Catastrophe in Care

Hospitals are being crippled by the costs of treating migrants--and that could be just the start of an immigrant-related health crisis

If you drive along Southern Arizona's border with Mexico long enough, you might see a lone illegal wandering the desert. Or maybe he's hunched at the roadside sipping water from his milk jug. What's he doing there, and where are his compatriots, the people he broke into the country with?

The uninformed might ask those questions, but those who live with the daily invasion across our open borders can make a pretty good guess what's happening. The fellow got bounced from his group by the coyote-guide. Two transgressions will get an illegal cut loose with certainty: Either he can't pay, or he shows signs of tuberculosis.

You think these coyotes are fools? They don't want some hollow-eyed lunger hacking and coughing blood on them. So it's adios, pal, and now you're America's problem. But they know that already. Every illegal realizes that if he makes it to an emergency room in Southern Arizona, or anywhere around the country for that matter, he can get treatment, free of charge.

It's federal law, and has been for 20 years. In its evolution, the policy has become a kind of federal health insurance program for illegals, and its rising costs are eating up resources that could otherwise go to poor and uninsured American citizens. It has created a financial nightmare for border hospitals and contributed to cutbacks in services at Tucson hospitals.

Is this an outrage? A scandal? Some think it's both. But going back to our active TB sufferer, here's something even worse: The guy can't get treatment anywhere, goes underground and takes a job at a restaurant in Tucson or L.A., and coughs his way to infecting scores of others.

Talk about a Hobson's choice. But as with everything in the ongoing crisis of illegal immigration, the hard choices would largely evaporate if the federal government fulfilled its constitutional duty and took control of our border.

The threat illegal immigration poses to American public health plays out every day at Arizona's hospitals. Until recently, the issue remained only marginally public, a problem medical people batted around among themselves, not with the media. Even today, several hospitals contacted for this story declined comment.

The Copper Queen Hospital in Bisbee, one of the hardest hit, helped break that barrier when CEO Jim Dickson began returning reporters' calls, even though the subject, as he puts it, has become "like the third rail. You don't want to touch it."

But his problem had grown severe. Dickson's uncompensated costs for treating illegals rose from $35,000 in 1999 to $450,000 in 2004. His total shortfall now sits at about $1.4 million, a hefty deficit for a 14-bed hospital. To make ends meet, he had to close, in June 2000, the Copper Queen's long-term care facility, and cut back on staff and hours, forcing some employees to take second jobs to survive.

The hospital has seen a ray of light, however. In the first months of 2005, the Copper Queen has gone back into surplus, in part because more illegals are in Border Patrol custody when brought in to the hospital. That means the Border Patrol must reimburse the Queen for the cost. In the past, agents would drop injured illegals not in their custody at the ER and take off, sticking the hospital with bills that never got paid.

Another reason for the decrease, says Dickson: the Minuteman Project.

"It's been terrific for us in April," he says, cutting down on the number of people coming across and therefore the number requiring ER treatment. Dickson says the hospital wrote off about $6,000 in losses in April this year, compared to about $35,000 in April 2004.

The central issue, though, remains in place--the hospital has had to scale back health services to American citizens to treat illegals. Bisbee isn't alone.

The most comprehensive study on the subject found that 24 counties in four states bordering Mexico wracked up $190 million in unpaid emergency medical bills caring for illegals in the year 2000. The study, commissioned by the U.S.-Mexico Border Counties Coalition, found that California spent $79 million of that; Texas, $74 million; Arizona, $31 million; and New Mexico, $6 million.

Bear in mind that these numbers, the best available, are from 2000. We can assume, with increasing rates of crossings since then, the costs are considerably higher today. Nor do the above figures take into account non-border counties. Treating illegals in Maricopa County costs as much as $50 million a year, according to an estimate used by Republican Sen. Jon Kyl. Nationally, American hospitals lose $1.45 billion a year.

The Medicare reform bill passed in 2003 allocated $1 billion to reimburse states for federally mandated ER care given to illegals--about $45 million a year of that to come to Arizona over four years. But even that, some hospital staffers say, is little more than a Band-Aid on a huge problem.

Ruth Kish, director of patient care services at Copper Queen, expects that under the repayment formula, her hospital will receive only 10 cents of every dollar they spend on illegals. "But every bit helps," says Kish.

