The illegal effect: Who pays for treatments?

Every week or so, another person sends the same scathing e-mail to April Foran, who answers electronic communications for Parkland Health and Hospital System in Dallas. "Does our public health care system treat illegals better than American citizens? Yes it does!" it reads.

A then-pregnant military wife -- upset with Parkland's charity care for illegal immigrants -- wrote it in the fall, said Foran, director of corporate communications.

Some people read the e-mail and write to thank Parkland for providing health care to people who need it most. But others write to tell Ron Anderson, MD, Parkland's president and CEO, that he should force undocumented pregnant women out of the hospital to have their "anchor babies" in the street.

Welcome to the debate over U.S. immigration policy, health care style. Parkland exemplifies how some hospitals and physicians get caught in the middle. The hospital system is struggling to balance federal law, public opinion, a crushing and costly load of uninsured patients, and its responsibility to patients.

The hospital legally can't and doesn't discriminate between illegal immigrants and citizens, says Dr. Anderson, head of Parkland since 1982. Doctors have an oath to care for people, he said. Only the federal government can enforce immigration law.

The legal and ethical obligation to treat illegal immigrants puts extra pressure on a system already providing vast amounts of care to patients who can't pay.

Parkland, in majority-Hispanic Dallas County, and its 10 health centers accumulated $409 million in uncompensated care charges in fiscal year 2005. The system had $1.04 billion in revenues, including $329 million in local property taxes, during the same period.

The hospital and health centers had $100 million in uncompensated care costs for people who couldn't prove American citizenship between March 1, 2005, when it first started tracking this figure, and Sept. 30, 2006.

Undocumented women gave birth to about 30 babies every day at Parkland in fiscal year 2006, Dr. Anderson estimates. That's almost 70% of the 16,489 births at the hospital.

The federal Emergency Medical Treatment and Active Labor Act requires emergency departments to stabilize critical patients -- regardless of immigration or insurance status. A first-time EMTALA violation can earn a doctor and a hospital $25,000 fines each, Dr. Anderson said.

The federal government gives hospitals some money to help cover the cost of uninsured and undocumented patients, but not enough to cover EMTALA requirements. Federal reimbursements are tied to the percentage of the hospital's emergency patients not qualifying for Medicaid, the number of uninsured patients it serves, and more recently, the number of illegal immigrants cared for in the emergency department.

Illegal immigrants aren't eligible for Medicaid and Medicare.

"So the irony of this is there are prohibitions against providing care for these people because they're undocumented, on one hand," Dr. Anderson said. "On the other hand, the federal government pays for it and encourages you to take care of them and will penalize you very smartly if you don't take care of them."

It's difficult to estimate the cost of charity care for illegal immigrants. The vast majority of hospitals do not collect patients' citizenship data, said Carla Luggiero, senior associate director of federal relations at the American Hospital Assn.

The research firm RAND Corp. estimates that federal, state, and local governments spent $1.1 billion on health care in 2000 for illegal immigrants between the ages of 18 and 64. The figures were extrapolated from a survey of almost 2,400 adults in Los Angeles County in 2000 and 2001.

Only in the last 12 to 18 months have hospitals begun to estimate the value of the care they provide to illegal immigrants.

Their efforts were spurred by the Medicare Modernization Act of 2003, which included $250 million a year between 2005 and 2008 to help pay for emergency care for illegals. The funding formula for this money, known as Section 1011 funds, is heavily influenced by immigrant patient population estimates.

To be reimbursed, hospitals estimate the value of emergency care they provide to illegal immigrants each quarter. Parkland staff have been watching for certain signs -- such as not having a valid Social Security number -- to calculate its Section 1011 bill.

"We've been billing [the government] more and more and more each quarter. But with each quarter, we get less and less money," Dr. Anderson said. This is because more hospitals are asking to be repaid from a limited pool of money. Dr. Anderson expects to bill about $8 million in 2006 but only to receive about $600,000.

Other public hospitals in border states are in a similar situation.

For example, the two Scripps Mercy hospitals in San Diego and Chula Vista, Calif., requested $1.6 million in Section 1011 funds in fiscal year 2005, but only received $296,000, according to spokesman Don Stanziano.

