Immigrant Care Costs Fuel Debate : Finances: Fuzzy data on the undocumented makes it hard to gauge the extent of the public subsidy, experts say.


Matilde Monzon, expecting her first child, has no driving desire to become a symbol for anything. Her principal wish is for a healthy baby.

Nonetheless, the 31-year-old former garment worker embodies many of the contradictions and complexities swirling around the incendiary debate over the costs of illegal immigration.

Monzon has been receiving prenatal care and hopes to give birth to her first child at County-USC Medical Center, the sprawling Eastside facility that is the nation's busiest public hospital complex. Medi-Cal, the government-funded insurance plan for the poor, is picking up the tab.

"Without this care, I don't know what I'd do now," Monzon said on a recent day as she sat in the waiting area of Women's and Children's Hospital, part of the vast County-USC complex.

Monzon suffers from epilepsy, but she said she never sought out medical care, public or private, until eight years after she crossed the U.S.-Mexico border and became pregnant--challenging the popular notion that such benefits draw immigrants, who subsequently burden the system.

Although debated for years, the extent of the public subsidy of illegal immigrant health care costs remains a matter of much dispute and questionable numbers. "It's a very difficult population to measure," noted Theresa A. Parker, chief deputy director of the California Department of Finance.

With Los Angeles County teetering on the brink of insolvency, the emotion-charged issue has received renewed scrutiny: House Speaker Newt Gingrich (R-Ga.) is seeking bolstered federal reimbursements for emergency services, Gov. Pete Wilson is ratcheting up demands for U.S. assistance and two Los Angeles County supervisors have publicly called for slashing county subsidies of non-emergency aid for illegal immigrants.

"We should be providing just what Newt Gingrich said we are going to get money for--emergency care," said Supervisor Deane Dana, who, along with fellow conservative Republican Mike Antonovich, has called for an end to non-emergency care for illegal immigrants.

Both San Diego and Orange counties have made illegal immigrants ineligible for subsidized primary care, which may include everything from checkups to dental visits to elective surgery and treatment for progressive, ultimately life-threatening ailments.

Opponents say such a drastic county policy shift would be both inhumane and fiscally unsound, scaring off even legal immigrants from seeking crucial preventive services and forcing more patients into emergency rooms--where care is inevitably more costly. Board Chairman Gloria Molina calls such assistance a "moral responsibility," particularly since illegal immigrants pay sales tax and, if employed, income taxes, just as everyone else.


To be sure, providing care to illegal immigrants is a huge expense in a county with the nation's largest undocumented population--one that tends to be, like Monzon, poor and uninsured.

U.S. law requires that hospitals provide emergency services to all patients, regardless of immigration status. But Washington generally only reimburses providers for the costs of illegal immigrants who qualify under Medicaid (Medi-Cal in California). State taxpayers pick up half of Medi-Cal costs, while counties and, to a lesser degree, private providers, are often left with the huge medical bills for poor illegal immigrants ineligible for Medi-Cal.

For legal and other reasons, most undocumented patients simply aren't asked about their immigration or citizenship status. (That may soon change, following a court ruling last year upholding California officials' right to quiz all Medi-Cal applicants about their status.)

The most authoritative official estimate of illegal immigrants' use of health care services dates back to 1992, when a Los Angeles County study reported that a quarter of all patients treated in county facilities were unlawful residents. Their care, the study calculated, cost the county $159.5 million in the previous year--almost one-third of unreimbursed county health expenditures.

A separate official estimate, calculated during 1990-91, found that nearly two of every three babies delivered at county hospitals were born to undocumented mothers. During last year's heated Proposition 187 debate, this finding became a kind of rallying cry for proponents. The measure sought to slash publicly funded health and other benefits for illegal immigrants.

But despite the wide use of the county estimates, some experts say the numbers are probably inflated. In particular, critics say that county officials, unschooled in the intricacies of immigration law, mistakenly count many legal residents as illegal immigrants.

