Health Systems in Bind on Care for Illegal Immigrants : Finances: Federal law requires treatment but funds for state and county are scarce. Reform plan skirts the issue.


An illegal immigrant from Mexico collapses in the Alhambra bakery where he works for minimum wage and no health benefits. Rushed to the nearest county hospital, he undergoes an emergency appendectomy. Cost to taxpayers: $1,990.

An impoverished Salvadoran, also in the United States illegally, receives gall bladder surgery and antibiotic treatment. Cost to taxpayers: $9,318.

And in Los Angeles County’s crowded public hospitals, two out of three births are to illegal immigrants. Annual cost to taxpayers: $60 million.

For years, compassionate federal and state laws have required hospitals in California to treat virtually anyone who is poor and seriously ill, allowing hundreds of thousands of illegal immigrants to obtain free care.


A seemingly bottomless well of government health care dollars paid the bills. But the well has a bottom. Soaring medical costs have priced 37 million Americans out of health insurance. And shrinking public health budgets are forcing officials to do more with less, focusing unprecedented attention on the costs of treating illegal immigrants.

Nowhere is that scrutiny greater than in California, where more than half the nation’s 2.4 million illegal immigrants reside. Projections by the state Health and Welfare Agency show that their health care will cost Medi-Cal about $880 million this fiscal year, nearly triple what the insurance program for the poor paid out four years ago.

And nowhere is the search for a solution more pressing than in Los Angeles County, where officials say illegal immigrants account for one-quarter of the patients in the overburdened public hospital and clinic system.

“We can’t treat the whole world,” complained a doctor at Los Angeles County-USC Medical Center, where budget deficits have forced staff and pay cuts.


Reliable statistics on the costs of illegal immigrant health care are hard to come by, as are solutions untainted by politics or even racism. Even tougher to ascertain are the potential costs of denying health care benefits to illegal immigrants, a money-saving measure proposed by Gov. Pete Wilson earlier this month. Public health officials warn that neglecting those health needs escalates the spread and cost of communicable disease in California, as demonstrated by the resurgence of tuberculosis.

There is little evidence that resident illegal immigrants use the public health care system cavalierly. Studies show that illegal immigrants, fearful of deportation, often are reluctant to use public health facilities until their conditions are life-threatening. Such delayed care, experts say, further escalates costs because it is usually least expensive to treat an illness early.

These costs are borne by taxpayers through government-sponsored health programs for the poor. This situation is unlikely to change because President Clinton’s national health reform plan is expected to exclude illegal immigrants from coverage.

Elusive Data

Many of these programs are funded with a combination of federal, state and county tax dollars. Comprehensive data on health care costs for illegal immigrants does not exist because most hospitals and clinics have no means of determining how many of their patients are undocumented.

But California health officials were able to roughly gauge the impact on the state’s largest health program--Medi-Cal--because of special codes used by hospitals to claim reimbursement for certain kinds of illegal immigrant care.

Since 1986, federal law has required states to use such programs to provide emergency and obstetrical treatment to illegal immigrants.

California’s study--undertaken in hopes of obtaining more federal aid--concluded in January that illegal immigrant health costs accounted for the fastest-growing part of the Medi-Cal budget, rising from $299.4 million in fiscal 1989-1990 to a projected $880 million this fiscal year. Officials expect no reversal of this trend, in light of state projections that the number of illegal immigrants will increase by at least 100,000 a year.


“This situation is breaking California,” said Jennifer Nelson of the state Health and Welfare Agency, which compiled the data used by Gov. Wilson earlier this year to plead for more federal aid.

Los Angeles and other hard-hit counties launched their own studies, hoping to get more money from the state.

More than half of the state’s illegal immigrants live in Los Angeles County. Demographers estimate that the county has 700,000 illegal immigrants--a population that grows by 66,000 annually. Most of their care is provided by the county’s six public hospitals and 45 health centers, the most extensive network of publicly financed health facilities in California.

A county study, based on fiscal 1990-91 data, found in November that illegal immigrants used $159.5 million, or nearly a third of the county’s expenses for care of the indigent, although they make up only 7.6% of the county’s population. Experts say this reflects the dependence of illegal immigrants on county emergency rooms to meet most of their health needs, rather than their overuse of services.

Those county expenditures were over and above the $273.7 million that Medi-Cal reimbursed public and private hospitals in Los Angeles County that year for obstetrical and emergency treatment of illegal immigrants.

The county study also included the contributions of undocumented residents--information requested by Supervisor Gloria Molina, who feared that they were being made scapegoats for the county’s financial troubles. Illegal immigrants generated $904 million in taxes, fees and other revenues, researchers found. But 97% of the money went to the state and federal governments, leaving very little in the county to offset the cost of county-financed services.

Although considered the most comprehensive in the state, Los Angeles County’s study remains controversial. The Urban Institute, a respected Washington think tank, faulted the 118-page report for inadequate documentation but called it “a significant step” forward in assessing the impact of illegal immigration.

