Homeless dumping

Homeless veteran receives medical treatment. Homeless patients are one of the groups who are especially vulnerable to patient dumping.[1]

Homeless dumping or patient dumping is the practice of hospitals and emergency services inappropriately releasing homeless or indigent patients to public hospitals or on the streets instead of placing them with a homeless shelter or retaining them, especially when they may require expensive medical care with minimal government reimbursement from Medicaid or Medicare.[2][3][4][5] The term homeless dumping has been used since the late 19th century and has resurfaced throughout the 20th century alongside legislation and policy changes aimed at addressing the issue.[4] Different research studies have had mixed results as to the effectiveness of the United States' policy interventions and have propose varying ideas to remedy the issue.[5][6][7]

History

Early history

The term "patient dumping" was first mentioned in several New York Times articles published in late 1870's, which described the practice of private New York hospitals transporting poor and sickly patients by horse drawn ambulance to Bellevue Hospital, the city's preeminent public facility.[4] The jarring ride and lack of stabilized care typically resulted in death of the patient and outrage of the public.[4] Scholars report that private hospital administrations were motivated by a desire to keep mortality rates and costs down when they advised ambulance drivers to send poor patients in critical condition directly to the public hospitals like Bellevue even if a private hospital was closer.[4] After the deaths associated with patient dumping or inappropriate patient transfer added up, the first attempt at legislative reform in the United States was pushed through the New York Senate around 1907, largely by Julius Harburger.[4] The legislation penalized private hospitals when they sent ill patients away or obligated staff to transfer them to another hospital.[4] Notwithstanding the passage of city ordinances prohibiting the practice, it continued.[4] The practice of patient dumping continued for several decades, and in the 1960s it was brought back into the public eye by the media, but not much was done to resolve the issue.[4] Many homeless people who have mental health problems can no longer find a place in a psychiatric hospital because of the trend towards mental health deinstitutionalization from the 1960s onwards.[8][9]

1980's resurface in the public eye and policy interventions

"Patient dumping" resurfaced in the 1980s, nationwide, with private hospitals refusing to examine or treat the poor and uninsured in the emergency departments (ED) and transferring them to public hospitals for further care and treatment.[4][10][11] In 1987 33 complaints of patient dumping were made to the US Department of Health and Human Services, and the following year 1988, 185 complaints were made.[5] Since private hospitals ceased publishing their mortality rates, analysts pointed to high costs of dealing with Medicaid's reimbursements and uninsured patients as the motivation.[4] This refusal of care resulted in patient deaths and public outcry culminating with the passage of a federal anti-patient dumping law in 1986 known as the Emergency Medical Treatment and Active Labor Act (EMTALA).[4] In 1985 the Consolidated Omnibus Budget Reconciliation Act (COBRA) was passed which was meant to regulate how patients were transferred and also end patient dumping.[12] Unfortunately, COBRA was not a complete solution, and in the years after its passage hospitals struggled with creating appropriate discharge protocols and the cost of providing health care for homeless patients.[12] Statistically, Texas and Illinois had the highest rates of patient dumping because of economic difficulties.[5] Researchers have reported that the language in COBRA was not precise enough to significantly disincentivise healthcare providers to discontinue patient dumping practices.[6] For example, in the 1980s Texas state law had a loop hole that allowed hospitals to transfer patients to nursing homes.[5]

Early 21st century policy

Homeless dumping continued to be an issue in the United States into the 21st century.[4] University of California Los Angeles professor, Abel (2011) claimed that these policy interventions have not been effective because the United States' health care system is too heavily influenced by the patients ability to pay.[4] In the early 21st century, immigrant groups were vulnerable to patient dumping by being deported or repatriated which in many cases led to their death.[4] Research articles also describe dumping of homeless individuals or mentally ill individuals by police as another form of inappropriately shifting people from one area of a city to another instead of taking them to adequate care facilities like shelters.[13] In September 2014, the U.S. Commission on Civil Rights issued a report entitled "Patient Dumping."[14]