"I think the extent of county care for the undocumented is definitely overstated," said Yolanda Vera, staff attorney with the National Health Law Program, a nonprofit group that seeks to increase poor people's access to health care.

Irene Riley, the county official who helped compile the critical county estimates on health care for the undocumented, acknowledged in an interview that the numbers are "fuzzy," based largely on non-scientific survey data, and could exaggerate or understate the problem. But Riley, the county's chief of governmental relations, defends the data as the best numbers available for a population that is, by definition, hard to track.

From the perspective of Los Angeles and other fiscally strapped counties, illegal immigrant patients are hardly a complete financial drain. The considerable Medi-Cal reimbursements provide public and private facilities serving the undocumented population with a much-desired revenue stream, though Medi-Cal does draw 50% of its funds from state coffers.

"We want Medi-Cal patients," noted Linda Felix, assistant administrator at Women's and Children's Hospital.

Part of the county's problem, critics say, is officials' lack of aggressiveness in pursuing funding from Medi-Cal and other sources--a shortcoming that county authorities acknowledge.

"In many cases L.A. doesn't even try to get reimbursements when they should," said Melinda R. Bird, managing attorney of Protection and Advocacy Inc., a nonprofit firm that assists disabled people.

Those who qualify under Medi-Cal guidelines are a substantial, but by no means all-inclusive, segment of the illegal immigrant population. For one thing, Medi-Cal benefits for illegal immigrants are largely restricted to emergency care (including labor and delivery) and prenatal services. Moreover, along with meeting income, asset and residency guidelines, Medi-Cal beneficiaries generally must also fulfill other requirements such as age, pregnancy, disability or being members of single-parent households.

The governor's office estimates that Medi-Cal paid the bills for more than 300,000 illegal immigrants during fiscal 1994-95, costing California taxpayers almost $400 million--a figure that has skyrocketed almost twentyfold in seven years.

However, studies by two respected independent organizations, the Urban Institute and the congressional General Accounting Office, have faulted the state's methodology. California officials--like their Los Angeles County counterparts--may mistakenly lump many legal residents together with the undocumented, the experts said.

"We really don't know with accuracy what share of people getting Medi-Cal benefits are undocumented," said Wendy Zimmerman, a research associate with the Urban Institute, a Washington-based think tank that examined California's numbers.

For the poor and uninsured ineligible for Medi-Cal, it is typically left to other levels of government, or private institutions, to pay the medical bills.

One such patient was Joel Cardona, a 23-year-old Eastside resident who was among the more than 600 people waiting on a recent hazy morning at the walk-in emergency room of County-USC. He was seeking treatment for a nagging knee injury that had been bothering him for weeks.

"I know my medical care costs the government, but I pay my taxes like everyone else," Cardona noted, echoing the comments of others interviewed.

While still serving severe trauma cases--gunshot victims, heart attack patients and the like--emergency rooms such as those at County-USC have evolved into the walk-in clinic of choice for the poor, complete with triage systems designed to separate serious cases in need of immediate treatment from the lesser ailments that can wait.

Cardona, an undocumented native of the northern Mexican state of Zacatecas and one of a family of nine brothers and sisters, said he works 10 hours a day, six days a week, at a butcher shop in East Los Angeles. His pay: $200 a week, cash, no benefits. During his two years in the United States, Cardona said, he had sought out medical care only once before: after a group of punks mugged him one Friday evening, taking his hard-earned weekly wages and beating him badly.

That Cardona, like Matilde Monzon, has seldom sought care is not unusual, experts say. Studies have shown that Latino illegal immigrants tend to be young and healthy, and are generally hesitant to visit doctors' offices, because of costs, unfamiliarity with the system and fear of being reported.

Along with pregnancy, officials say, a relatively high-volume area of treatment for illegal immigrants is preventive services--including immunizations, tuberculosis screening and treatment and detection of sexually transmitted diseases. Public health experts say excluding the undocumented from such public health programs--as Proposition 187 seeks to do--would simply increase the risk to everyone.