San Diego County undertook a similar study last year but looked primarily at costs. Its report, prepared by the state auditor general’s office, attributed about $42 million in health care costs to illegal immigrants in fiscal 1990-91. Of this, $30.8 million was billed to the state Medi-Cal program.


Orange County has no county hospitals, but private facilities provide an estimated $31 million a year for hospital care and an undetermined amount for outpatient treatment for illegal immigrants, said Donald Hicks, a planning executive at UC Irvine Medical Center, which treats most of the county’s poor.

Orange County supervisors and the county grand jury conducted studies of the impact of illegal immigration on all public services earlier this year but failed to identify specific health care costs.

But state records show that Medi-Cal costs for illegal immigrant residents of Orange County more than doubled between fiscal 1990 and 1992, from $29.5 million to $59.8 million.

The increased burden on county and state programs has coincided with a slumping California economy.

Three years of state budget shortfalls have drained Medi-Cal coffers and reduced state contributions to local health programs for the poor. Health officials say they lack the resources to adequately care for poor and uninsured Californians, let alone illegal immigrants.

“It really is a crisis,” said Mary Pitman, outgoing president of the California Assn. of Public Hospitals. “We have just seen an enormous increase in demand, but no increase in funding.”

Public and private hospitals in California cannot turn away these patients. They are enmeshed in federal and state laws that obligate hospital emergency rooms to treat all seriously ill patients, regardless of immigration status, country of origin or ability to pay.

The Alhambra bakery worker, for example, was entitled to a taxpayer-financed appendectomy under the 1986 federal law requiring states to pay for emergency and obstetrical care.

Federal law also compels hospitals to treat all seriously ill patients who enter through emergency rooms, regardless of their ability to pay. In counties with public hospitals, such as Los Angeles, those facilities absorb most of the caseload. In counties with no public hospitals, such as Orange, private hospitals get the patients.

Besides emergency treatment, California law mandates prenatal care for illegal immigrants. California law also makes county-run hospitals and clinics health care providers of last resort--barring them from turning anyone away.

As health resources become scarce, waiting times at Los Angeles County’s public hospital emergency rooms have grown so long that some seriously ill people leave without being seen, studies show.

Now, with the county health department facing a potential budget shortfall of $100 million, 24 health centers may be closed, forcing even more people to queue up for emergency care.

“We can’t refuse emergency care (to undocumented foreigners)--and we have no place to send these patients,” said Los Angeles County’s health director, Robert Gates. “But it means cutting services to everyone, including the legal indigents.”

Hospital executives said such a move would be disastrous to all patients in Los Angeles County, not just the poor. Private hospitals and clinics, they said, simply could not absorb the displaced patients.

“Nearly two-thirds of Los Angeles County hospitals operated last year in the red. The other one-third have very little (profit) margin,” said David Langness, spokesman for the Hospital Council of Southern California. “If this dumping occurs, we believe that at least 20 (private) hospitals and 10 more emergency rooms and trauma centers will close.”

Advocates for illegal immigrants said the immigrants’ health--already precarious--will certainly deteriorate if care becomes less available.

“I am terrified that . . . we are going to go back to having farm worker women delivering babies in the field,” said Lucy Quacinella, a lawyer with the National Immigrant Law Center.

Yet the advocates also acknowledge that illegal immigrants are adding to the strain on California’s health care system.

Dr. Aliza Lifshitz, president of the California Hispanic Medical Assn., representing 1,400 physicians, believes California is paying the price of poor federal control of U.S. borders. “Once (illegal immigrants) are already here, we can’t just say, ‘To hell with you, we won’t take care of you,’ ” she said. “The enforcement really has to come from officials at the border to make sure we don’t get more in.”

Who are these patients? Los Angeles County records, obtained under the California Public Records Act, dryly list them by immigration status, treatment and cost.

Among these faceless entries are one illegal immigrant who received $4,065 in hospital treatment for diabetes and hypertension and another who got $3,200 in obstetrical care.

But there are faces.

They can be found in barrios where 15 people call a garage home, in free clinics that cater to the poor, in hospital emergency rooms and at an El Monte community center where local activists are trying to organize preventive care services for illegal immigrants.

Like the Alhambra bakery worker, most of those interviewed by The Times have jobs. Many have children in public schools. All were afraid to allow their full names to be used, for fear of discovery by immigration authorities.

The same fear, they said, keeps them from using health services until symptoms become severe.

Desperate Choices

“Only the most desperate will resort to seeking health care from the county hospitals . . . usually under conditions where they are so ill that they have no choice,” said Linda Wong, a former staff attorney with the Mexican American Legal Defense and Educational Fund. Studies tend to support the observation--and it is borne out daily at Los Angeles County hospitals.

For example, Cora, an illegal immigrant from Mexico, gave birth to two children at public hospitals. Those births represent the total of her taxpayer-financed medical costs during 10 years in California.

Home for Cora’s family is a leaky 7-by-10-foot trailer in a South El Monte alleyway. She and her husband, a furniture factory worker, rely mainly on home remedies when family members get sick. They avoid clinics and hospitals because they are afraid of being turned over to immigration authorities. “We just take care of ourselves,” Cora said.