Another factor: The counties in the above-mentioned study spent an additional $13 million in 2000 on emergency transportation, such as helicopters and ambulances, to pick up illegals injured after sneaking across the line.

The Bisbee Fire Department's ambulance responds to about one of these calls a day during the summer, says Chief Jack Earnest. Asked how many of these patients pay up, Earnest wasn't sure, and recommended contacting the billing office in Sierra Vista. The billing office knew exactly how often illegals pay their ambulance bills--never.

But there's another category--Mexicans injured in Mexico who call American ambulances for help. By federal law, they have to respond, which makes Bisbee's Copper Queen the trauma center of choice for Sonora's northern frontier.

The calls come from Naco, Sonora, the town across the line just south of Bisbee, where, in spite of widespread poverty, cell phones are popular, and everybody knows the Americans are bound by law to treat them.

"When we get a call we go, and we don't ask where the person's from," says Earnest. Naco residents needing care go to the port of entry and declare an emergency to American officials. When they're waved through, they're transported to the Copper Queen's ER in Bisbee's ambulance, or they drive themselves in private cars.

The policy is called Compassionate Entry, and it applies to hospitals up and down the line. The Copper Queen averages about five such cases a month. Some abuse the privilege, says ER Manager Josie Mincher.

She's seen Compassionate Entries with bad sore throats and others who aren't sick at all. One pregnant girl landed in the ER recently complaining of morning sickness.

Most are seriously sick, though, and the staff rushes to help, "because that's what we do," says Mincher. But it doesn't take much to blow the budget. "Just walking in the door is $400," says Mincher. "It's not unusual to have one UDA (undocumented alien) cost $5,000, and we know we're not going to get that back. We're playing with monopoly money here."

Here's an example of how one patient can wrack up a huge bill:

A young Mexican man had a bad auto accident across the line and was taken to Douglas' Southeast Arizona Medical Center with severe neurological problems. After being stabilized there, he was transferred to Barrow's Neurological Center in Phoenix.

He spent a costly month there, courtesy of the Center, and was transferred--with a tracheotomy tube in his throat and supplies to clean it, also provided gratis by Barrow's--to a hospital in Hermosillo. That facility kept him less than a day before releasing him to his home in Naco. But for reasons no one can explain, the Hermosillo hospital kept his trach kit and cleaning supplies.

As a result, he became septic--a bad infection--and came through the Naco port under Compassionate Entry to the Copper Queen. He spent three days there, then the staff sent him off, with more free supplies, to a clinic in Agua Prieta for continued care.

How much did this fellow cost the American health care system? A figure of a quarter-million dollars would surprise no one. Cost to the Copper Queen? Almost $6,000, and they got none of it back.

Northern Cochise Community Hospital is in Willcox, far enough from the border that it doesn't get patients crossing the line for health care. But that doesn't mean it escapes the invasion.

CEO Chris Cronberg loses about $100,000 a year caring for illegals, mostly those injured in traffic accidents when their loaded vehicle flips while speeding north. "It's not make or break for us," says Cronberg. "But as a small hospital, we depend on cash, and those are dollars that aren't coming in, so it has an impact."

The same is true at Sierra Vista Regional Health Center, according to Vice President Marie Wurth. She expects the hospital to lose $250,000 this year treating those who jump the line, get hurt doing it and don't pay their bills.

The big squeeze is on in Tucson, too. Tucson Medical Center loses an estimated $4 million every year treating illegals.

The corresponding figure at UMC, which includes some foreign nationals, was $3.5 million for fiscal 2004, a $2 million increase from the previous year. Part of that is attributable to UMC, in July 2003, becoming Tucson's only Level One trauma center, meaning it saw the most serious cases.

Chief Financial Officer Kevin Burns says the hospital's re-payment rate for treating illegals is about 5 cents on the dollar. "It's very expensive for us and continues to grow," says Burns, who says many illegals, as well as uninsured Americans, use his ER like a primary care physician. "We hear anecdotally that people come here from across the border because they know they can get cared for, and if they present at the ER, they can get that care at no cost."

The federal law that put the hospitals on the hook for the medical bills of illegals goes by the acronym EMTALA--Emergency Medical Treatment and Active Labor Act. It says that anybody who shows up in an ER must get screened, treated and stabilized, regardless of citizenship or ability to pay.

