For some ill migrants, free care has a price
Some hospitals eventually send them out of U.S.
by Daniel Gonzalez - Aug. 3, 2008 12:00 AM
The Arizona Republic
When Fidel Delgado arrived at a Catholic hospital in Phoenix in mid-June after a heart attack, doctors performed life-saving bypass surgery, even though Delgado is an undocumented immigrant with no way to pay his medical bills.

Federal law requires hospitals to provide emergency care regardless of immigration status or ability to pay.

But once Delgado had been stabilized, officials at St. Joseph's Hospital and Medical Center faced a serious dilemma: As a hospital certified for acute, or short-term, care, St. Joseph's determined that it couldn't keep Delgado any longer. But the severely diabetic and obese man was still too sick to go home.

Sending Delgado to a rehab facility also was not an option because Medicaid would not pay for the care.

Transferring him to a hospital in Mexico could be traumatic: Delgado, 64, hasn't lived in his native country for more than 40 years.

The decision St. Joseph's would make initially - to send Delgado to Mexico - represents one of the most wrenching policy approaches taken in recent years as part of a state and national crackdown on illegal immigration.

St. Joseph's now sends an average of seven uninsured immigrants a month back to their native countries for treatment, often against the wishes of family members, hospital officials say. Before 2000, the hospital rarely transferred any patients out of the country, perhaps only two or three times a year, the officials said.

Not all patients who are sent back are undocumented immigrants. The hospital also is sending back legal immigrants who don't qualify for long-term Medicaid. Hospital officials attribute the practice to stricter laws and tighter controls at the state and federal levels that have made it harder for immigrants to obtain non-emergency Medicaid care, for which U.S. citizens are eligible. The hospital says the changes have forced it to transfer more immigrants to their native countries when they require long-term care and lack insurance.

The patients transferred back to their homelands typically have spent weeks and sometimes months at the hospital and have racked up huge medical bills that they cannot pay, officials say. The hospital bill for Delgado, for example, reached $837,950.

Some critics suggest that St. Joseph's, a non-profit hospital that is exempt from taxes and must provide some charity care, is simply dumping patients to save money. The hospital denies the allegation.

Immigrant advocates fear that other hospitals around the country will follow St. Joseph's lead as a way of dealing with the most vulnerable of the nation's 46 million people who lack health insurance. About 1.1 million people in Arizona are uninsured.

For the patients' families, the transfers can be devastating.

When members of Delgado's family were told that he might be sent to Mexico, they were shocked. His wife is a U.S. citizen, and all of his close relatives live in Arizona.

"He is going to die if he has to go to Mexico," said Delgado's sister, Rosa Aguirre of Phoenix. "He has no family there."


Others do the same

St. Joseph's is not the only Valley hospital that sends uninsured immigrants to Mexico for long-term care, but its number of transfers is much higher.

Maricopa Medical Center has sent five non-citizens out of the country for treatment since October, hospital officials said. Banner Good Samaritan Medical Center sent seven in 2007 and six the year before, officials said.

St. Joseph's officials said they don't track the numbers on an annual basis.

"These are not easy decisions," said Sister Margaret McBride, vice president of St. Joseph's Mission Services. "Our legal responsibility is to provide a safe discharge. Whether the family agrees or not, we have to provide for a safe discharge," even if that means out of the country.

The patients being transferred are typically either severely ill or have been severely injured. Like Delgado, many of them have lived in the United States for years, so transporting them to another country can mean uprooting an entire family. And hospitals, including St. Joseph's, don't track what happens to the patients after they have been evacuated.

"The problem is hospitals can't properly guarantee that the proper level of care will be provided," said Sonal Ambegaokar, the health-policy attorney at the National Immigration Law Center, a public-interest law group in Washington, D.C.

Several recent transfers have drawn intense media attention, especially in the Spanish media, and have put St. Joseph's hospital under scrutiny.


• In December, Jose Abraham Arvizu, an 18-year-old undocumented North High School student and a member of the Junior ROTC, died of a highly curable form of leukemia after St. Joseph's sent him to a hospital in Mexico. One parent of a North student called the boy's death "an absolute community disgrace."


• In May, the family of Sonia del Cid Iscoa, a legal immigrant who has been living in the U.S. for 17 years, went to court to block St. Joseph's from shipping the comatose woman back to her native Honduras. The hospital eventually agreed to allow Iscoa to remain at the hospital, and she later became well enough to go home.


• In June, St. Joseph's arranged to transfer Antonio de Jesus Torres Aguayo, 19, a legal permanent U.S. resident who had suffered a head injury in a rollover accident near Gila Bend, to a hospital in Mexicali, just over the Mexican border from California. But at the border, family members had to call for a Mexican ambulance to meet them, and officials at the hospital in Mexico gave conflicting reports about whether they knew Torres was coming.

Torres was later accepted at a hospital in El Centro, Calif., and a rehabilitation center in San Diego. California is paying his medical bills through an assistance program, according to his father, Jesus Torres of Gila Bend.

