On the day American researchers visited them in the hills of Guatemala, Enrique’s family killed a chicken as a mark of celebration. They hoped that by sharing their story and welcoming the researchers, Enrique might finally get the medical help he needed. It was likely false hope.
Enrique’s story in the U.S. began like many immigrant stories: illegal border crossings and a dream of a better life. Today, his story is uncertain. It’s unclear if Enrique is still alive. What is known is how his time in the United States came to an end. He was deported more or less, but not by our government and not after he had exhausted the usual legal remedies of appeal or his right to request asylum. Enrique was sent back to his home country by a corporation by way of a process known as medical repatriation, or medical “deportation.” He was not sent back because he could get better care in Guatemala. He was sent back so the corporation could save money by not continuing to treat his serious condition.
As the population of undocumented persons living in the U.S. has grown, so has this dangerous practice of corporate “deportation” by hospitals. It is an unsavory practice hidden in the shadows that has only come to light in recent years.
Enrique had lived as an undocumented immigrant in New Jersey until 2008 when he was “deported” by a hospital corporation because he could not pay his medical bills following a stroke that left him braindamaged and half-paralyzed.
In 2010, American researchers from Seton Hall found Enrique in the small village of Chimaltenango, where he lived mostly confined inside his family’s home. He had been forced from the U.S. with only the prescriptions for the medications he needed, medications his family was too poor to buy. There were no open beds at a Guatemalan rehabilitation hospital, and the nearest medical facility that could meet Enrique’s needs was more than an hour’s drive away across miles of unpaved mountain roads, and his family could not afford the transportation to access those services regularly.
On the day researchers visited, Enrique had received none of the treatment required for his recovery.
Back in the states, when he was first admitted to the New Jersey hospital following his stroke, hospital staff immediately contacted Enrique’s Guatemalan family asking for permission to send him home.
The hospital will pay for his transportation, a nurse told Enrique’s sister. His medical care will continue in Guatemala.
Serious rehabilitation is almost nonexistent in Guatemala outside of expensive private facilities, and Enrique’s sister had five children and worked fulltime. So she refused to have Enrique flown home, knowing she could not pay for his treatment and that he would receive inadequate medical care if he left the U.S.
The hospital warned her to consider Enrique’s immigration status. How is he going to pay his U.S. medical bills, they asked? Guided by a financial incen tive to get rid of a costly uninsured and undocumented patient, the hospital called Enrique’s sister over and over again.
But to no avail, she still refused to have Enrique sent home, believing he should stay in New Jersey until he received the rehabilitative care he needed.
Finally, the hospital called and said that Enrique was dying. So his sister agreed to have him sent home, believing it would be to bury him.
There was one problem, however. Enrique was not dying. He was too sick to leave the hospital and was no doubt hurting the hospital’s profits, a problem the corporation remedied by tricking his sister in order to make the medical expenses go away. This “deportation” based on questionable information and enforced by a corporation rather than a government was bad for Enrique and his family, but good for the hospital’s bottom line. If the first rule is to do no harm, somebody wasn’t, and isn’t, playing by the rules.
As is the case with uninsured immigrants nationwide, the hospital was not being reimbursed for Enrique’s medical care beyond his initial emergency needs, so they wanted him gone.
U.S. hospitals tell lies like this often enough that it’s appalling, says Kimberly Krone, one of the American researchers who visited Enrique and others like him in the summer of 2010.
Influenced by financial concerns, Krone says hospitals use varying degrees of coercion and mistruth to get families to consent to having loved ones shipped home for medical reasons.
Due to the lack of governmental oversight and the messiness of both immigration and health care policies, hospitals are allowed to ship hundreds of patients like Enrique out of sight, out of mind every year — often to countries with medical facilities so inadequate they are debilitating, or often even life-threatening.
From 2007 to 2012, nearly 900 cases of coerced or unconsented medical repatriations were tracked by the Center for Social Justice at Seton Hall University School of Law, the only organization that attempts to track or record medical repatriations nationwide and the first to release a report on the issue.