"What are we going to do, let people remain contagious in the community because they're illegal?" said Dr. Shirley Fannin, chief of communicable-disease control for Los Angeles County. "We can't do that. That's irrational."

Indeed, even in San Diego County, which has aggressively limited funding for both emergency and primary care for illegal immigrants, the undocumented can avail themselves of immunizations and other public health services.

Joel Reyes, a 29-year-old illegal immigrant from the southern Mexican state of Veracruz, said he recently went to a county clinic for an AIDS test, which turned out negative. He, like other undocumented people interviewed, scoffed at the notion that health and other benefits drew immigrants.

"It's absurd to say I came here all this way just to see if I have AIDS," said Reyes, a recent arrival who spoke outside the Edward R. Roybal Comprehensive Health Center in East Los Angeles. "Besides, everyone knows that disease doesn't have fronteras [borders]."

A few miles across town, at a County-USC waiting room, hundreds of poor patients waited to speak with doctors and financial aid screeners positioned behind a bulletproof wall and windows--part of the increased security regimen imposed after a former patient went on a shooting rampage in 1993, injuring three physicians.

"This is the only place we can come to," said Loida Cruz, in pain from gallbladder stones as she patiently awaited her turn.

A physician at a private hospital had diagnosed the problem, she said, but directed the uninsured, undocumented Cruz to County-USC--a typical scenario, health experts say. Three weeks earlier, Cruz, 23, had given birth to her third child; all of them are U.S. citizens.

As his wife clutched her aching midsection, Joel Cruz Martinez explained that his day-labor work had been slow of late. At any rate, his $40-a-day salary was hardly enough to pay the rent on the family's Eastside apartment and meet other living expenses.

"What am I supposed to do: Allow my wife to go without treatment and just die because we have no money and no papers?" Cruz asked as he waited for his wife's name to be called over the loudspeaker. "Is that supposed to be just?"

Times staff writers Josh Meyer and Tony Perry contributed to this report.


The Impact of Immigration

Nobody can prove precisely how many illegal immigrants live in the United States, much less whether they drain more from public funds as recipients of public services than they contribute in economic activity and tax revenues. Still, there is no shortage of claims, estimates and studies on the issue. Here are some examples:

What one Side Says: A widely quoted 1993 study of immigrants--legal and illegal--who had arrived in the United States since 1970 said undocumented immigrants cost taxpayers almost $12 billion a year.

The Opposing View: Some immigration specialists dismiss the work as anti-immigrant and outside the academic mainstream. They say the methodology and assumptions were skewed to drive up costs and hold down revenue data.

What one Side Says: In 1993, Gov. Pete Wilson said illegal residents and their U.S.-born children absorb $3 billion in state and local services: about $1.1 billion in education, $950 million in health care and nearly $500 million each in welfare and prison costs.

The Opposing View: Critics say Wilson's numbers ignore economic activity and tax revenue generated by illegal immigrants. Many take low-wage services jobs, they say; those who work for companies provide a low-cost labor pool that may keep U.S. firms from relocating overseas.

What one Side Says: A 1992 study found that L.A. County spent $308 million on illegal immigrants, and that the immigrants paid $36.2 million in county taxes and $777 million in state and federal taxes.

The Opposing View: The study was criticized by a national think tank that said cost estimates were generally too high and revenue estimates too low, largerly because the study underestimated the immigrants' incomes.

What one Side Says: A survey by the County Department of Health Services found that nearly two-thirds of all mothers who gave birth in the county's four public hospitals in the 1990-91 fiscal year were undocumented (Critics say that estimate is grossly inflated. Under the Medi-Cal program, illegal state residents are eligible only for emergency care and obstetrics, including delivery.

The Opposing View: Under the Constitution, children born in the United States are automatically U.S. citizens. That in turn makes their parents eligible for welfare benefits for the children. Anti-immigration forces have called for a constitutional amendment to remove this guarantee, which they contend is drawing women into the country to give birth. (Others call such an amendment immoral and anti-American.)

Source: Times files

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