But since its passage in 1985, the definition of emergency has evolved to include just about anything, and because Congress didn't fund the requirement, hospitals have had to eat the costs as word has spread that the federal goodie wagon is parked at the ER door.

In cities with huge illegal populations, such as Los Angeles, the effects have been disastrous. In its spring 2005 issue, the Journal of American Physicians and Surgeons reported that between 1993 and 2003, 60 California hospitals closed because, for several reasons including EMTALA, half of their services became unpaid.

Another 24 are near closing, says author Madeleine Pelner Cosman. She also writes that in 1983, before EMTALA, L.A. County put together a trauma network that was "one of America's finest emergency med response organizations."

A mere 22 years later--again, in part because of EMTALA--Cosman says the system is coming apart, with most trauma hospitals having left the network, along with physicians, surgeons and others.

The law has caused a similar situation in Tucson, on a smaller scale. "With EMTALA, the government created an unfunded national health insurance program, and it has caused real problems in this community," says Dr. Herb McReynolds, who works for a company that manages the ER department for St. Mary's Hospital, which treats a large number of illegals.

Lawmakers wrote the legislation to prevent patient dumping--in which one hospital refuses to accept, say, an uninsured woman in labor, telling ambulance personnel to take her to the county hospital instead.

It stopped that practice. But it has caused a big increase in the amount of un-reimbursed care that hospitals provide, and in McReynolds' words, "made physicians rethink their careers and lifestyles."

"The price of it has come over time, because after so much uncompensated care, it forces physicians off our call list," says McReynolds. "Physicians have a practice to go to the next day and a family, and ask themselves, do I really want to be up at 2 a.m. providing care when I won't get comp, and I can still get sued?"

Some docs have removed themselves from on-call lists by going to work at outpatient surgical centers not affiliated with a hospital. Others stay on call, but limit the amount of time they're available. A neurosurgeon might take call one day a week, and that satisfies the law. EMTALA says that you must provide a reasonable amount of coverage, without being strict or specific about how much that is.

McReynolds says that EMTALA--in tandem with the malpractice crisis--has caused the loss of medical coverage at many hospitals around the country and in Tucson, including St. Mary's.

"Several years ago we had five neurosurgeons on staff here, and now we have two," he says. "We had hand surgery coverage every day, and now we have it one week a month. We used to have full ob-gyn coverage, and now they've left and gone to TMC. We have no ob-gyn and one gynecologist on staff covering emergencies one day a week."

With docs all over Tucson running for cover, trying to stay off call and away from ERs, the variety of emergency health care available to Tucsonans has seriously diminished. And here's the most maddening irony of all: The feds now reimburse American hospitals for treating non-paying illegals, but not for treating American citizens. Exception: Those eligible for care under Federal Emergency Services, a fairly restrictive program.

For a year and a half now, UMC has approached non-paying illegals in a novel way--it actually reports them to immigration officials.

"Some people find that cold, but we have a responsibility to protect this charitable asset (hospital)," says CFO Burns, adding that UMC's status as a public entity requires a different approach. "Our belief is that to the extent people have ability to pay, we expect them to."

After triaging and stabilizing an ER patient, the hospital sets out to learn who that patient is, and how he or she plans to pay. To those who are uninsured and underinsured, the hospital offers the option of applying for its innovative Charity Care program. Under it, the hospital charges the patient the same rate it would receive for that service from Medicare, a possible reduction of up to 70 percent.

Patients unable to pay at that discounted rate are eligible for further discounts that can tear up the bill entirely. To apply for Charity Care, the patient need only return to the hospital with a W-2 or other documents. Those who cooperate and return with the required documents don't get reported to the feds.

But the hospital does report those who take the medical care and run. How many illegals cooperate with this generous offer? Ten percent.

Burns says UMC began reporting the 90 percent who don't pay in November of 2003. So far, they've reported 565 persons. Why start reporting?

"Maybe a bit of it was born of frustration because people use our resources and make no effort to work with us and pay," he says. "Even if part of the population doesn't pay, I still have to hire new people and buy and upgrade equipment, which costs $15-$20 million a year. When you have these strains on resources, from foreign citizens and as well as Medicaid patients, you have to manage cash flow very carefully."

As with most issues related to the illegal invasion, those who live along the Mexican border, the scene of the crime, have the best view. Where health issues are concerned, it's not a pretty sight.

