* * * * *
DES MOINES — Days after they were badly hurt in a car accident, Jacinto Cruz and Jose Rodriguez-Saldana lay unconscious in an Iowa hospital while the American health care system weighed what to do with the two immigrants from Mexico.
The men had health insurance from jobs at one of the nation's largest pork producers.
But neither had legal permission to live in the U.S., nor was it clear whether their insurance would pay for the long-term rehabilitation they needed.
So Iowa Methodist Medical Center in Des Moines took matters into its own hands: After consulting with the patients' families, it quietly loaded the two comatose men onto a private jet that flew them back to Mexico, effectively deporting them without consulting any court or federal agency.
When the men awoke, they were more than 1,800 miles away in a hospital in Veracruz, on the Mexican Gulf Coast.
Hundreds of immigrants who are in the U.S. illegally have taken similar journeys through a little-known removal system run not by the federal government trying to enforce laws but by hospitals seeking to curb high costs.
A recent report compiled by immigrant advocacy groups made a rare attempt to determine how many people are sent home, concluding that at least 600 immigrants were removed over a five-year period, though there were likely many more.
In interviews with immigrants, their families, attorneys and advocates, the Associated Press reviewed the obscure process known formally as “medical repatriation,” which allows hospitals to put patients on chartered international flights, often while they are still unconscious. Hospitals typically pay for the flights.
“The problem is it's all taking place in this unregulated sort of a black hole ... and there is no tracking,” said law professor Lori Nessel, director of the Center for Social Justice at Seton Hall Law School, which offers free legal representation to immigrants.
Now advocates for immigrants are concerned that hospitals could soon begin expanding the practice after full implementation of the Affordable Care Act, which will make deep cuts to the payments hospitals get for taking care of the uninsured.
Health care executives say they are caught between a requirement to accept all patients and a political battle over immigration.
“It really is a Catch-22 for us,” said Dr. Mark Purtle, vice president of medical affairs for Iowa Health System, which includes Iowa Methodist Medical Center. “This is the area that the federal government, the state, everybody says we're not paying for the undocumented.”
Hospitals are legally mandated to care for all patients who need emergency treatment, regardless of citizenship status or ability to pay. But once a patient is stabilized, that funding ceases, along with the requirement to provide care. Many immigrant workers without citizenship are ineligible for Medicaid, the government's insurance program for the poor and elderly.
That's why hospitals often try to send those patients to rehabilitation centers and nursing homes back in their home countries.
Civil rights groups say the practice violates U.S. and international laws and unfairly targets one of the nation's most defenseless populations.
“They don't have advocates, and they don't have people who will speak on their behalf,” said Miami attorney John De Leon, who has been arguing such cases for a decade.
Estimating the number of cases is difficult because no government agency or organization keeps track.
The Center for Social Justice and New York Lawyers for the Public Interest have documented at least 600 immigrants who were involuntarily removed in the past five years for medical reasons. The figure is based on data from hospitals, humanitarian organizations, news reports and immigrant advocates who cited specific cases. But the actual number is believed to be higher because many more cases may go unreported.
Some patients who were sent home subsequently died in hospitals that weren't equipped to meet their needs. Others suffered lingering medical problems because they never got adequate rehabilitation, the report said.
Gail Montenegro, a spokeswoman for U.S. Immigration and Customs Enforcement, said the agency “plays no role in a health care provider's private transfer of a patient to his or her country of origin.”
Such transfers “are not the result of federal authority or action,” she said in an email, nor are they considered “removals, deportations or voluntary departures” as defined by the Immigration and Nationality Act.
The two Mexican workers in Iowa came to the U.S. in search of better jobs and found work at Iowa Select Farms, which provided them with medical insurance even though they had no visas or other immigration documents.
An Iowa Select Farms spokeswoman said Tuesday that she could find no record that the men worked for the company under those names. The attorney for the two men said he learned through subpoenas that they had worked for a pork company that he believes was once a subsidiary of Iowa Select.
Cruz had been here for about six months, Rodriguez-Saldana for a little over a year. The men were returning home from a fishing trip in May 2008 when their car was struck by a semitrailer truck. Both were thrown from the vehicle and suffered serious head injuries.