The 2012 report chronicles cases in which hospitals, oftentimes having paid tens of thousands of dollars to private transportation companies, oversaw critically injured or ill immigrant patients who were loaded onto air ambulances or commercial planes and flown back to their native countries. In cases where the patient was unconscious at the time of their forced exit from the U.S. or their consent to be sent back to their home country was uninformed or based on questionable information, critics of such medical repatriations argue that the practice wrongly and illegally circumvents the federal deportation process. The idea being that if the U.S. government can’t pick up an undocumented immigrant and simply put them on a plane back to their country of origin without following certain legal procedures, then why should a corporation have the power to do so? It’s a good question that apparently isn’t being asked or answered by the federal government or anyone else.
It’s not a simple problem. There is no question that undocumented patients needing longterm treatment create a sticky situation for U.S. hosptials and there is no consensus on how such patients should be cared for. While hospitals are required by federal mandate to admit patients in need of emergency care, their obligation and financial reimbursement to care for an uninsured immigrant ends when the patient is stabilized.
For patients requiring continued treatment, federal discharge planning laws require hospitals to transfer or refer them to “appropriate” post-hospital care. Yet U.S. nursing homes and rehab centers are under no mandate to accept uninsured patients, and they typically refuse. This means that hospitals are increasingly left with immigrants who are physically unable to leave their acute care setting but who are also unable to pay for their care. This can mean millions of dollars in unreimbursed medical expenses for the corporations that own many of the nation’s hospitals.
So hospitals look to international facilities or families to take back their native citizens.
• • • •
The type of patient at risk of being forced out of the country by a hospital corporation is not cut-anddry, says Lori Nessel, a law professor at Seton Hall University and the supervising author of the 2012 report. Patients with varying immigration statuses have faced real or attempted medical repatriations, including a 19-year-old lawful permanent resident and a 2-day-old U.S. citizen born to undocumented parents.
“People assume it’s private hospitals doing this in border states,” says Nessel. “But it is really a much bigger issue than that. We have found both public and private hospitals that do these. And this doesn’t just come up for people who just arrived in this country. There was a case of a Polish woman who had been here 30 or 40 years who had no connection and no family back in Poland. Sometimes people don’t even speak the language of their country of birth.”
A case in 2008 at St. Joseph’s Hospital in Phoenix outraged the Latino community. According to The New York Times, the hospital planned to send a comatose, legal immigrant mother of seven U.S.- born children back to Honduras. Community leaders were enraged and their involvement delayed her removal. During ensuing negotiations, the patient awoke from her coma and returned to her Phoenix home.
What is consistent about medical repatriations, explains Nessel, is that they happen “when no one is looking” and are incredibly tricky to track, meaning the number of cases are “grossly underreported.”
“It is very hard to track down actual cases,” she says. “By definition they tend to happen quickly and without government oversight.”
Colorado is one of 16 states with the highest number of unauthorized immigrant residents, according to the Washington Post. Medical repatriation has occurred out of Denver, but most hospitals in the state say they don’t practice repatriation. With no state agency tracking such cases, finding one is like finding a needle in a haystack.
Though most hospitals don’t release how many patients they repatriate, St. Joseph’s in Phoenix told The New York Times in 2008 that they repatriate roughly 96 patients a year.
“When you look at the grand scheme of things, enough patients are moved back via repatriation to probably fill a hospital every year,” says Alex Quintana, a flight coordinator and repatriation specialist at AeroCare, an air ambulance company that conducts international medical transfers.
“I’ve definitely flown enough patients to fill a hospital, myself, over the years,” says Quintana, who has worked at AeroCare for eight years.
Private repatriation companies are growing by leaps and bounds, says Nessel, who keeps track as new transportation companies pop up all the time.
“It’s a real growth industry because hospitals will pay substantial amounts of money for this service,” she says, explaining that both the lack of funding available to hospitals to treat uninsured immigrants and the lack of accountability for unlawful repatriations made way for these profit-making companies.
Nessel worries the industry will continue to grow and the practice will occur more frequently nationwide under the Affordable Care Act because of decreased funding available to hospitals that care for the uninsured. Under health reform, the number of uninsured patients is expected to continue to decrease and so the federal government is reducing this state funding.
Undocumented immigrants are expected to make up 25 percent of the uninsured after the Affordable Care Act is fully implemented, according to a report by the Urban Institute and Wake Forest University.