Residents say they've come across ground dotted with discarded pills, syringes containing nobody knows what, and used needles. Some report riding horses along creek beds, popular pull-up areas for groups heading north, and finding 70 or 80 piles of human feces, some of it blackened and running with blood.

It's as disgraceful as it is disgusting--and it raises a question: What happens when rain washes all this into the water supply? Is it a threat to spread diseases such as hepatitis? Some believe it might be.

What happens when cows drink from these contaminated creeks? And what happens when this constant flow of Third World humanity goes north, fanning out all across Arizona and the country? What kind of diseases do they bring with them?

ER workers like Mincher live with that question every day. "We protect ourselves best we can," she says, "but if somebody comes in with a contagious disease, I might as well buy the farm, because I don't know what it is. A lot of times, they don't know what they have either. If they came off a ranch in southern Mexico, they've had no immunizations, no health care, nothing."

Most of what she sees at Copper Queen--around 75 percent--is orthopedic, falls suffered while jumping fences, for instance. Dehydration, too. Some of these are pregnant women nine months along, who, in Mincher's words, "are so desperate to have their babies born in the U.S., they'll do whatever it takes."

She sees cardiac-related cases among illegals who've been given crack, methamphetamine or speed by their coyote so they can keep walking. But she's also treated illegals with active chicken pox, tuberculosis, all varieties of hepatitis and AIDS.

The Web and print media are full of stories about the diseases illegals carry, and their effect on American health. But some writers make alarming claims with sketchy evidence at best. In the cases of two diseases, however--Chagas and tuberculosis--the evidence is clearer that they're indeed coming across our border.

Chagas, a potentially fatal illness spread by contact with the feces of the reduviid bug, called the "kissing bug," is prevalent in South and Central America. Fifteen million people in that region are infected with the parasite, and 50,000 die of it every year, according to the World Health Organization. A person can be infected for 10 or 20 years or more before showing symptoms, making it particularly insidious. At its most severe, the disease can cause the heart to fail, and literally explode.

In the United States? Louis Kirchhoff, of the University of Iowa Medical School, estimates that between 80,000 and 120,000 Latin Americans with Chagas live here. Matching prevalence studies and immigration numbers, Kirchhoff figures about 10 Chagas-infected persons entered every day from Mexico alone in the 1990s.

The disease can be transmitted four ways, but for Americans, the most worrisome is the blood supply. In the United States overall, the chance of contracting Chagas from a blood transfusion is small, one in 25,000, according to David Leiby, a research scientist at the American Red Cross in Washington.

But in cities with high populations from Latin America, the numbers fall to much riskier levels. In Miami, for example, the chance is one on 9,000. In L.A., 1 in 5,400.

Researchers have confirmed seven cases of people contracting Chagas through blood transfusions--five in the U.S., two in Canada--and they say the number of unknown cases is probably much higher.

"A rate of one in 5,400 is something we're concerned about," says Leiby, adding that the FDA is still a few years away from a useable blood-screening test. "Chagas is overlooked by the health care system in the United States. Our physicians aren't aware of it and wouldn't recognize it in most cases."

Tuberculosis, which also shows up in high rates in Mexico, is migrating north as well. Many assume a place like Cochise County, right on the border and overrun by illegals, would have a high incidence of TB. But it doesn't, says Edith Sampson, of the Cochise County Health Department. "The immigrants only pass through here on the way to Atlanta, or whatever city they're going to," she says.

Exactly the problem--which is a big reason why 53 percent of the TB in the United States in 2003 was among foreign-born persons, up from 29 percent in 1993, according to the Centers for Disease Control. In L.A., again because of its huge illegal population, the figure is closer to 80 percent.

Only 15,000 Americans suffer from active TB, the only dangerous kind because it can be passed to someone else, usually by coughing and expelling the bacteria from the throat or lungs. That's a small number, but the New York Academy of Sciences estimates that each victim will "infect 10 or 20 or more people--in whom the disease will likely remain latent, creating the potential time-bomb effect."

The State Health Department says that Arizona had 295 reported cases of active TB in 2003, a jump from the previous year. Why the increase? More of the disease was found among kids under 5 years old and prisoners. The latter were mostly Immigration and Customs Enforcement detainees--in other words, illegals.

Sixty-eight percent of Arizona's foreign-born TB cases are from Mexico, says state health. Will TB return to the United States in a big way?