This sort of self-reliance does not necessarily translate into lower health care costs. Delayed care can lead to more serious health problems, often resulting in expensive hospitalization, doctors say. Without routine checkups, especially in the case of children, health problems can go undetected.

Take Luis, 6, the Mexican-born child of an undocumented housekeeper. Earlier this year, he got the first checkup of his life at the Venice Family Clinic, where about 25% of the free clinic’s pediatric cases are illegal immigrants.

“Usually they have horrible teeth and sometimes a little anemia because they are not eating properly,” said Dr. Norma Rosales, the clinic’s chief pediatrician. Many also are not immunized against deadly and contagious childhood illnesses such as measles and whooping cough.

Luis had all of those problems, plus a serious heart defect, said Rosales, who arranged to have him seen by a specialist at Childrens Hospital Los Angeles. Untreated, it could have disabled Luis by early adulthood. And without immunizations, he posed a threat to other children susceptible to communicable disease.

Communicable illness is already on the rise in California--a trend partly attributable, infectious disease experts say, to inadequate preventive care for illegal immigrants. Fresh in their memories is the measles epidemic that killed 72 children in California--34 of them in Los Angeles County--from 1988 through 1991.

Spreading TB

“Bugs don’t know the difference between illegal and legal immigrants, nor from people who have lived here for generations,” said Dr. Lester Breslow, professor of public health at UCLA and a former state health director.

Dr. Shirley Fannin, head of disease control for Los Angeles County, points to a steady rise in tuberculosis cases since 1988. “We believe (the caseload increase) is the manifestation of the full impact of a decade of immigration from nations with high TB incidence,” Fannin said, noting that 68% of the county’s new cases over the last five years have involved foreign-born patients.

Her concerns are underscored by a county study last November that reported evidence of untreated tuberculosis and of high rates of measles, hepatitis and HIV infection in the undocumented population.

“The absence of accessible public or private sources of detection, prevention and treatment impacts the health of the entire community,” warned the report by the Los Angeles County Task Force on Health Care Access.

The impact was illustrated recently at a Koreatown community center in Los Angeles when an elderly illegal immigrant called to say he had run out of tuberculosis pills prescribed in Korea and now was coughing again.

Dr. Myoung O. Ahn urged the caller to get treatment at a county TB clinic, assuring him that no immigration-related questions would be asked. But the man remained doubtful and would not seek treatment.

“He was producing TB bacillus through the air! He was walking in the community,” said Ahn, who runs the community center’s health education and outreach program.

To date, the public health and financial problems associated with illegal immigration have stymied California health officials.

They have no power to stem illegal immigration at the border and can do little to change laws requiring them to care for undocumented residents.

So the remedies proposed thus far amount to little more than a shift in costs from state to county health programs.

In April, Medi-Cal eliminated coverage of so-called “continuing care” for illegal immigrants--a move that the state Department of Finance estimates could save the program $180 million this fiscal year. The regulations enable a diabetic to get treatment for life-threatening coma, but Medi-Cal will not cover the cost of insulin needed to stave off such a crisis.

The new payment restriction has brought protests from county health officials.

“It’s irresponsible,” Los Angeles County Health Director Gates said, because public hospitals will end up stuck with the cost of “continuing care” of the poor.

Dr. Molly Joel Coye, director of the California Department of Health Services, acknowledged the extra burden on counties, but defended the regulations as necessary to safeguard scarce Medi-Cal dollars. A comprehensive solution, she said, can only come with federal help.

The federal government, however, has different priorities. The primary one in health care is providing coverage to the country’s 37 million Americans who lack health insurance.

The White House’s health reform task force has specifically excluded illegal immigrants from its proposals, despite the arguments of some task force members that undocumented workers should get the same benefits as their legal co-workers.

A senior White House official said that including undocumented foreigners would have made the plan too hard to sell politically, especially because only a handful of states besides California have large numbers of illegal immigrants.

TOMORROW: Foreign visitors who come for free treatment.

Immigration: the Health Care Toll

California has half the nation’s illegal and amnesty-eligible immigrants, and a third of the recent immigrants. The foreign influx has placed an enormous strain on publicly financed hospitals and health programs, especially in Los Angeles County.


Shown are the costs to the county for health services by population group in 1991-92. Of $539 million spent on health care for the poor, $369 million was for both legal and illegal immigrants, as well as U.S.-born children of illegal immigrants.

Percentage of Percentage of total population health-care costs Children of illegal immigrants 2.7% 6.8% Recent legal immigrants* 6.9% 23.7% Illegal immigrants 7.6% 29.6% Admitted under amnesty 7.8% 7.6% Rest of population 75% 32.2%


Treatment costs for illegal immigrants represent the fastest-growing part of the state’s Medi-Cal budget (In millions). ’89-'90: $299.4 ’90-'91: $494.7 ’91-'92: $658.2 ’92-'93: $782.8 ’93-'94*: $879.9 * Projected


Experts say inadequate health care for illegal immigrants is contributing to the spread of tuberculosis and other communicable diseases. Shown are TB rates per 100,000 population.

Sources: L.A. County and state of California