Quintana says the emotional aspects of repatriations can be challenging, admitting that he has struggled to conduct repatriations where families were broken apart and unlikely to ever see each other again. But, he says, healthcare in the U.S. is expensive and, “If you want it, you’re going to have to pay for it.”
Ultimately, Quintana says patients need to be transferred to facilities that have their appropriate level of care, and if they need long-term care, he says, they don’t need to be in an acute-care hospital setting.
“If you came to the country wanting to find the American Dream, I don’t blame you because if I was in one of those countries, I would be doing the same thing,” he says. “But at the end of the day, you have to look at the fact that we expect health care to be available to us in this country and if they don’t get discharged from that facility, whether it be an American needing to be in the ICU or another foreign national, then those services aren’t going to available to you or me or anybody. The hospital is a business and that’s the sad reality of health care in this country.”
• • • •
The varying degrees of coercion involved in medical repatriation and the lack of advocacy for informed consent in hospitals across the country is one of the most tenuous aspects of the practice.
The inability to track how hospitals are presenting their options to patients is concerning, says John Sullivan, a Fulbright research scholar and social worker studying medical repatriation in Mexico.
“I’ve been asking patients how repatriation was presented to them,” says Sullivan. “Did they go through real informed consent and [did the hospital] lay out all the options that were available, like other funding [options]? From my interviews right now, there is a lot of doubt about that. The families feel pressure that they won’t be able to get any other treatment if they don’t take the hospital’s offer.”
Quintana says patients transferred by AeroCare are given the option to refuse medical repatriation.
“If a patient can make their own health care decisions mentally, we cannot force their hand because then you’d be looked at as deporting somebody against their rights and we don’t have the authority to do that,” he explains. “If they agree to it, then it’s viewed as a standard hospital transfer, that’s where they want to go.”
Quintana says no records leading up to a patient’s transfer, including documents pertaining to their consent, are kept by AeroCare. The transfer itself, he says, is proof of their consent.
In 2010 AeroCare transported an undocumented quadriplegic, Quelino Ojeda Jimenez, from Advocate Christ Medical Center in Chicago to Oaxaca, his home state. The Mexican roofer had accrued a roughly $650,000 medical bill after he fell more than 20 feet from a rooftop, according to the Chicago Tribune.
In 2011, Ojeda told the Tribune he had been transferred against his will and that he did not want to return to Mexico because he knew he wouldn’t get the rehabilitation he needed. Amid criticism, Advocate Health Care, the largest hospital network in Illinois, acknowledged it did not obtain consent from Ojeda, though a judge had declared him capable of making his own decisions, according to the paper.
Ojeda died of pneumonia and other complications in 2012 in Mexico in a small-town hospital.
Quintana says he believes that the medical repatriation process has improved in recent years. He says just a few years ago “consulates weren’t very involved and a lot of hospitals were doing this on their own,” and that, mainly as a result of the Ojeda case and the negative attention it received, all repatriations conducted by AeroCare from Chicago now go through consulates.
Even in cases where consulates are involved, Sullivan says that among the repatriations he has studied in Mexico, what gets put on paper often looks different than reality.
“I am also looking at how patients access services here,” he says. “The consulates are supposed to link patients up with Mexican health services, but in some cases, though the paperwork may get done, later it’s not carried out.”
Sullivan shared the story of a patient whose family he interviewed in Mexico City. “Lorenzo” was a Mexican national and former law student who went to Chicago for two years to earn money to finish his education. In 2010, he was brutally assaulted in an alley and admitted to Mt. Sinai Hospital. After three months of care, Mt. Sinai convinced Lorenzo’s family it would be best for him to go back to Mexico, that he needed long-term care and there was nothing more they cold do. Sullivan says Lorenzo’s medical records weren’t transferred to a Mexican facility and they weren’t translated into Spanish.
From Mt. Sinai, Lorenzo was taken — along with one wheelchair, some adhesive tape, catheters, pillows and medications that would last three months — directly to his parent’s tiny apartment in Mexico City, where he lives in a narrow bed in the family living room and relies solely on the care of his mother and sister.
