High in the hills of Guatemala, shut inside the one-room house where he spends day and night on a twin bed beneath a seriously outdated calendar, Luis Alberto Jiménez has no idea of the legal battle that swirls around him in the lowlands of Florida.
Shooing away flies and beaming at the tiny, toothless elderly mother who is his sole caregiver, Mr. Jiménez, a knit cap pulled tightly on his head, remains cheerily oblivious that he has come to represent the collision of two deeply flawed American systems, immigration and health care.
Eight years ago, Mr. Jiménez, 35, an illegal immigrant working as a gardener in Stuart, Fla., suffered devastating injuries in a car crash with a drunken Floridian. A community hospital saved his life, twice, and, after failing to find a rehabilitation center willing to accept an uninsured patient, kept him as a ward for years at a cost of $1.5 million.
What happened next set the stage for a continuing legal battle with nationwide repercussions: Mr. Jiménez was deported — not by the federal government but by the hospital, Martin Memorial. After winning a state court order that would later be declared invalid, Martin Memorial leased an air ambulance for $30,000 and "forcibly returned him to his home country," as one hospital administrator described it.
Since being hoisted in his wheelchair up a steep slope to his remote home, Mr. Jiménez, who sustained a severe traumatic brain injury, has received no medical care or medication — just Alka-Seltzer and prayer, his 72-year-old mother said. Over the last year, his condition has deteriorated with routine violent seizures, each characterized by a fall, protracted convulsions, a loud gurgling, the vomiting of blood and, finally, a collapse into unconsciousness.
"Every time, he loses a little more of himself," his mother, Petrona Gervacio Gaspar, said in Kanjobal, the Indian dialect that she speaks with an otherworldly squeak.
Mr. Jiménez's benchmark case exposes a little-known but apparently widespread practice. Many American hospitals are taking it upon themselves to repatriate seriously injured or ill immigrants because they cannot find nursing homes willing to accept them without insurance. Medicaid does not cover long-term care for illegal immigrants, or for newly arrived legal immigrants, creating a quandary for hospitals, which are obligated by federal regulation to arrange post-hospital care for patients who need it.
American immigration authorities play no role in these private repatriations, carried out by ambulance, air ambulance and commercial plane. Most hospitals say that they do not conduct cross-border transfers until patients are medically stable and that they arrange to deliver them into a physician's care in their homeland. But the hospitals are operating in a void, without governmental assistance or oversight, leaving ample room for legal and ethical transgressions on both sides of the border.
Indeed, some advocates for immigrants see these repatriations as a kind of international patient dumping, with ambulances taking patients in the wrong direction, away from first-world hospitals to less-adequate care, if any.
"Repatriation is pretty much a death sentence in some of these cases," said Dr. Steven Larson, an expert on migrant health and an emergency room physician at the Hospital of the University of Pennsylvania. "I've seen patients bundled onto the plane and out of the country, and once that person is out of sight, he's out of mind."
. . .
Medical repatriations are happening with varying frequency, and varying degrees of patient consent, from state to state and hospital to hospital. No government agency or advocacy group keeps track of these cases, and it is difficult to quantify them.
A few hospitals and consulates offered statistics that provide snapshots of the phenomenon: some 96 immigrants a year repatriated by St. Joseph's Hospital in Phoenix; 6 to 8 patients a year flown to their homelands from Broward General Medical Center in Fort Lauderdale, Fla.; 10 returned to Honduras from Chicago hospitals since early 2007; some 87 medical cases involving Mexican immigrants — and 265 involving people injured crossing the border — handled by the Mexican consulate in San Diego last year, most but not all of which ended in repatriation.
Over all, there is enough traffic to sustain at least one repatriation company, founded six years ago to service this niche — MexCare, based in California but operating nationwide with a "network of 28 hospitals and treatment centers" in Latin America. It bills itself as "an alternative choice for the care of the unfunded Latin American nationals," promising "significant saving to U.S. hospitals" seeking "to alleviate the financial burden of unpaid services."
Many hospitals engage in repatriations of seriously injured and ill immigrants only as a last resort. "We've done flights to Lithuania, Poland, Honduras, Guatemala and Mexico," said Cara Pacione, director of social work at Mount Sinai Hospital in Chicago. "But out of about a dozen cases a year, we probably fly only a couple back."
Other hospitals are more aggressive, routinely sending uninsured immigrants, both legal and illegal, back to their homelands. One Tucson hospital even tried to fly an American citizen, a sick baby whose parents were illegal immigrants, to Mexico last year; the police, summoned by a lawyer to the airport, blocked the flight. "It was horrendous," the mother said.
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For the reader who asks, "Why should anyone in the US pay for this man's health care?", I reply with a question of my own. Why can't a country that has spent $648 billion* subduing and occupying two foreign countries - the eventual cost of both invasions may eventually total three trillion dollars - provide health care to anyone who needs it?
It's not as though the bed once occupied by Mr. Jiménez automatically goes to a needy US citizen. Only those who can afford it.
Also note "medical repatriation" is not limited to illegal immigrants. Legal immigrants can get the boot, too.
* By my partner's calculations, that comes out to: $22,222,222 every hour, or $370,370 every minute, or $6,172 per second since October 2001.