When uninsured immigrants are hurt, who pays?
By Alan Bavley
The Kansas City (MO) Star, March 24, 2005
Caesar Sacaries-Barrios is lucky to be alive and to still be in the United States.
The 23-year-old restaurant worker is an undocumented immigrant originally from Guatemala. He barely remembers a car wreck in November that left him in a coma at North Kansas City Hospital.
He knows nothing about the estimated $250,000 the hospital has spent to keep him alive.
He's still unaware that the hospital faced with the possibility of rapidly mounting bills tried to fly him to his home country in a specially equipped plane while he was comatose.
That shows you just how expensive this guy's care is, said Chuck Chionuma, a Kansas City lawyer who has been fighting a legal battle to keep Sacaries-Barrios in the United States. They were willing to foot that bill just to get him back to Guatemala.
Shipping a patient home may be an extreme measure. But it's a sign of the frustration at many hospitals across the country as they care for growing numbers of poor, undocumented immigrants.
The immigrants often work at low-paying jobs that do not provide health insurance. They often do not qualify for government health programs, such as Medicaid, or are too fearful to apply.
Christina Vasquez Case, director of Alianzas, a University of Missouri-Kansas City initiative that works with the Hispanic community, said she understood how unpaid medical bills could frustrate communities, but said the American labor market had a role in creating the situation.
Undocumented workers get here, and within 36 hours of being here, the people who want to work, can work, Case said. That is the reality of it.
When undocumented immigrants show up at emergency rooms in critical condition, hospitals are ethically and legally bound to treat them.
It does seem to be a problem of growing dimensions, said Carla Luggiero, who handles immigration concerns for the American Hospital Association. At some point, our nation is going to have to grapple with the issue.
Officials at North Kansas City Hospital declined repeated requests to discuss its care of Sacaries-Barrios but issued this statement: We are glad that Mr. Barrios is recovering from his injuries, and we wish him well as he continues to progress during his recovery. At this time, we feel it's best not to provide any further comment.
The cost of caring for undocumented immigrants is impossible to calculate nationally because hospitals rarely track patients' immigration status.
But when the Florida Hospital Association polled its member hospitals in 2002, it received 700 reports of uninsured non-citizens who ran up bills totaling more than $40 million for childbirth, brain tumors, heart surgery and other care.
In counties that border Mexico, hospitals and ambulance services estimated that they spent more than $200 million in 2000 caring for undocumented immigrants who were uninsured
The problem is reaching deep into the heartland as well.
Luggiero says she regularly gets calls from states with growing immigrant populations, such as New York, New Jersey, Illinois, North and South Carolina and Kansas.
Immigrants have been streaming into southwest Kansas for years, attracted by jobs in the region's meatpacking plants.
In Dodge City, 30 percent to 40 percent of patients arriving at the emergency room of the Western Plains Medical Complex are undocumented immigrants, said Brian Roland, the hospital's business office director.
Most of them are uninsured, he said. We do have some folks who do what they can to pay, but a large majority does not.
Truman Medical Center estimates it spends at least $500,000 a year providing dialysis for eight kidney patients, all undocumented or resident immigrants who do not qualify for public programs such as Medicaid.
Because the patients are uninsured, the hospital has been unable to find any outpatient dialysis clinics willing to care for them.
Rather than force the patients to wait until they are critically ill to receive dialysis at the emergency room, the hospital schedules them for visits three times a week.
Several of the patients are young adults with families young children they're responsible for who are U.S. citizens. How do you say no to them? said Suzanne Meyer, Truman's director of social work.
Although Medicaid has provisions to pay for the emergency care of some immigrants, eligibility is just as limited as it is for other patients, said Anne Dunkelberg of the Center for Public Policy Priorities, a Texas-based advocacy group for people with low or moderate incomes.
You have to look like a (regular) Medicaid recipient in every way except for your immigration status, she said.
When Congress approved a new Medicare drug benefit in 2003, it included $1 billion that will be paid out over the next four years for emergency care to undocumented patients.
Dunkelberg said that the program would pay only pennies on the dollar.
It would be a little marginal bonus to hospitals, she said.
Most of the money will go to states with large numbers of immigrants, such as California and Texas. Kansas is scheduled to receive $1.1 million this year. Missouri would get $525,000. Sacaries-Barrios' care would absorb almost half that amount.
Sacaries-Barrios is recuperating at Integrated Health Services of Kansas City at Alpine North, a Riverside nursing home. His lawyers say the hospital is paying his bills.
A legal battle
Through an interpreter, Sacaries-Barrios said that he came to the United States about two years ago from Mexico. He worked as a restaurant cook and dishwasher, sending money back to his family.
The night of Nov. 17, Sacaries-Barrios was riding in a car with a friend. He remembers the car turning over, and he remembers feeling blood.
According to court documents, doctors at North Kansas City diagnosed Sacaries-Barrios as comatose and suffering head injuries and a ruptured spleen. They placed him on a ventilator to assist his breathing and fed him through a tube.
When the hospital transferred Sacaries-Barrios to Alpine North on Dec. 23, his condition had stabilized, but he was in a persistent vegetative state, incapable of conscious thought or behavior.
A month later, a hospital physician said that his condition had not changed and that his long-term prognosis was poor, court records said.
As the hospital worked to identify Sacaries-Barrios and look for family members, word of his case reached Spanish-language radio station La Super X, 1250 AM. Rosa Quintana, an account executive with La Super X, said hospital officials told her they intended to send Sacaries-Barrios to Guatemala.
Although Guatemala has public hospitals open to the poor, they do not provide the same care as U.S. hospitals, said Gustavo Lopez, the Guatemalan consul general in Chicago, who is familiar with Sacaries-Barrios' situation.
He wouldn't have the same assistance, Lopez said. That's the plain truth.
Quintana contacted Chionuma, who is an immigrant from Nigeria. He agreed to represent Sacaries-Barrios free of charge.
Chionuma said he met with hospital officials Jan. 26 and pleaded with them to let Sacaries-Barrios stay here. Hospital officials told him they were going ahead with their plan, he said.
Chionuma began legal proceedings in Clay County Circuit Court to prevent North Kansas City Hospital from moving Sacaries-Barrios. By mid-February, the hospital sent word to Chionuma through its attorneys that it had no intention of returning Sacaries-Barrios to Guatemala.
The federal Emergency Medical Treatment and Active Labor Act requires hospitals to screen, treat and stabilize anyone who arrives at an emergency room, regardless of income or immigration status.
It sounds to me that (North Kansas City) hospital at least met its stabilization requirements (with Sacaries-Barrios), said Steve Hitov of the National Health Law Program in Washington.
The real question now is: Where does he go? You can't discharge a person into the same danger or worse danger than they were in before.
In 2003 a Florida hospital flew a patient home to Guatemala after he had run up bills of more than $1 million. The man had come out of a coma but was severely brain damaged. A court later ruled that the hospital did not have a good plan for his continued care and should not have discharged him.
But it is exceedingly rare for hospitals to avoid giving legally required care to undocumented patients, said Gabrielle Lessard of the National Immigration Law Center in Los Angeles.
I think health-care providers try to do the right thing for patients, she said.
Many undocumented immigrants still stay away from hospitals or fail to apply for government programs because they are afraid their immigration status will be reported, Lessard said.
These are people who try not to use health services, she said. They only go to the hospital if there's no alternative.
Meanwhile, Sacaries-Barrios is making a remarkable recovery. By early February, he appeared to be regaining consciousness. By the end of the month he was out of bed and talking. He's thinking of returning home.
The man is coming back to life, Chionuma said.