His mother sells tamales by day and has no medical background, but she changes Lorenzo’s feeding tube and has figured out how to prevent bedsores.
When she first took her son for a hospital visit in Mexico, it was an ordeal to find someone who could read the English records. The hospital believed Lorenzo’s mother was lying and that Lorenzo was born with his condition, says Sullivan, because none of his information had been transferred to them.
“It was a complete drop of the ball,” he says.
It took nearly five months before Lorenzo was in the medical system in Mexico.
“I have serious concerns about the coordination between U.S. and Mexican health institutions when carrying out medical repatriations,” Sullivan explained in an email to Boulder Weekly. “With little or no follow-up by U.S. hospitals and no American governmental agencies stepping in to track or regulate these international transfers, many vulnerable patients like Lorenzo are falling between the cracks of two health systems.”
Centers for Medicare and Medicaid Services, a federal agency within the Department of Health and Human Services, is charged with ensuring discharges are done appropriately, but they lack the authority to investigate the adequacy of international facilities and have no discharge requirements that are specific to hospitals transporting undocumented immigrants back to their country of origin.
“If hospitals in the U.S. are going to discharge someone to another [domestic] facility, there are legal requirements that include follow-up and handing off of medical records,” Sullivan says. “And that is lacking, totally lacking in all of the Mexican cases I’ve seen.”
Sullivan says he worries because every repatriation he hears about — from the degree of uninformed consent, to the level of consular involvement, to the transportation method and company — is different.
“In every case, the process is a little bit different. That is not the way to handle these cases. I think larger agencies need to lend support and clarify what is right and what is wrong here and how to go about it. Things now are really ad hoc.”
Some repatriations are very privatized, explains Sullivan, and hospitals will pay private transportation companies to transport patients. Other transfers include more involvement from consulates, which can provide some funding for a patient’s transport.
Quintana says not all repatriation companies work in the same model. He says AeroCare facilitates the removal and transfer of patients to varying degrees — sometimes gathering the necessary travel documents, contacting the patient’s family and putting all the information into a package to give to consulates, which can help arrange follow-up care in the receiving country.
“We try to work within the standards of the consulates,” he says. But he acknowledges that not every repatriation company is as responsible as his, noting that at least one prominent repatriation company might pay Latin American hospitals a lump sum of money to just keep a patient there for a certain period of time.
“And then who knows what happens,” he says. “Then it’s a Mexican problem, not a U.S. problem.”
One transportation company, MexCare, advertises itself as “an alternative choice for the care of the unfunded Latin American national.” Their advertised service is, “Delivering high quality medical treatment to the unfunded Latin American national. Resulting in significant savings to the U.S. hospital.”
MexCare answered telephone calls from Boulder Weekly but deferred anwering questions due to being “in a conference call,” “in a meeting,” and then “on the way to a meeting,” and declined to return BW’s later inquiries.
Quintana says AeroCare turns down more cases nowadays than ever before because “the hospital is not doing things the proper way, or they are inexperienced.”
“They think we can come in, pick up the patient and stuff them somewhere,” he says, “and that does not happen with us. I am sure it has happened in the past because there are a lot of horror stories people are afraid of.”
Quintana adds that some hospitals care more about their patients than others, and Sullivan agrees.
“Some hospitals don’t do repatriations, which is kind of encouraging,” he says. “What can we learn from those hospitals?”
• • • •
One of the first medical repatriations that got media attention — and still one of the only cases to see legal action — involved Guatemalan native Luis Alberto Jiménez.
In 2000, Jiménez was working as a landscaper and living illegally in Stuart, Fla. Driving home from work one day, he was struck head-on by a drunk driver with blood alcohol content four times the legal limit. Jiménez sustained a severe head injury, was unconscious, his face was severely torn, his arm broken, both of his thighbones were broken and he had multiple internal injuries. He was admitted to Martin Memorial Hospital with a “poor” prognosis, according to a 2008 New York Times story.
Martin Memorial saved Jiménez’s life.
Though his initial medical care was covered by emergency Medicaid, the medical bills that accumulated over the weeks and then months and then years that Jiménez stayed at Martin Memorial were not.
