Over the river: treating the flood of uninsured illegal immigrants threatens to erode the quality of care hospitals can afford to provide.

• Author: Martin, Edward
• Position: FEATURE

On good days, her dark eyes sparkled, but those days grew rare. The walls of her heart were becoming rigid from restrictive cardiomyopathy, and Jesica Santillan seemed to become even tinier inside her print hospital gown. Spirits leaped when a donor was found and a Duke University Hospital surgeon opened her chest and replaced her heart and lungs. Joy turned to despair when the accidentally mismatched organs failed, and despite a second transplant a week later, she died. Santillan, who turned 17 while awaiting her first transplant, ignited a firestorm over hospital safety and costs. Her bill: nearly $900,000.

Duke University Hospital wrote it off, settled a lawsuit by the family and began rebuilding its reputation. But other circumstances surrounding the girl's death, less noted at the time, are becoming one of the most volatile issues in health care.

Her mother and stepfather had paid a smuggler $5,000 to bring them and their three children from Mexico to the U.S. They settled in Franklin County, near Raleigh, where jobs were plentiful and employers wouldn't delve too deeply into immigration status. Her mother became a housekeeper at Louisburg College, and her stepfather was a construction worker.

As many as 600,000 illegal immigrants live in North Carolina, by some estimates a third more than when Jesica died in 2003. Thousands pour into Tar Heel hospitals each year, straining budgets stretched by skimpy Medicare and Medicaid payments and managed-care discounts. No hospitals are immune, not even the best in the state, as ranked for BUSINESS NORTH CAROLINA by Lakewood, Colo.-based Health Grades Inc. Solutions are scarce, emotions high.

"In most circles, it's politically difficult to say, 'Let's provide health care for illegal or undocumented immigrants,'" says Edward Norton, professor of health-care policy and economics at UNC Chapel Hill. "However, when they have a medical emergency, it's ethically and legally required that hospitals and physicians provide care."

The result can be health-care delivery at its worst. Lacking insurance and family doctors for routine care, illegal immigrants often postpone treatment. Chronic conditions become acute. High blood pressure becomes a stroke. A breast lump metastasizes. "By not providing routine care and checkups, we collectively end up paying more," Norton says.

Those who pay their own medical bills take a big hit, and care for uninsured illegal immigrants pushes up premiums and co-payments for those who have insurance coverage. Nobody is certain how much it's costing the state and its legal residents. Educated guesses place it at $500 million to $1 billion a year. A study by Menlo Park, Calif.-based Kaiser Family Foundation and the Pew Hispanic Center in Washington, D.C., found that more than 60% of illegal immigrants are uninsured. In a 2006 study of Hispanic immigration's economic impact in North Carolina, paid for by the Mexican consulate and the state bankers association, the Kenan Institute of Private Enterprise at UNC Chapel Hill pegged the health-care cost at nearly $300 million, though it used figures that were several years old. Researchers also grouped legal immigrants with illegal ones. Illegals typically work poorer-paying jobs and are less likely to be insured or able to pay their own bills. Eventually, hospital administrators wind up with the issue in their laps.

They complain that the federal Emergency Medical Treatment and Active Labor Act of 1985--EMTALA--compels them to treat anybody who shows up with an acute problem, regardless of ability to pay. It also discourages them from asking about immigration status for fear of being accused of discrimination. Some cite another factor--the inherent nature of health care.

"Hospitals and their people tend to be compassionate places," says Don Dalton, vice president of the 135-member North Carolina Hospital Association. "A lot of the people who run hospitals take the position that we're here to serve the people of the community, regardless of who they are."

On a blustery winter morning in Concord, two men prop their elbows on the hood of a battered Dodge Neon in the parking lot outside NorthEast Medical Center's emergency department. On the car's front bumper is a green, white and red plate, a rendition of the...