Dr. Anderson said the reimbursements help, but they could help more. "The amount of money that they put in this was really an apology for poor policy. But it's at least a step," he said.

10-hour days, 10-minute lunches

A nurse shouts "Maria! Martinez!" to a room of more than a dozen people waiting patiently for their appointments at Parkland's East Dallas Health Center. Some have children at their sides. Some may have waited two or three months to get in the door.

On the center's seven floors, patients can have prescriptions filled, have a pediatrician examine their children, talk to a social worker and more.

"An individual really can have all of their physical and emotional needs met there," said Marcene Royster, director of community services for Parkland's health centers.

Prevention is the mantra of the centers. Patients receive primary care, but there are also dieticians, counselors, and, in certain facilities, psychologists and psychiatrists.

Noel Santini, MD, is one of six internists at the East Dallas Health Center. He's the lead internist for adults and has been working here since he finished his residency at Parkland hospital 10 years ago.

About 65% of the people Dr. Santini sees are Hispanic. Next are African-Americans, then a mix of Vietnamese, Laotians and Caucasians. The health center has been in this building for 11 years, but it started as a facility to care for refugees during the Vietnam War.

Here the health needs of illegal immigrants are evident.

Dr. Santini's pace is steady. He arrives at 7:30 a.m., takes 10 minutes to eat lunch, and often works more than his allotted eight hours. There is no shortage of patients. The clinic had 43,766 patient visits in fiscal year 2006.

When he hears people criticize immigrants for crowding American hospitals, Dr. Santini shrugs it off. "I try not to pay too much attention to that. I come here, and I do the opposite of what they're saying, and I feel good about it."

Anyone who thinks immigrants are getting a free ride in America needs to spend a day with an immigrant and learn what his or her life is really like, Dr. Santini said. In his 10 years, he has found that many of the symptoms that bring people to the health center are related to the stresses of leaving family members behind, learning a new language, adjusting to a new culture and making a living.

"We identify depression every single day," Dr. Santini said.

Forts on the frontier

For Texas, 18 of 495 hospitals -- including Parkland -- provide more than half of the charity care, Dr. Anderson said. Thirty-two others provide most of the rest.

"Those places are kind of like sentinel forts on the frontier," he said. "And it just seems like they're under siege."

The U.S. needs to create better insurance or better infrastructure to care for people, here legally or not, Dr. Anderson said. "Right now policymakers are not doing either. I'm pretty pragmatic. I'll take funding for my hospital if you're not going to give us insurance. But give me direct funding and let me take care of these folks."

Congressional attention this year focused on the broader issue of how to control illegal immigration. Lawmakers passed a measure to spend $1.5 billion to build a 700-mile, double-layered fence along the Mexican-American border.

Dr. Anderson said he wasn't sure the law would help reduce Parkland's illegal immigrant patient load. The federal government should either enforce immigration laws at the workplace or the border, or it should create a guest worker program with a provision for the purchase of health insurance, he said.

Regional funding of public hospitals, beyond the county line, would be a good idea for Texas, Dr. Anderson added.

Billing Mexico

Dallas County's Commissioners Court wishes it had the authority to make Mexico and other countries pay for some of the health care their citizens receive at Parkland.

The five-member panel could vote as soon as this month on an unusual proposal to send a bill to Mexico for the $748,000 in charges 124 of its citizens racked up at Parkland between June 1 and Dec. 31, 2005. A handful of other nations would also get bills.

People who need emergency treatment -- regardless of their legal status -- should be able to go to the hospital, especially for infectious diseases, said Margaret Keliher, immediate past CEO of the court.

But, "this burden can't be on the back of the Dallas County taxpayers," she said.

Foreign countries aren't the biggest source of Parkland's uncompensated care. The system spent $21.4 million on care for uninsured Texans who live in adjacent counties. The Dallas county commissioners sent bills to those counties in July.

Keliher, who left the commissioners court at the end of last year after losing her re-election bid, said she doesn't expect Mexico or other countries to send checks to Dallas County. But she and the remaining commissioners would like to see some effort.

"If I got to be king, I'd change [the Mexican] economy for them and let [people] stay there where they'd like to be anyway," Keliher said.