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.

Meanwhile, from 1998 to 1999 Casa Juan Diego documented a 400 percent increase in the number of people seeking medical services at its clinic. Mark and Louise Zwick, the center's co-founders, were unable to provide specific data on the number of patients, but both assert the situation deteriorated.

"Medical services to the Spanish-speaking in Harris County are in a state of crisis," Louise Zwick wrote last year in the Houston Catholic Worker, a newspaper published by Casa Juan Diego. "[P]eople come from all over Houston asking us to help them get a gold card. They are desperate."

There was plenty of desperation to go around. By the end of 1999 the hospital district itself was in a state of crisis, with day-to-day operations threatened by a looming multimillion-dollar deficit. Longtime CEO Lois Jean Moore had stepped down. All eyes turned expectantly toward a man who soon would arrive from San Antonio to take the reins of the beleaguered system.

Guest inherited a deficit-plagued hospital district.
Guest inherited a deficit-plagued hospital district.
Finder says he never dreamed there would be criminal implications from the statute.
Deron Neblett
Finder says he never dreamed there would be criminal implications from the statute.

John Guest was 51 years old when he arrived in Houston last year, having spent half of his life in Bexar County's University Health System, the final 16 years as president. The fact that the Bexar County system had built up huge cash reserves made Guest appealing to county officials determined to pull the district out of its budgetary abyss. At the same time, his conversion to a community health model that focused on prevention and brought medical care to the city's barrios appealed to champions of the poor.

Houston activists met with the new CEO to discuss what they found to be erratic handling of undocumented residents. Best, of the Houston Immigration and Refugee Coalition, pointed out that the district's lack of a policy on undocumented immigrants contributed to the confusion at the five eligibility centers. She found him receptive to their concerns.

"He basically understood that there wasn't a clear eligibility policy and said he would consider the issue," she recalls.

Guest, who declined comment to the Press, asked board members at a December 7 meeting to vote on a modest reform. It read: "An applicant's citizenship or immigration status will not be considered in determining residency."

Immigrant advocates, including the Zwicks, McColloster and University of Houston immigration law professor Joe Vail, attended the meeting to urge support for the measure. The issue quickly dominated the proceedings. Minutes show that Larry Finder, chairman of the nine-member board, was wary of doing anything that would incur the wrath of county commissioners, who controlled the embattled district's purse strings. He asked if the provision would open the floodgates for immigrants into the system.

A lawyer and former prosecutor, Finder also had legal questions. Then-county attorney Michael Fleming had recently brought to his attention a 1996 federal law aimed, in part, at cutting off public benefits to undocumented immigrants. Prior to the meeting, Finder asked the county attorney whether Guest's proposal would violate the Welfare Reform Act and jeopardize federal funding for district programs like Medicaid.

"The county attorney didn't have an answer," Finder recalls.

Finder recommended to the board that it seek a state attorney general's opinion on the legalities of the proposed immigrant policy. By a one-vote margin, the board voted to table the provision pending further clarification from Attorney General John Cornyn.

Today, Finder says he was simply trying to do the responsible thing for the district. He declines to discuss his personal views on what kinds of treatment the hospital district should extend to undocumented immigrants, calling his opinions "irrelevant." He does concede that his decision to seek an A.G.'s opinion proved fateful.

"At no time did I or anybody else in that room, that I know of, ever think that there would be criminal considerations associated with this federal statute," Finder says. He adds, with a laugh, "Little did I know, right?"

The Personal Responsibility and Work Opportunity Reconciliation Act passed in 1996 with all the subtlety of a tidal wave. Democrats and Republicans alike scrambled to take credit for the measure that would "end welfare as we know it."

Sweeping in scope, the law, dubbed the Welfare Reform Act, impacted a host of public assistance programs. In the realm of health care, undocumented immigrants and those who provided health care to them stood to take a hit.

Under the federal law, immunizations, treatment for communicable diseases, emergency care and other critical services would remain available. However, in the area of subsidized or free primary and preventive care, it was less clear-cut. Under the law, many services no longer could be provided, but it did not set penalties for those who continued to do so. The Justice Department was expected to issue guidelines to help states and local governments implement the law, but it never did, says Vail, the UH law professor.

"The federal government was saying, 'We are going to tell you what you can and cannot do…but we're not going to give you guidelines about how to do it,' " Vail says.

The law essentially put local health care personnel in the role of immigration officers, he adds, calling upon them to make determinations of legal standing for people with temporary protective status, pending legalization claims, temporary work authorizations and a variety of complex scenarios.

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