It hasn't yet, says Lee Reichman, executive director of the New Jersey Medical School's National Tuberculosis Center. But he adds that with globalization--the ability to get around the world in 20 hours--and because "we can't stop people from getting in to this country, no matter how hard we try," the potential exists for a new epidemic.

His particular concern is with multi-drug-resistant TB, fatal in 60 percent of cases. This strain requires a long regimen of costly drugs that illegals are unlikely to take, or have access to. Arizona has a small number of MDR-TB cases, and all of them in the past five years have been among foreign-born persons.

"The reason you haven't heard about TB here is that good public health is working," says Reichman. "People who are symptomatic go to physicians, and the physicians don't ask questions. As soon as you have to ID yourself, or say we're going to send you back to Mexico, these people go into hiding and spread more TB. Any physician who cares about being a physician isn't going to ask those questions, because he took an oath to treat sick people."

The Copper Queen's Rush Kish says that under Medicare reimbursement guides, her hospital cannot ask patients if they are in the country illegally. But how do you bill the feds to get money back for treating illegals if you can't ask if someone is illegal?

Well, you play a little Orwellian word game, probing around the issue with a list of government-approved questions, then make educated assumptions. But the illegal holds the trump card, because he can refuse to answer every question. "We don't know yet what evidence Medicare will accept when we apply for reimbursement," says Kish. "But at least we can begin documenting the enormity of this problem."

The question isn't whether those with genuine emergencies should get treatment. Of course they should. In Naco, residents have no access to ER care and many would die if they didn't get to the Copper Queen. The real question is: Who pays?

Rev. Tom Buechele, pastor at St. John's Episcopal Church in Bisbee, thinks it's appropriate for the federal government to keep ponying up, as long as American companies "maintain their illegal trafficking in human labor."

"Until we have comprehensive immigration reform, we need to bear the health-care costs for undocumented workers, whatever those costs are," says Buechele, who, for almost a year now, has been running a free monthly clinic in Naco, Arizona, catering to the poor and uninsured on both sides of the line.

Although they talk a different language, politicians, even Republicans, promote policies that further Buechele's liberal vision. They boast to constituents that they've saved border hospitals by pushing through the Medicare reimbursement plan, which provides a relatively small amount of money over four years.

But that's another Hobson's choice, which is to say no choice at all. What do you do, let hospitals go under? Kyl, who pushed to get the reimbursement money, says an emphatic no.

"If we want those ERs to be there for us, then we'd better keep them in business," says the Arizona senator. "If our hospitals are required by federal law to treat anybody who comes into the ER, and the federal government has failed to control the border, then it's appropriate for the government to reimburse these hospitals."

But some argue that the system as it stands now, with EMTALA firmly in place, is rigged to produce two results: The federal treasury will remain wide open to illegals, and that all but guarantees that more and more of them will bust the line to get here.

After all, this is the end of the rainbow for them, where jobs await, education is free, health care is free. Who wouldn't come? And the more they come, the more American health suffers--from such diseases as Chagas and TB, further cutbacks in hospital services to American citizens, and even possible closures.

Where's the compassion in that? Copper Queen ER nurse Josie Mincher, herself Hispanic, puts her health, and possibly her life, on the line to treat illegals. Listen to the emotion in her voice as she describes what that's like:

"I go to work every day feeling like I'm on a torture wrack. My heartstrings get pulled in one direction by these sick people I want to help. Because I'm Hispanic, I know how they live. And I'm pulled in the other direction, too, thinking that if our hospitals aren't around, where do I take my own kids?

"But we have to treat them because of EMTALA. It says that anybody who comes within 250 yards of an ER gets treatment. What would happen to Safeway if the law said anyone who comes within 250 yards of the store gets free food? They'd go out of business. Well, we're a business, too."

Mincher's solution? "Send the bills to Mexico. If it affected them financially, they might do something about all these people coming across. My grandparents came here legally, and it took a long time and a lot of money. They respected the law. These people just walk across now. They weren't brought up the same way."

Burns at UMC says he wants the U.S. and Mexican governments to work together to find a solution. But, as Kyl cautions, don't expect any breakthrough soon. Mexico benefits far too much from our illegal immigration nightmare--in jobs for its citizens and cash sent home--to step up with money to care for its own people.

Until the border brought under control and the invasion stopped, we'll continue to pay the bills of people who illegally tiptoed across the line in the dead of night.