Paying the Price

Hospital district officials wanted a simple one-sentence policy on immigrant health care. What they got instead was a criminal probe and plenty of politics.

Citing attorney-client privilege and privacy exceptions to the Texas Public Information Act, Assistant County Attorney Sarajane Milligan, on behalf of the hospital district, refused to provide data requested by the Houston Press on the number of patients it serves and the costs.

County records show that undocumented immigrants accounted for 22 percent of the 48,909 inpatient visits and 25 percent of the 959,898 outpatient visits recorded in the district's fiscal year that ended in February. The vast majority of cases entered through emergency rooms at Ben Taub and Lyndon B. Johnson hospitals, says King Hillier, the director of legislative relations for Harris County and the district's former director of government relations.

The district racked up $67 million in costs treating undocumented immigrants in fiscal year 2001, representing 13 percent of the total budget. Of that $67 million, taxpayers contributed $59 million, or 88 percent; insurance and reimbursements through Medicaid and other programs accounted for 10 percent; patients kicked in the rest.

Casa Juan Diego, with its chained air conditioner, helps treat immigrants.
Deron Neblett
Casa Juan Diego, with its chained air conditioner, helps treat immigrants.
McColloster found out from former patients that the district turned away immigrants.
Deron Neblett
McColloster found out from former patients that the district turned away immigrants.

The district has struggled to stay solvent in recent years, in part because of declining reimbursements for Medicare, a federal program, and Medicaid, which is both federally and state funded. Reimbursements for the two programs dropped from $151 million in 1996 to $98 million in 2000. Meanwhile, taxpayers have had to pick up the slack.

An increase in the tax rate in fiscal year 2001 raised the local contribution to the district by more than $100 million, to $305 million of a $534 million total budget. Care to immigrants represents only a portion of that, but it's enough to make the issue contentious in a cash-strapped system.

Still, county officials argue that the costs would be much higher if the district did not offer undocumented immigrants a safety net. Without preventive and primary services, more would turn to already overburdened emergency rooms, says Dick Raycraft, the county budget officer. He adds that treatable conditions like diabetes and hypertension often develop into emergencies when not controlled under a doctor's regular care.

"You end up seeing them in the ER, when it's a more acute case and the costs are greater," Raycraft says. "You could have dealt with it in a clinical setting, and in the long term you avoid some costs and you've got a healthier person."

Most immigrants are here to work, often in high-risk industries or in service jobs where they are in close contact with the public, adds Eckels. The community has a vested interest in their health, particularly when it comes to containing contagious diseases like tuberculosis.

"Whether they're documented or not, they are residents of the county. They pay taxes in the county," Eckels says. "I don't think there's anybody who would just turn folks away and say, 'I'm sorry, just go home and die.' "

The weather-beaten frame house on Rose Street sags with age and the ravages of termites. The musty interior thrums with an air conditioner's metallic gasps. Three men -- one from China, the others from Latin America -- wait in silence to see the doctor on this typical morning at Casa Juan Diego, a center for immigrants near Washington Avenue and Shepherd.

A 50-year-old day laborer from Guatemala tells of trying to get a gold card more than a year ago because he was having difficulties walking. He says he was unable to prove county residency because he lived at a friend's apartment and the utility bills, lease and other documents were not in his name. He was later diagnosed with diabetes at Juan Diego, he says.

Pat McColloster looks right at home in the threadbare setting of the clinic, which runs on charitable donations. A tall, curly-haired man of 40 who wears jeans and a T-shirt under his white lab coat, he says that when he first came to work for the hospital district in 1993, there was no need for him to volunteer at Juan Diego. Back then, undocumented immigrants had no problem gaining access to the district's clinics.

Starting around 1996, the New Orleans native began to notice fewer and fewer Spanish-speaking hospital district patients but had no idea why.

When he began working Saturdays at Juan Diego, he saw many former patients and learned they were having trouble getting their gold cards renewed at some registration centers. District policy allows applicants to use a variety of documents to prove their identity, address and income, but in some cases clerks insisted on those that undocumented immigrants can't get, like a Texas driver's license, McColloster says. In other cases, the patients simply didn't have any of the requisite proof. His patient with breast cancer tried to renew at the North Loop Registration Center but didn't have a license, passport, picture ID from work, birth certificate or any of the other documents to establish her identity.

"So many of my patients were getting booted out of the system that I ended up taking off one day a week to do volunteer work" at Juan Diego, he says.

Hospital district spokeswoman Dinah Massie says she heard "gossip" to the effect that some registration centers were more exacting than others, but doesn't know if that was true. The apparent obstacles for undocumented immigrants dovetailed with a drop in the overall number of new gold cards being issued, from 205,000 in 1997 to 155,000 in 2000.

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