Insurance paid more than $100,000 for the two men's emergency treatment. But it was unclear whether the policies would pay for long-term rehabilitation. Two rehabilitation centers refused to take them.
Eleven days after the car crash, the two men were still comatose as they were carried aboard a jet bound for Veracruz, where a hospital had agreed to take them.
Rodriguez-Saldana, now 39, said the Des Moines hospital told his family that he was unlikely to survive and should be sent home.
The hospital “doesn't really want Mexicans,” he said in a telephone interview with the AP.
“They wanted to disconnect me so I could die. They said I couldn't survive, that I wouldn't live.”
Hospital officials said they could not discuss the case because of litigation. The men and their families filed a lawsuit in 2010 claiming that they received minimal rehabilitative care in Veracruz.
A judge dismissed the lawsuit last year, ruling that Iowa Methodist was not to blame for the inadequate care in Veracruz. The courts also found that even though the families of the men may not have consented to their transport to Mexico, they also failed to object to it. An appeals court upheld the dismissal.
Patients are frequently told that family members want them to come home. In cases where the patient is unconscious or can't communicate, relatives are told that their loved one wants to return, De Leon said.
Sometimes they're told that the situation is dire and that the patient may die, prompting many grief-stricken relatives to agree to a transfer, he said.
Some hospitals “emotionally extort family members in their home country,” De Leon said. “They make family members back home feel guilty so they can simply put them on a plane and drop them off at the airport.”
In court documents, Iowa hospital officials said they had gotten permission from Saldana's parents and Cruz's long-term partner for the flight to Mexico. Family members deny that they gave consent.
There's no way to know for sure whether the two men would have recovered faster or better in the United States. But the accident left both of them with life-altering disabilities.
Nearly five years later, the 49-year-old Cruz is paralyzed on his left side, the result of damage to his hip and spine. He has difficulty speaking and can't work.
“I can't even walk,” he said in a telephone interview, breaking into tears several times. His long-term partner, Belem, said he's more emotional since the accident.
“He feels bad because he went over there and came back like this,” she said. “Now he can't work at all. ... He cries a lot.”
She works selling food and cleaning houses. Their oldest son, 22, sometimes contributes to the family income.
Rodriguez-Saldana said he has to pay for intensive therapy for his swollen feet and bad circulation. He also said he walks poorly and has difficulty working. He sells home supplies such as kitchen and bath towels and dishes, a business that requires a lot of walking and visiting houses. He often forgets where he lives, but people recognize him on the street and take him home.
The American Hospital Association said it does not have a policy governing immigrant removals, and it does not track how many hospitals encounter the situation.
Nessel expects medical removals to increase with implementation of the federal health care law, which makes many more patients eligible for Medicaid. As a result, the government plans to cut payments to hospitals that care for the uninsured.
Some hospitals call immigration authorities when they get patients without immigration documentation, but the government rarely responds, Nessel said. Taking custody of the patient would also require the government to assume financial responsibility for care.
Jan Stipe runs the Iowa Methodist department that finds hospitals in patients' native countries that are willing to take them. The hospital's goal, she said, is to “get patients back to where their support systems are, their loved ones who will provide the care and the concern that each patient needs.”
The American Medical Association's Council on Ethical and Judicial Affairs issued a strongly worded directive to doctors in 2009, urging them not to “allow hospital administrators to use their significant power and the current lack of regulations” to send patients to other countries.
Doctors cannot expect hospitals to provide costly uncompensated care to patients indefinitely, the statement said. “But neither should physicians allow hospitals to arbitrarily determine the fate of an uninsured noncitizen immigrant patient.”
Arturo Morales, a Monterrey, Mexico, lawyer who helps Cruz and Rodriguez-Saldana with legal issues, is convinced that the men would have been better off staying in Iowa.
“I have no doubt,” he said. “You have a patient who doesn't have money to pay you. You can't let them die.”
Three cases of 'medical repatriation'
Over the last five years, American hospitals have sent at least 600 immigrants who were in the U.S. illegally back to their home countries to avoid paying for long-term care after serious illness or injury.
The Center for Social Justice at Seton Hall University has documented “medical repatriation” cases in 15 states involving patients from El Salvador, Guatemala, Honduras, Lithuania, Mexico, the Philippines and South Korea. Here's a look at three cases from a report issued in December:
Quelino Ojeda Jimenez
Jimenez was working on a building at Chicago's Midway Airport in 2010 when he fell, suffering injuries that left him nearly quadriplegic and reliant on a ventilator.
