Illegal Immigration: Closing the Gates

Ana-Cecilia de Marquez, 43, rubs her belly when she talks. The illegal immigrant has bothersome and sometimes painful symptoms that require her to stay close to her Goose Creek mobile home.

"It's ... like I'm going to deliver a baby," de Marquez said. "It feels like a wound inside."

De Marquez, who moved from El Salvador to the United States three years ago, is uninsured. She said she has been bounced around the health care system for two years, unable to get her symptoms under control.

"So what?" say some opponents of illegal immigration, who don't think undocumented people should be able to receive health care at public expense.

Russ Henderson, a U.S. citizen and retired military man, lives in neighboring Ladson and is outspoken on the issue. "Every time an illegal uses services the American people pay for, they are stealing," he said. "Go back and let your government take care of you."

Henderson is not alone. Illegal immigration was second only to the economy in the top four issues that matter most among South Carolina Republicans surveyed in primary exit polls.

State legislators responded and passed the Illegal Immigration Reform Act, which became law in June.

The law, among other measures, bans any state-funded, non-emergency medical care for adult undocumented immigrants. Exceptions are made for immunizations, prenatal care and communicable diseases.

Senate President Pro Tem Glenn McConnell, who championed the reform, said, "There's no reason taxpayers should foot the bill for illegals. It's flat wrong. We're having trouble keeping up with those already here. Adding the burden of those not contributing to the system is unfair."

Jack Feussner, chairman of Medical University of South Carolina's Department of Medicine, said he can understand why legislators want to make resources for legal residents a priority. "But it's much more complicated than that," he said.

MUSC, which receives 6.4 percent of its operational budget from the state, is reviewing the legislation to identify issues and figure out how to comply. MUSC, like nearly all hospitals, accepts Medicaid funds, which are a combination of state and federal money. For every dollar the state sets aside for Medicaid, the federal government provides $3.

That means the hospital is caught between the new state law and federal law, which also mandates that people must be treated without discrimination. Any test for legal residency must be applied to everyone.

Here's one way the laws could conflict: An illegal immigrant shows up at a hospital clinic, which is bound by federal law regarding emergencies and discrimination. The immigrant doesn't speak English. Before an interpreter is brought in to help interview the immigrant about his condition, which might constitute an emergency, should that patient's legal status be screened?

Another problem with implementing the law is separating federal and state. More than 130 clinics, both hospital- and physician-based, are affiliated with MUSC. Separating the funding streams to insure that no state funds go to illegal immigrants is complicated and might be impossible for an organization of MUSC's size.

For that reason, Tammy Besherse, staff attorney with S.C. Appleseed Legal Justice Center, a low-income advocacy group, is skeptical that the law will have any effect. "I don't know of any place that only gets state money," Besherse said.

What will the law change?

To avoid a direct conflict with the federal law requiring emergency care, regardless of immigration status, legislators targeted a limited health care scenario with their bill. It prohibits illegal immigrant adults from seeking care in a state-funded facility for non-life-threatening and noncommunicable ailments.

De Marquez fits the bill.

Her womb is filled with lime-size fibroid tumors. Common in premenopausal women, the noncancerous tumors often are symptomless, but they can sometimes be painful and bleed. De Marquez also suffers from diverticulitis, a digestive condition that also can cause abdominal pain.

Neither condition is immediately life-threatening for her, so if de Marquez visits a clinic that receives state funds, she could be turned away, according to the law. Clinics that rely on membership dues, donations and federal grants are not affected by the law, but they are few and have limited resources.

It's still unclear how the law will be enforced. It requires any adult seeking medical care at a clinic or hospital that receives state funds to assert in an affidavit that he is lawfully present in the U.S. It does not ask for proof of citizenship.

The affidavit will be accepted as proof of citizenship until status is verified through the Systematic Alien Verification Entitlement program operated by the Department of Homeland Security.

No agency is charged with enforcing the prohibition against state-funded care, Lynn Bailey, a Columbia-based health care consultant, pointed out. "It's a piece of feel-good legislation that's absolutely impossible to administer," she said.

Andres Arias, an Orangeburg internist who also runs a North Charleston clinic four days a week, said a misconception exists that immigrants are using up resources at ambulatory clinics, the primary target of the legislation.

Undocumented adults would rather go to private clinics and pay up front, he said, rather than leave a paper trail of bills. Patients visit him from as far away as Georgetown and Myrtle Beach. One man comes from Virginia, he said.

Even before the law passed, not having insurance was a roadblock to receiving comprehensive care. Most insured adults with de Marquez's conditions would be treated in a doctor's office. But without insurance, de Marquez is unable to afford to go to a doctor.

When her symptoms become crippling, she goes to the emergency room, which under federal law must stabilize her. But emergency physicians treat only her current symptoms, rather than perform diagnostic tests necessary to determine why her conditions are disabling.

De Marquez always gets billed for her treatment, and invoices are piling up. Unable to work because of pain, she can't pay, she said.

Hospitals have long felt the pinch of treating uninsured patients. Most facilities ask patients to pay up front for non-emergency and elective procedures.

Officials at the Medical University of South Carolina, Trident Health System, Roper St. Francis Healthcare and East Cooper Regional Medical Center confirmed that they ask for payment up front, sometimes at discounted rates if patients do not qualify for charity care.

The move is necessary to remain financially solvent, officials said. In fiscal 2006, state hospitals reported they delivered more than $500 million in uncompensated care.

How much is attributed to illegal immigrants is unknown, since health-care providers do not record patients' legal status.

Based on other data, the S.C. Hospital Association estimated that in 2006 there were 27,000 discharges of uninsured non-citizens. That's not necessarily illegal immigrants, said Rozalynn Goodwin, director of policy research for the association.

The term "uninsured non-citizens" encompasses legal permanent residents and holders of temporary visas, as well as illegal immigrants.

South Carolina hospitals charged uninsured non-citizens about $117 million, including $59 million in emergency room charges, according to the association. Patients paid for an undetermined amount of those charges, Goodwin said.

Fear

In the end, whether the law has teeth or not might be irrelevant. Fear may reduce the number of illegal immigrants seeking health care.

Arias, the Orangeburg internist, said there is fear in the Latino community about going anywhere they have to identify themselves. "The perception that things are going to change makes people really nervous," said Arias, whose North Charleston patients are almost all Latino.

One of his patients, Delfino, is an undocumented laborer who did not want to disclose his full name. He suffered a puncture wound when a cement mixer collapsed on his leg.

Delfino said his boss did not take him to a doctor but instructed him to pour gasoline on the gash. He did not seek medical help for fear of being deported, until a week later, when his ankle swelled to three times its normal size.

After extensive hospital treatment, he owed $3,600, which he pays off in $100 weekly installments.

The law actually might end up costing the health care system more money if many illegal immigrants, like Delfino, wait to seek medical care until a little problem becomes a big one.

"This is going to be complicated to say the least," MUSC's Feussner said.

Reach Jill Coley at 937-5719 or jcoley@postandcourier.com.