"It is outrageous. It's just a total lack of humane treatment for these people," Democratic state Rep. Ben Miranda said of the patient transfers. Miranda's west Phoenix district has many Latino immigrants.


Revising procedures

St. Joseph's officials say they have improved their procedures for transferring patients out of the country and are working more closely with Mexico's consul general in Arizona and other foreign consulates to avoid confusion and ensure that facilities in other countries can provide adequate care.

In the wake of the negative publicity, the hospital also has hired a public-relations firm to help address questions about the transfers and has appointed a panel of Latino leaders to look for possible alternatives.

In the meantime, the transfers continue. Joe Mislove, St. Joseph's senior attorney, said the recent growth in out-of-country transfers is the result of a surge in the Valley's undocumented population and a series of changes, dating back to 1996 federal welfare reforms, that have made it harder for immigrants to qualify for non-emergency Medicaid. The joint state and federal program, which pays for medical care for the poor, is known in Arizona as the Arizona Health Care Cost Containment System, or AHCCCS.

"We do not look for these opportunities," Mislove said. "Hospitals are increasingly seeing this as the only alternative."

The 1996 Welfare Reform Act restricted Medicaid benefits to legal immigrants, requiring them to wait five years after receiving a green card to become eligible. It also closed a loophole that had allowed many undocumented immigrants to receive Medicaid benefits, even though they technically were not eligible, Mislove said. That's because, prior to the law, immigrants had only to sign a paper declaring that they were eligible and to show documents indicating that they resided in the state, Mislove said.

"The focus was on residency vs. immigration status," he said. As a result, "chances were much more likely that you could qualify for benefits if you were undocumented."

In 2001, Arizona voters passed a proposition that expanded AHCCCS benefits to more people. The law absolved counties from having to pay for a medical-care program for indigents that had served as a safety net for immigrants, Mislove said. In 2005, Arizona adopted a federal law that required Medicaid applicants to verify their citizenship, further ensuring that ineligible immigrants did not receive benefits, he said.

Some states, such as California, have created their own programs with state tax dollars to continue providing benefits to immigrants. But Arizona has passed laws that further restrict benefits for immigrants.

Hospital officials say there are other reasons that St. Joseph's is shipping so many immigrants back to their native countries: The hospital receives a high number of severely ill or injured immigrants because of its trauma center. Many immigrants also choose to go to St. Joseph's because they know it is a Catholic-run hospital devoted to charitable care.

St. Joseph's mission statement says the hospital is devoted to "serving and advocating for our sisters and brothers who are poor and disenfranchised."

Last year, the hospital spent about $17 million on charity care for indigents, more than double the amount that it spent two years earlier, according to hospital figures. The 2007 amount represented 2.3 percent of its net patient revenues, which hospital officials said was significant and attributable to the growing number of uninsured.

St. Joseph's declined to provide its financial statements, but its parent company, Catholic Healthcare West of San Francisco, has done well in recent years. From 2005 to 2007, its operating income rose 43 percent, to nearly $300 million.


Bounced around

Fidel Delgado's hospitalization didn't start at St. Joseph's. On June 4, Delgado's sister, Rosa Aguirre, drove him to Maricopa Medical Center, the county public hospital, after Delgado woke up that night with chest pains and trouble breathing. On June 13, the county hospital transported Delgado to St. Joseph's for heart surgery because the county hospital doesn't have a cardiac surgeon, said McBride, who oversees St. Joseph's Missions Services.

The surgery was successful, but Delgado suffered kidney failure and needed dialysis as well as long-term treatment for other problems tied to his diabetes, McBride said.

St. Joseph's contacted Maricopa Medical Center, she said, but the county hospital refused to take Delgado back. So on July 8, a social worker at St. Joseph's called Delgado's wife, Noelia Guillen, in Phoenix and explained the situation. Delgado still needed more treatment, but since he was an undocumented immigrant without insurance, no facility in Arizona was going to take him. The hospital was going to send him to a facility in Mexico, perhaps in Nogales or Hermosillo.

On July 10, Noelia and her husband's sister met with a reporter and said they were afraid that Delgado wouldn't receive adequate care if he was transferred to Mexico and that he would die. Noelia also said she could not travel with her husband because she has epilepsy.

The next day, Noelia received another call from the social worker. St. Joseph's wasn't going to send Delgado back to Mexico after all. Instead, he was going back to Maricopa Medical Center.

Delgado's family was relieved. McBride said the hospital's decision not to send Delgado to Mexico had nothing to do with the interview Delgado's relatives had with the reporter. She said the patient was transferred to the county hospital only after officials there called and said they were willing to take Delgado back.

Warren Whitney, a spokesman for Maricopa Medical Center, said Delgado's condition had improved enough for the hospital to take him back.

"We'll continue to provide the care for him as long as he needs it," Whitney said.

At some point, he said, the hospital hopes to place him in a home setting.


La Voz reporter Angel Larreal contributed to this article. Reach the reporter at daniel .gonzalez@arizonarepublic.com or 602-444-8312.



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