Advocate Christ Medical Center cared for Jimenez for four months, absorbing more than $650,000 in costs, according to a 2011 Chicago Tribune story.
Three days before Christmas that year, the hospital put him aboard a medical flight and sent him to Mexico, even though his family protested. Crying and unable to speak, Jimenez could do nothing to prevent his removal.
The receiving hospital in Mexico lacked rehabilitation services and could not afford new filters for his ventilator. After suffering two heart attacks and a septic infection, Jimenez died on Jan. 2, 2012.
Luis Alberto Jimenez
Jimenez was working as a landscaper in Florida when the car he was in was struck by a drunken driver in February 2000.
Jimenez, then 35, suffered brain damage and other injuries and was treated at Martin Memorial Medical Center in Stuart, Fla., until June, when he was transferred to a nursing home.
The following January, he was readmitted to the hospital with an infection that doctors feared could be fatal. He stayed at the hospital for a year because no other long-term care provider would take him.
The hospital eventually filed a lawsuit in state court seeking permission to transport him to a hospital in his native Guatemala. A judge approved the flight in June 2003, and Jimenez was flown to Guatemala before the court could rule on an appeal filed by his legal guardian.
In mid-2004, the Florida District Court of Appeals overturned the lower court's order, declaring that state courts do not have the authority to permit deportations, which are regulated by federal immigration law. But by then Jimenez had been returned home, bedridden and suffering from seizures, to live with his elderly mother in a remote area of Guatemala.
Latasiewicz was working as a housekeeper in the Chicago area in 2009 when she had a stroke while scrubbing a bathtub. The Polish woman was paralyzed on her left side and needed around-the-clock care.
Adventist La Grange Memorial Hospital tried to find her long-term care, but 30 facilities refused to take her. Latasiewicz had overstayed a temporary visa after arriving in the U.S. in 1990.
The hospital allowed her to stay without insurance or any other way to pay for more than two years at a cost of more than $1.4 million.
In early 2012, arrangements were made to transfer her to a stroke-specialty unit in Poland. She refused to consent to the transfer, which would separate her from her son and grandchildren. The hospital got a judge's order allowing her transfer to Poland.
A March 1 story in the Chicago Tribune says the 60-year-old woman cried while sitting in the airport awaiting a flight out, knowing she would probably never return to the U.S., which had been her home for more than 20 years.
Immigrants fare better here, area groups say
Area groups that assist immigrants say they haven't heard of cases of local hospitals sending people living here illegally back to their home countries.
Representatives from Nebraska Appleseed, Catholic Charities and the Latino Center of the Midlands said they were unaware of any recent cases similar to the 2008 Des Moines case in which hospital officials flew two men to Mexico while the men were still comatose.
“We don't have those kinds of stories,” said Carolina Quezada, executive director of the Latino Center of the Midlands. She said she had heard of hospitals helping immigrants to get care.
The Center for Social Justice at Seton Hall University has documented “medical repatriation” cases in 15 states, including Nebraska. The Nebraska case cited in the report happened in 2002 and involved BryanLGH Medical Center in Lincoln. According to World-Herald files, the hospital flew a car accident victim to a hospital in his native Mexico, where he would be closer to family, after a nine-month stay that cost BryanLGH $1 million.
Sara Juster, vice president of compliance for Methodist Health System, said hospitals are required by federal law to conduct a screening exam and provide emergency care to all people regardless of their ability to pay. Hospitals also must find an appropriate place to discharge a patient, whether that's to a skilled nursing center or the person's own home where home health nurses can visit, she said.
About five years ago, Juster said, Methodist treated a patient from a Central American country who wasn't here legally. The woman ended up going back to her home country, where she could get long-term rehabilitation coverage. “We worked really closely with the family and her — she was awake, competent,” Juster said. “All agreed it was in her best interest. ... We didn't just put her on a plane and ship her off.”
The idea that hospitals would call immigration authorities about a patient “is certainly something we would never, ever do,” Juster said. “Not that we condone people being here illegally, but it's not our job to be law enforcement or immigration enforcement. It's our job to take care of patients.”
– Bob Glissmann