Program Makes Hospitals Determine Immigrant Status

Guillermo Contreras, San Antonio Express-News, September 9, 2006

When Claudia De Leon, nine months pregnant, stepped inside University Hospital in January, she expected the first questions she’d be asked would be about the imminent birth of her fourth son.

Instead, she first was met with requests to produce her birth certificate, she said.

“You go with intentions to pay (the medical costs), but those types of questions make you feel like a criminal,” the 24-year-old Mexico native said.

De Leon, who is married to a U.S. citizen, eventually delivered a robust Luis Fernando by Caesarean section on Jan. 11, but she still owes about $1,500 for the medical bill.

Her immigration status was, until recently, in the gray. In December, she got a visa that allowed her to return to San Antonio from Mexico to her husband of five years, Victor De Leon, 30. The visa is an initial step to obtaining permanent residency here.

But she says the hospital experience and prior difficulties getting prenatal care and health care for the couple’s other three sons make her feel unwelcome.

“It’s a cold way to treat you,” she said.

That’s unintentional, local medical providers say, but they can and do ask any of Bexar County’s 350,000 uninsured residents something other than, “Where does it hurt?”—such as proof of where they were born.

The reason is the federal government has up to $1 billion to pay hospitals and doctors who provide emergency treatment to undocumented immigrants. The four-year program makes $250 million available each year among all states, with Texas and other border states getting the lion’s share.

But the program, medical providers say, puts them in an uncomfortable spot—smack in the middle of the immigration debate.

To get reimbursed with federal dollars, hospitals have to collect documents and ask “indirect questions” about the patient’s origins.

It has proven a difficult, and confusing, task.

“We want the money, but we’re not Border Patrol or immigration services,” said Leni Kirkman, a spokeswoman for University Health System, Bexar County’s lone public health district. “We have to document the citizenship of the undocumented population. Think about that. They’re undocumented. How do we document it? That’s what the problem is.”

Federal law requires hospitals to provide emergency medical care, regardless of a patient’s ability to pay.

To date, University said it has recouped roughly 32 percent of its $3.1 million in total costs for treating undocumented immigrants in the first six months the money became available. It can only bill the government for up to 48 hours of emergency care, and of that amount, it received less than half.

Impact on hospitals

In 2004, Congress’ investigative arm, the General Accountability Office, attempted to identify the impact of undocumented immigrants on hospitals’ uncompensated costs. It was hard to gauge, a GAO report concluded.

“Hospitals generally do not collect information on patients’ immigration status, thereby making it difficult to identify patients who are undocumented aliens and the costs associated with treating them,” it stated.

By then, Congress had passed the Medicare Prescription Drug, Improvement and Modernization Act of 2003, which provided $1 billion over fiscal years 2005 to 2008 to reimburse hospitals along the U.S.-Mexico border or in states with large immigrant populations.

The report recommended that the U.S. Health and Human Services Department implement controls for reimbursement, and the government’s early guidelines would have directed providers to ask patients whether they were undocumented.

After complaints, the Centers for Medicare and Medicaid Services tweaked the guidelines and finalized them in May 2005.

They require providers to determine if a patient is eligible or enrolled in Medicaid or emergency Medicaid, and if the person is in the United States with a border-crossing card or has been “paroled”—allowed to enter the country for humanitarian reasons or while a green-card application is pending.

If patients say they were born in another country, they must show a birth certificate, passport, foreign voting card, expired visa, foreign driver’s license or other foreign identification.

Health care providers and immigrant advocates, however, remain concerned that the guidelines are ambiguous and conflicting and could lead to intrusive and potentially intimidating questioning of patients, the National Immigration Law Center said in a report last year.

“We’re there to take care of people, not play police,” said Bill Rasco, president and CEO of the Greater San Antonio Hospital Council, an advocacy group with 53 health provider members. “The problem with all of this is as soon as you start asking those kinds of questions, (patients) may not return for follow-up care if you’ve already identified them as undocumented immigrants. The last thing we want is people being afraid to access the system.”