When they determined Jiménez needed long-term rehabilitative care for his brain injury, Martin Memorial attempted to discharge Jiménez to a nursing home. But all the nursing facilities they contacted refused to take Jiménez.
Because no rehabilitative center would accept an uninsured patient, Jiménez stayed, predominantly, at the hospital for more than two years and accrued a $1.5 million medical bill. Only $80,000 of his care was ever covered by emergency Medicaid, according to court papers reviewed by The New York Times.
Desperate, the hospital chartered an air ambulance and loaded Jiménez up in the early morning hours and sent him back to Guatemala without his guardian’s consent. He was sent to his elderly mother’s house in a tiny village where he had no access to medical care.
In Guatemala, he was admitted to a rehabilitation center with an annual budget of $400,000 where he stayed for two weeks before being discharged because the hospital “needed the bed,” according the hospital’s former director, Harold Von Ahn.
“The main problem we have here in Guatemala is that we don’t have enough budget to take care of the patients, so we send them home,” Von Ahn tells Boulder Weekly. He says most repatriated patients sent to his hospital probably stayed for 15 to 20 days before being sent home. The question is: Sent home to what?
Though he says he does not believe the practice is morally acceptable, Von Ahn says Guatemalan hospitals have no choice but to accept the patients sent to them from the U.S.
“We couldn’t say no because it is arranged through the consulates. We just receive them.”
The legal battle in the U.S. over Jiménez’s case was the first of its kind. The court found that Martin Memorial’s discharge plan violated federal requirements and that there was not enough evidence that Jiménez would be met with adequate treatment in Guatemala. Martin Memorial’s president and chief executive, Mark Robitaille, said the U.S. “political leadership” has failed to address the difficulty hospitals face paying for the care of undocumented immigrants.
He told The New York Times it was unfortunate none of the health care reform bills, which were being debated in Washington at the time, addressed the issue: “That means there are still cases like Luis Jiménez’s in hospitals across the country and there will continue to be cases like Luis Jiménez’s.”
Nessel says the issue is simply too controversial for politicians to tackle, and that Obamacare never would have passed had it included provisions for covering undocumented immigrants.
Miguel Garces, a Guatemalan public health advocate and pathologist, says he has no way of knowing the exact number of patients sent to Guatemala by U.S. hospitals every year but that, “It’s at least one a month. At least.”
“If a patient arrives today at the airport, it doesn’t matter what condition they are in, they will be accepted at some hospital here if we have the resources to care for them,” he says. “In general, we don’t.”
What exactly “we don’t” means for those being medically deported is not tracked, but it can be assumed that some immigrants are being deported to their deaths.
Garces says he wants to see the medical repatriations stopped, calling it an “inhumane and highly unethical” practice.
“Doctors are involved in this that really do not care about the health of their patients,” he told Boulder Weekly in an email. “Perhaps the American Medical Association should be made aware of this situation. But do not be disappointed if they do nothing because most physicians do not care about the health of poor people, especially if they are Latinos in the U.S.”
The American Medical Association did not respond to interview requests for this story from Boulder Weekly.
The AMA Council on Ethical and Judicial Affairs did release a statement in 2009 recommending that hospitals “assist a patient who is unwilling to accept the discharge plan to seek independent ethics consultation or other means of resolving the disagreement; and refrain from signing a discharge order that would result in involuntary discharge of a patient who is not a U.S. citizen to his/her country of origin and advocate for the patient’s opportunity to seek formal review of the proposed involuntary removal from the U.S. by appropriate government authorities.”
• • • •
Quintana says the financial burden placed on hospitals to care for undocumented patients cannot be ignored.
“From a financial perspective I can understand that there is pressure put on patients to want to transfer because a hospital has limited number of beds,” he says. “But if they refuse, they refuse. They will probably continue to be asked, ‘What do you want to do? We need to find another facility.’”
While the financial side of medical repatriations unsettles her, Nessel says, she understands the plight of hospitals.
“On one hand I understand that this is a real cost to hospitals,” says Nessel. “I don’t think that is exaggerated. But at the same time hospitals aren’t supposed to be governed by financial decisions. They are supposed to do no harm, and they are not supposed to risk someone’s life, placing their health in great jeopardy or doing repatriations without informed consent.”
