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Michael Easterbrook and Jean P. Fisher, Staff Writers

Mac Pannill was moving fast on a recent round at the WakeMed Raleigh Campus. Within an hour, he needed to see six mothers and their newborns.
Wearing a button pinned to his white jacket that read "Hablo Espanol" (I speak Spanish), he swept into the wood-floored hospital room of one patient and lifted her newborn from a bassinet. "He's big!" Pannill said in nearly accent-free Spanish. "Do you have a name picked out?"

Speaking Spanish is a crucial skill for Pannill, a physician assistant at a medical practice that treats a growing number of pregnant women from Mexico and other Latin American countries. Pannill doesn't ask their immigration status, but he knows that many of them slipped across the border illegally.

As the immigrant population, both illegal and legal, grows in North Carolina and throughout the country, so too does the strain immigrants place on social service providers to make sure their basic needs such as food, housing and education are satisfied. Of all those needs, one of the most costly is health care.

It's difficult to pinpoint the state health-care system's cost of treating illegal immigrants. The main reason is that health-care providers do not ask about immigration status when they treat patients. So they have no accurate way of tallying the costs associated with caring for illegal immigrants.

"People in health care want to stay focused on their jobs, which is to provide care to the sick and injured," said Don Dalton, a spokesman for the N.C. Hospital Association.

He said many providers think asking patients about their immigration status on a routine basis would deter illegal immigrants from seeking needed treatment.

Hospitals, where the most costly care is provided, do measure the costs of treating uninsured patients. Many can track expenses incurred by uninsured Hispanics -- the largest and fastest-growing immigrant group in North Carolina. However, those estimates include medical expenses for citizens and legal residents as well as illegal immigrants.

In a report in January on the economic impact of Hispanic immigration in North Carolina, researchers at the Kenan Institute of Private Enterprise at UNC-Chapel Hill estimated the state's 2004 cost for health services provided to all Hispanics, legal or otherwise, at $299 million. That includes hospitals' uncompensated care -- costs not paid by patients or insurance plans -- as well as costs covered by Medicaid, the joint local-state-federal health insurance program for the poor.

Under federal law, Medicaid pays for care of illegal immigrants only when they have medical conditions that could jeopardize their health or lives.

But a somewhat conflicting federal law requires hospitals to examine -- and if an acute medical problem is found, treat -- anyone who shows up at emergency rooms, regardless of legal status. If an uninsured illegal immigrant receives emergency care and Medicaid does not pay, it is a form of uncompensated care.

Medicaid, unlike hospitals, does try to separately account for illegal-immigrant care. Spending on such care in North Carolina doubled from $25.8 million in 2000 to $52.8 million in 2005, according to the N.C. Division of Medical Assistance, the state's Medicaid manager.

Still, care for illegal immigrants absorbs just a small portion of North Carolina's total Medicaid spending. In fiscal year 2005, the cost of care for illegal immigrants was less than one half of 1 percent of the Medicaid program's total budget of $8.2 billion. Most of the money went to hospitals to cover delivery costs for pregnant women, but Medicaid also paid for ambulances, diagnostic imaging and other emergency care.

As long as the law requires hospitals to provide emergency care to all, there is little prospect of reining in the cost of treating illegal immigrants, unless the flow of immigrants is reduced.

"Politicians may be tempted to keep illegal aliens from using health-care services, but that will not be possible," said Steven Camarota, research director at the Center for Immigration Studies, a Washington group that wants to reduce the flow of immigrants to the United States. "If you allow illegal aliens to stay, those costs will be unavoidable."

Frequent? Likely

It's unclear how often Medicaid picks up the bill for illegal immigrants who give birth in North Carolina, but a glimpse at the patients Pannill works with suggests that it happens frequently.

Pannill works for WakeMed Faculty Physicians OB/GYN, a collaboration between WakeMed and UNC-Chapel Hill. It treats patients referred from the county health department who are high-risk and need specialty care. Few have health insurance or Medicaid coverage, said Dr. Juan Granados, the practice's director.

Births by Hispanic women through the practice grew 293 percent from 1997 to 2005 -- from 463 to 1,819, Granados said. The practice delivers about 3,900 babies a year.

Most of the Hispanic patients are from Mexico or Central America. Granados estimated that at least 85 percent of the Hispanic patients are illegal immigrants.

According to statewide estimates by one large insurer, the cost of delivery ranges from $6,800 for a straightforward birth to as much as $18,000 for a Caesarean section with complications. Medicaid typically reimburses the hospital for illegal immigrants' deliveries.

Nearly all of the medical practice's 28 staff members rely on interpreters based at the hospital when interacting with Spanish-speaking patients.

The only two who are bilingual are Granados, who comes from Spain, and Pannill, who learned Spanish through classes geared toward health-care professionals.

Pannill said most of his Spanish-speaking patients work as housekeepers or cooks.

"The face of our patients has changed dramatically," said Pannill, who has worked at the practice for 17 years.

Other needs, too

Illegal immigrants have health-care needs other than childbirth: Many also appear in emergency rooms with injuries and other health problems.