Intentions to pay

On a recent evening at the De Leon’s modest home in Northwest San Antonio, Claudia De Leon waited for the return of her husband, who leaves for his construction job at 6 a.m. It was approaching 8 p.m. and he wasn’t due for another hour—a typical 14-hour workday.

Their oldest son, Victor Manuel, 3, sat with twins Emilio and Carlos, 21 months, watching “La Fea Más Bella,” a Mexican television series, in a bedroom. De Leon, a full-time housewife, rocked Luis Fernando, 7 months, in her arms to try to get him to sleep. He gurgled and poked at her face, not wanting to snooze.

Noises outside prompted the older kids to run to the front door, only to be disappointed not to find their father there.

De Leon recounted living here illegally from May 2002 through November 2003. During that time, she had Victor Manuel, also at University Hospital. Much of that care was paid for by Medicaid, which allows emergency coverage for labor and delivery, even for those whose immigration status is uncertain.

She returned to Mexico in late 2003 after her husband petitioned the U.S. government for her permanent residency. She had the twins while she was in her hometown of Nueva Rosita in Coahuila state. Her husband’s visits to see her and the kids only made them long to be together.

Two years later, she received a visa and returned to the United States. By then, she was pregnant with Luis Fernando.

She sought prenatal care at two clinics on the West Side, but said she was turned away because her husband makes too much—upward of $35,000 gross pay a year.

“That seems like a lot, but when you take rent, (utility) bills, diapers and food, you end up short,” said Victor De Leon, who was born in San Antonio but lived half his life in Mexico.

But as Luis Fernando’s due date came closer, she got help from a friend and the League of United Latin American Citizens. She waded through the process at University Hospital. She was able to get emergency Medicaid to pay for much of the $7,500 bill, according to a statement she showed a reporter.

She still has a balance of $1,500. Collectors have called and demanded immediate payment in full.

“Our intentions are to pay, but we can’t pay all at once,” Claudia De Leon said.

All four children were sick with cold and bronchial-related symptoms in February—not to an extent that required emergency care—but the couple was left trying to find a clinic that would examine them without demanding payment of more than $50 apiece.

“The situation is bad,” Claudia De Leon said. “You are forced to lie to get medical attention or you don’t ask for it at all.”

Bitter pill

Some who seek greater U.S. limits on immigration, such as the Washington-based Center for Immigration Studies, argue that immigrants make up a large portion of the uninsured because they generally have less than a high school education and work at jobs that don’t provide them with insurance or don’t pay them enough to afford it.

“Why not select immigrants who are self-sufficient?” asked Steven Camarota, the group’s research director. “This is one of the big problems with illegal immigration. It’s not that everybody’s lazy or came to get welfare, they’re just unskilled, and unskilled people tend to cost taxpayers a lot of money, whether they’re immigrants or natives. The unskilled natives we’re stuck with, but should we continue to take in a lot of unskilled immigrants? That’s the big question.”Others argue undocumented immigrants contribute to society.

“Many undocumented immigrants pay taxes and don’t get any benefits, so when you talk about this, that’s not taken into account,” said Martha I. Lara, Mexican consul in San Antonio. “If they buy a house or if they pay rent, a portion goes to local and sales taxes. … Unfortunately, there’s no structure that affords them regular medical care.”

Immigrant advocates said the approach by some hospitals will further alienate undocumented immigrants, who typically don’t seek out medical care for fear of being discovered. Some argue that the impact will be felt beyond the undocumented.

“Who this ultimately is going to also impede is the health care of American citizens, especially Hispanics,” said Steve Saldaña, president and CEO of Catholic Charities of the Archdiocese of San Antonio, which runs the oldest immigration-aid program in the state. “They will be put through so much of a ringer that they’re not going to participate in the process because it becomes terribly burdensome and insulting even though they are American citizens.”

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In Dallas, hospital officials have struggled with the issue and decided to bill Mexico for treating undocumented immigrants, according to The Dallas Morning News.

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