel van de Illegaal, Spring 2007

Websites

www.axielijst.nl (June 21, 2007)

www.lampion.info (July 24, 2007)

www.johannes-wier.nl (July 24, 2007)

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Netherlands Netherlands 2007

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