Although it's hard to gauge how much, the growth of the illegal immigrant population is pushing up uncompensated-care costs at hospitals throughout the state, said Dalton, the hospital association spokesman. The association estimates that illegal immigrants account for about a third of the 1.3 million North Carolinians who have no health insurance.

Since those without insurance often can't afford to pay, the cost of their care is typically absorbed by hospitals and passed on to insured patients in the form of higher bills. The cost of health care for the uninsured in North Carolina was more than $1.4 billion in 2005, according to research compiled by Families USA, a national consumer advocacy group. Most of those costs were absorbed by hospitals.

"Hospitals are going to continue to serve [the uninsured] as best they can," Dalton said. "But serving them does come at a price, and that price is being paid by the hospitals and those who have insurance."

Nationally, about 35 percent of Hispanics are uninsured, compared with about 14 percent of non-Hispanic whites, according to research by the Kaiser Family Foundation and Pew Hispanic Center. Illegal immigrants are the least likely of all Hispanics to have coverage. A Kaiser/Pew survey released in 2003 concluded that 60 percent of the country's estimated 11 million illegal immigrants are uninsured.

Jerry Leon, human resources manager for Rifenburg Construction in Durham, has been trying for the past three years to get more of his Hispanic workers to invest in health insurance, with little success. As enticement, he offers an additional $1 per hour in wages to employees who sign up.

So far, however, just a few of the company's approximately 35 Spanish speakers have bought coverage.

Leon blames high premiums -- now at $400 per month for a single employee and $1,300 per month for a family.

"Most are here for the money, and to send money back to their country," he said. "They don't really want to invest in a health plan."

And if they get sick?

"A lot of them use the community clinics," Leon said.

Half are Hispanics

Piedmont Health Services, a network of six federally supported community health centers serving Orange, Chatham, Caswell and Alamance counties, estimates that half its patients are Hispanics. Piedmont provides urgent care and primary care, including prenatal visits for pregnant women.

Brian Toomey, Piedmont's chief executive officer, said 24 percent of Piedmont's budget is provided by the federal government. But the remaining 76 percent comes from patient fees, and Piedmont's clients are faithful about paying their bills, Toomey said.

The clinics, whose patients are mainly poor and uninsured, charge a minimum of $20 per office visit. Toomey said only 4 percent of patients do not pay. He said more than 16,000 of Piedmont's 32,700 patients are Hispanic.

"These aren't freeloaders," Toomey said. "People pay for the service. They pay willingly, and they understand their obligation."

Raymundo, 32, who left home in Mexico about five years ago, appreciates the affordable care his family gets at Piedmont's health clinics. He lives in Wake County with his wife, Gloria, 33, and their two daughters. All of them came into the country illegally.

Raymundo and Gloria work as cooks in a fast-food restaurant, where he said they earn enough to pay for routine medical and dental care at Piedmont. Speaking through an interpreter, Raymundo said the family pays $30 a visit to see the doctor or dentist. Gloria, who is expecting the couple's third child in August, was at a Piedmont health center recently to begin prenatal care.

In Mexico, she would not have received such care, Raymundo said. The family could rarely afford to see a doctor there, he said. If someone got sick, they relied on medicinal teas or home remedies.

Coming up with money for a $30 office visit is one thing. Paying thousands of dollars in hospital charges is another entirely.

A few years ago, when Gloria had a miscarriage and was admitted to WakeMed, Medicaid paid for her care. Raymundo said that he is grateful that Medicaid did so but that if Gloria had not qualified for emergency coverage, he would have tried to pay.

Hospitals find that uninsured Hispanics, like most other uninsured patients, often can't afford to pay their entire bill, Dalton said.

Case in point in Duplin

One hospital that has been hit hard is Duplin General Hospital in Kenansville, about 75 miles southeast of Raleigh.

The 101-bed nonprofit is the only hospital in Duplin County, a region of farms and poultry-processing factories. About 17.5 percent of the county's 51,000 people are Hispanic -- giving it the highest proportion of Hispanics of any county in the state.

In 2004, for the first time ever, Hispanic births accounted for the majority of babies delivered at the hospital, said Doug Yarbrough, the hospital's executive director.

The growth of Duplin County's Latino population has coincided with a rise in the number of uninsured patients treated at the hospital. In 2003, the hospital lost $2 million because of the cost associated with treating uninsured patients -- its first loss since at least 1996, Yarbrough said.

In 2004, the loss was $2.3 million. The loss was expected to be less in 2005, partly because the hospital received an $800,000 infusion from a Medicaid program that provides additional payments to hospitals serving large numbers of indigent patients.

So far, Yarbrough has been able to avoid trimming hospital staff or closing units. If the losses continue, however, he might have no choice.

"We can go on like this for a few more years," Yarbrough said. "But at some point you run out of cash, and that's when the problems really start."

USE OF ANONYMOUS SOURCES: The last names of some people who appear in this series have been withheld. With rare exceptions, it is The News & Observer's policy to fully disclose the names of news sources. For these stories, some illegal immigrants -- and in one case, an employer -- agreed to be interviewed only if they were not fully identified. We included their comments to help explain what's happening with illegal immigration in North Carolina.

Staff writer Jean P. Fisher can be reached at 829-4753 or jfisher@newsobserver.com.