U.S. Hospitals in Business of Quiet Repatriation A Question of Post- Care for Immigrants

By Deborah Sontag

Pilar Conci contributed reporting.

*

High in the hills of Guatemala, shut inside the one-room house where he spends day and night on a twin bed beneath a seriously outdated calendar, Luis Alberto Jimenez has no idea of the legal battle that swirls around him in the lowlands of Florida.

Shooing away flies and beaming at the tiny, toothless elderly mother who is his sole caregiver, Jimenez remains cheerily oblivious that he has come to represent the collision of two deeply flawed American systems, immigration and health care.

Eight years ago, Jimenez, 35, an illegal immigrant working as a gardener in Stuart, Florida, suffered devastating injuries in a car crash with a drunken Floridian. A community hospital saved his life, twice, and, after failing to find a rehabilitation center willing to accept an uninsured patient, kept him as a ward for years at a cost of $1.5 million.

What happened next set the stage for a continuing legal battle with nationwide repercussions: Jimenez was deported – not by the U.S. government but by the hospital, Martin Memorial. After winning a state court order that would later be declared invalid, Martin Memorial leased an air ambulance for $30,000 and “forcibly returned him to his home country,” as one hospital administrator described it.

Since being hoisted in his wheelchair up a steep slope to his remote home, Jimenez, who suffered a severe traumatic brain injury, has received no medical care or prescription medication – just Alka- Seltzer and prayer, his 72-year-old mother said. Over the last year, his condition has deteriorated with routine violent seizures, each characterized by a fall, protracted convulsions, a loud gurgling, the vomiting of blood and, finally, a collapse into unconsciousness.

“Every time, he loses a little more of himself,” his mother, Petrona Gervacio Gaspar, said in Kanjobal, the Indian dialect that she speaks with an otherworldly squeak.

Jimenez’s benchmark case exposes a little-known but apparently widespread practice. Many U.S. hospitals are taking it upon themselves to repatriate seriously injured or ill immigrants because they cannot find nursing homes willing to accept them without insurance.

Medicaid does not cover long-term care for illegal immigrants, or for newly arrived legal immigrants, creating a quandary for hospitals, which are obligated by U.S. regulation to arrange post- hospital care for patients who need it.

The U.S. immigration authorities play no role in these private repatriations, carried out by ambulance, air ambulance and commercial plane. Most hospitals say that they do not conduct cross- border transfers until patients are medically stable and that they arrange to deliver them into a physician’s care in their homeland. But the hospitals are operating in a void, without governmental assistance or oversight, leaving ample room for legal and ethical transgressions on both sides of the border.

Indeed, some advocates for immigrants see these repatriations as a kind of international patient dumping, with ambulances taking patients in the wrong direction, away from first-world hospitals to lower-quality care, if any.

Hospital administrators view these cases as costly, burdensome patient transfers that force them to shoulder responsibility for the dysfunctional immigration and health care systems. In many cases, they say, the only alternative to repatriations is keeping patients indefinitely in acute-care hospitals.

“What that does for us, it puts a strain on our system, where we’re unable to provide adequate care for our own citizens,” said Alan Kelly, vice president of Scottsdale Healthcare in Arizona. “A full bed is a full bed.”

Medical repatriations are happening with varying frequency, and varying degrees of patient consent, from state to state and hospital to hospital. No government agency or advocacy group keeps track of these cases, and it is difficult to quantify them.

Many hospitals engage in repatriations of seriously injured and ill immigrants only as a last resort. “We’ve done flights to Lithuania, Poland, Honduras, Guatemala and Mexico,” said Cara Pacione, director of social work at Mount Sinai Hospital in Chicago. “But out of about a dozen cases a year, we probably fly only a couple back.”

Other hospitals are more aggressive, routinely sending uninsured immigrants, both legal and illegal, back to their homelands. One Tucson hospital even tried to fly a U.S. citizen, a sick baby whose parents were illegal immigrants, to Mexico last year; the police, summoned by a lawyer to the airport, blocked the flight.

Sister Margaret McBride, vice president for mission services at St. Joseph’s in Phoenix, which is part of Catholic Healthcare West, said families were rarely happy about the hospital’s decision to repatriate their relatives. But, she added, “We don’t require consent from the family.”

In a case this spring that outraged Phoenix’s Hispanic community, St. Joseph’s planned to send a comatose, uninsured legal immigrant back to Honduras, until community leaders got lawyers involved. While they were negotiating with the hospital, the patient, Sonia del Cid Iscoa, 34, who has been in the United States for half her life and has seven American-born children, came out of her coma. She is now back in her Phoenix home.

“I can think of three different scenarios that would have led to a fatal outcome if they had moved her,” said John Curtin, her lawyer. “The good outcome today is due to the treatment that the hospital provided – reluctantly, and, sadly enough, only in response to legal and public pressure.”

Unlike Iscoa and Jimenez, most uninsured immigrant patients in repatriation cases do not have advocates fighting for them, and they are quietly returned to their home countries. Sometimes, their families accept that fate because they are told they have no options; sometimes they are grateful to the hospital for paying their fare home, given that other hospitals leave it to relatives or consulates to assume responsibility for the patients.

Jimenez’s case is apparently the first to test the legality of cross-border patient transfers that are undertaken without the consent of the patients or their guardians – and the liability of the hospitals who undertake them.

“We’re the rhesus monkey on this issue,” said Scott Samples, a spokesman for Martin Memorial.

The average stay at Martin Memorial, a relatively tranquil hospital which features a palm frond design in its gleaming lobby floor and white-coiffed volunteers in its gift shop, is 4.1 days and costs $8,188. Patients rarely linger.

In addition to trauma patients, there are uninsured immigrants with serious health problems. “In our emergency room, we don’t turn anyone away,” said Carol Plato Nicosia, the director of corporate business services. “The real problem is if we find an underlying problem, and now we have six of them – six patients who showed up in renal failure and that we are now seeing three times a week for dialysis.”

“I don’t want to sound heartless,” Plato Nicosia said. “A community hospital is going to give care. But is it the right thing? We have a lot of American citizens who need our help. We only make about 3 percent over our bottom line if we’re lucky. We need to make capital improvements and do things for our community.”

Tax-exempt hospitals like Martin Memorial are expected to dedicate an unspecified part of their services to charity cases, and Martin Memorial devoted $23.9 million in 2006, about 3 percent, which was average for Florida, according to state data.

Jimenez was a very expensive charity case. In cases like his, where patients need long-term care, hospitals are not allowed to discharge them to the streets. U.S. regulations require them – if they receive Medicare payments, and most hospitals do – to transfer or refer patients to “appropriate” post-hospital care.

But in most states, the government does not finance post- hospital care for illegal immigrants, for temporary legal immigrants or for legal residents with less than five years in the United States.

Originally published by The New York Times Media Group.

(c) 2008 International Herald Tribune. Provided by ProQuest Information and Learning. All rights Reserved.