If you want care at the best hospital, worth millions of American dollars, and to be treated for free, all you need is a plane ticket. The only exception to this rule is that you can’t be an American citizen.

 In the 1980s the federal government, after huge multibillion dollar hospitals complained that they could not cope with taking care of the uninsured, began to make it quite easy for just about any person to obtain emergency Medicaid. Called EMTALA, which stands for the Emergency Medical Treatment and Active Labor Act, which was passed by your Congress in 1986, it mandates that all hospitals, if they wish to accept other payments from federally funded programs, including Medicare, provide all types of emergency care, even if it might be a million-dollar heart procedure, even if the patient just got off the plane at the local international airport.

The idea behind EMTALA was a good one: to protect undocumented workers and other illegal aliens who come down with an illness and require emergency care. In the past, as many of us remember, some hospitals turned away patients, regardless of their illness, while others closed because they could not afford to provide costly care without any payment. EMTALA was meant to fix that problem.

Most of us may not realize that for major surgical procedures, or very advanced care, Medicaid pays hospitals almost as well as most of the private health care insurers — hospitals make lots of cash caring for these poor even while they may publicly put some form of spin on this and portray their actions as purely altruistic. The doctors, the ones who treat the patient, on the other hand, are paid a small fraction of what most insurers would pay them for their professional fee — guess it’s nice to have some virtuous lobbyist on your side! Last year the Affordable Care Act promised to increase Medicaid fees to doctors, and provide some less unreasonable remuneration to physicians to care for people here illegally, but that small raise was as fleeting as a peace treaty with Hamas.

Again, as I must make it very clear to everyone, for the most part, this decision to treat the non-citizens who had an acute illness was unavoidable and perhaps the only reasonable decision that could be made. What other statement could a great society make when faced with a question to give, or deny, treatment to anyone, even if they broke the law and were living here unlawfully? Shall we leave them to die outside our hospitals or accept them and treat their illness, no matter what the cost?

The problem here, as you will see, is that there are very sophisticated people who are abusing this courtesy. And if you query my sincerity about this problem, ask any nurse or doctor who works in some of our best emergency rooms, especially at a hospital that is close to an international airport. Most of these nurses can tell you their own experience with a patient who took a flight, often on the advice of a relative who lives in the United States, and then, perhaps after spending a day with their family, come to an emergency room with complaints of an “acute” illness. It’s a game that might save someone’s life, but at what cost?

A 2007 report by the Journal of the American Medical Association found that in a four-year period, about 99% of those who used emergency Medicaid were determined to be immigrants who entered this country illegally. It is estimated that this gift of free health care is costing at least $4 billion every year.

Need coronary artery bypass surgery, an aortic valve replacement, or even an emergency ventricular assist device that might generate costs of over a million dollars? The answer to many who live outside the United States and in countries that refuse to care for them is to spend a few hundred dollars on an airplane ticket and, upon arrival, get to the hospital your contact, or the rating service you researched on the Internet, recommended.

This type of health care, sometimes better than many of us can afford, is being given out to foreigners who can’t obtain these services in their country. While health care bills are the most common reason people file for personal bankruptcy in the United States, and as your health insurance costs have climbed sharply, we’re all paying for the delivery of health care to just about any foreigner who wishes it. Again, if you need an emergency operation, even if you’ve got some type of health care insurance, you’re going to be forced to pay what’s not covered, and if you can’t the hospital will force you to bankruptcy unless you can prove that you’re not a citizen; then it’s free!

The dilemma is how does a compassionate country, one that would not turn away a person even if they came here just to get a triple-vessel bypass, stop this abuse? Can we put the person back on the plane and send him packing? It doesn’t seem so.

My plan is to reimburse Medicaid from funds that hitherto were destined to the third world country the patient came from.

It’s no secret, to any of us, that the United States gives billions of dollars in foreign aid to just about any country who asks, and my assessment of our foreign aid notes that most of the patients who seem to knock on the doors of our emergency rooms travel from the same countries that collect billions in aid from America. I suggest that Congress pass a law that will allow for the deduction of health care costs from the aid package to these countries.

If we use Pakistan as an example, the United States gave Pakistan more than $1.1 billion in economic assistance (not including military assistance) for the year 2012. Under my plan we would then deduct any emergency health care costs provided in the United States for Pakistani nationals from the next year’s scheduled economic assistance. This would reduce the burden on our health care dollars and perhaps give these countries an incentive to establish better quality health care in their own nation.

The people of the United States cannot afford to pay for the health care of cunning foreigners who make a trip to our country solely to obtain free health care, and it’s about time we take action. My plan would help eliminate this problem in a safe and just manner.


Evan S. Levine MD, FACC is director of the Cardiovascular Center at St. Joseph’s Hospital and a clinical assistant professor of medicine at Montefiore Medical Center — Albert Einstein College of Medicine. He is also the author of the book What Your Doctor Won’t (or Can’t) Tell You and editor of the Journal of Medicine. He lives in Ridgefield with his wife and children.