Without the proper federal funding and oversight to care for undocumented patients, Nessel says medical repatriations will continue to happen and are likely to happen more frequently.
“I think there really is a problem with the federal funding scheme that there isn’t funding available for people who are not lawful permanent residents,” she says. “It’s really Congress that needs to act for any real change.”
Her report and many immigrant advocates have called for Congress to immediately convene hearings to investigate the practice of unlawful repatriations and repeal laws that impose limits on Medicaid reimbursements to hospitals based on immigration status.
Nessel says these are often de facto deportations and are unconstitutional, violating immigrants’ rights to due process. Her report says that the U.S. has “failed to provide an adequate process” through which unlawfully repatriated immigrants can seek redress, and that until there are state or federal agencies paying attention, hospitals will have little incentive to ensure real informed consent.
Some academics have called for a branch of Immigration and Customs Enforcement (ICE) to get involved. For now, Nessel says hospitals only contact ICE in hopes that the federal immigration agency will put the person in removal proceedings in cases in which the patient is undocumented. In an effort to get a patient into the custody of Immigration and out of their hands, Nessel says hospitals sometimes call ICE, “But ICE has no interest in getting involved or taking custody of patients in need of costly treatment, so hospitals at times take matters into their own hands.”
According to an Immigration and Customs Enforcement spokesperson, ICE has no jurisdiction over medical repatriation because the immigrants are not actually in deportation proceedings.
“This is a total legal gray area,” says Longmont Immigration Attorney Ian McKinley. “Immigration law basically lists the reasons someone can be deported. There are no real penalties if somebody deports an individual and they don’t go through the process. Immigration law doesn’t set up punishment for this type of situation. It just lays out why people are deportable. Yet ICE has exclusive rights to deport people. If they are the only entity that can deport people, that means when hospitals are deporting people it’s illegal and I think it is as simple as that.”
Deportation proceedings, from the day an undocumented immigrant is served deportation papers could take two to three years, if not more. Immigrants have the right to prepare a defense against deportation and may qualify for a green card — for example, if they have been in the country for more than 10 years or have children who are U.S. citizens.
“So it’s crazy for a hospital to just ship them out of the country,” says McKinley. “What if someone was here for persecution and they have an asylum application? I am sure that the hospitals that do this have no idea if the undocumented person has a defense against deportation or not. They are completely ignorant of what these people’s circum stances might be and they don’t care. A lot of times these people will be sent back to their demise. They won’t have the same access to medical care and they may end up dying when they go back to their home country. Some people will say, ‘Well, they never had the right to be here in the first place.’ There’s nothing wrong with saying they don’t have the right to be here in the first place, but I think most people would consider this morally reprehensible.”
According to an ICE spokesperson, if consent is not obtained and a patient is still repatriated, the patient or the patient’s family would have to fight that through the legal system — in Luis Alberto Jiménez’s case, the hospital faced kidnapping charges.
The problem with that picture, says Boulder Civil Rights Attorney Wilbur Smith is that, “Litigation for a private individual is very expensive, and our legal system tends to be stacked toward the socioeconomically elite. An undocumented immigrant is going to have a very hard time accessing that, especially when they have been sent to an underdeveloped country. Once you send a person to an underdeveloped country, it’s pretty much over for them. That may be why [hospitals] can get away with this — because these people happen to be powerless.”
• • • •
Nessel says more generous federal funding would allow hospitals to better care for uninsured immigrants, though that is unlikely to happen anytime soon. Yet, she isn’t hopeless and says there are model programs that hospitals with a high volume of uninsured immigrants could replicate.
“Let’s say, for example, there was a particular area in Tucson, Ariz., where hospitals were spending a lot on repatriations,” says Nessel. “It might be cost effective for a few hospitals to come together and spend the money that would be spent on repatriations on a rehab center or a charity care center.”
Once a patient was stabilized and needed rehabilitative treatment, they could be transferred to the less costly and more logical care center.
In the meantime, McKinley says, immigrant rights groups should be worried about medical repatriation and should educate the community on immigrant rights against de facto deportations.
“This is truly worth protesting and calling to the public’s attention,” he says.
The names of some patients in this article were changed upon request to protect their identity.