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For Dr. Pat McColloster, she is one of the patients who got away.
He treated the 32-year-old woman in 1995 for a routine case of hypertension at Casa de Amigos, a clinic in the Harris County Hospital District system. Between her regular visits, the robust woman, a house cleaner from Mexico, discovered a lump in her breast. A biopsy at Ben Taub showed cancer, and she underwent a radical mastectomy.
The woman commenced a course of chemotherapy that lasted for several months, during which time she continued to see McColloster for her hypertension. Then she disappeared.
For more than a year the physician fretted over a patient who had always been a stickler for punctuality. Then, in 1997, he began volunteering on Saturdays at a charity health clinic for immigrants. On just his second week, the missing house cleaner showed up. Her arm was swollen to three times its normal size and her blood pressure was "out of control," he recalls.
The doctor chastised her for not keeping up with her treatments. He was outraged to learn that the woman, an undocumented worker, had been unable to continue because her gold card, the identification required for nonemergency care in the district, had expired. She had been denied a new one because of her inability to provide documents. McColloster says it is likely that the withholding of services caused her health to deteriorate.
"It was a distinct possibility that the cancer had recurred because she had not finished her full course of chemotherapy," he says grimly. "To have that interrupted because of an inability to get a gold card is, in my opinion, tragic."
Under state law, county hospital districts are required to provide care to "needy" inhabitants within their borders. Harris County, like almost all of its counterparts in the state, historically has offered subsidized nonemergency treatment to any county resident who demonstrates financial need. The district has never had a formal policy on undocumented immigrants but, in its silence, has offered a full range of services to county residents regardless of whether they are in the United States legally.
In recent years, however, undocumented immigrants have encountered obstacles. Clerks at the district's various registration centers had different ideas about what constituted requisite documentation. As a result, immigrant advocates charge, many of the county's neediest residents were left standing in the cold.
"We were concerned because there didn't seem to be any rhyme or reason to the district's policy toward immigrants," says Barbara Best, the health committee chair for the Houston Immigration and Refugee Coalition.
Under new leadership, the hospital district last year tried to establish a policy to bring uniformity to eligibility requirements. Instead of producing healthier residents, their efforts yielded a criminal investigation by District Attorney Chuck Rosenthal. Now, embattled hospital district officials are fending off possible jail time.
Looming behind these developments is a 1996 federal law meant to pull the plug on public assistance to noncitizens. Most hospital districts took a "don't ask, don't tell" approach to the law and quietly proceeded with business as usual. But Harris County officials pressed the issue and unwittingly opened a can of worms with implications that extend far beyond Houston's sprawl. The case marks an uneasy standoff between federal policy and local control, highlighting the combustible results when public health issues get mixed with the politics of immigration and use of taxpayer funds.
"[T]his is not a problem only of the taxpayers in Harris County. It is one for the region, if not the nation," says County Judge Robert Eckels.
In 1994, Texas, following the lead of other border states, sued the federal government for failing to control illegal immigration. That failure, said then-attorney general Dan Morales, cost the state hundreds of millions annually in public education, social services, criminal justice, incarceration and health care. Harris County and the hospital district joined as plaintiffs in the litigation.
Although the suit ultimately was dismissed, it underscored growing tensions between states and the federal government over who should foot the bill for immigrants. Today local officials are more apt to view undocumented workers in terms of their contributions to the economy, but they still slug it out with Uncle Sam for every dollar spent on health care for such immigrants.
"The issue is not for me whether the care is provided, because it will be provided. It's how it's billed and it's about who pays in the end," Eckels says. "It's the kind of cost that should not be borne totally by the local taxpayers."
The Harris County Hospital District is one of the largest public systems in the country, with two general hospitals, both with trauma centers, a rehabilitation and psychiatric hospital, 11 community clinics and other facilities. The need for its low-cost services is great in an area where more than 30 percent of the general population lacks medical insurance. The uninsured rate is double that for immigrants, according to the Washington, D.C.-based Center for Immigration Studies.
Immigrants represent more than half of Harris County's 1.1 million Hispanics. While the majority of them are here legally, the hospital district incurs significant expenses treating undocumented immigrants from Latin America and, to a far lesser degree, Canada, Vietnam, India and other parts of the world.