Patients undergo dialysis treatment. Image via flickr/Jim Forest.
Pedro*, a 76-year-old undocumented immigrant from Acapulco, Mexico, walked slowly towards my car. His skin was brown. His hair was gray. And he wore gloom on his face. We met outside the office of Justicia y Paz,* the organization where I volunteered, and I quietly asked whether he was okay.
“No, I’m not okay,” he said. “No one will ever be okay. People don't like to hear it, but that’s the truth.” He began to cry. “Why won’t anyone give me a job, man? Why won’t anyone help me?”
I didn’t have an answer.
For the last year, I’ve lived in Houston, studying the hurdles facing undocumented immigrants. I met many people like Pedro, but his story stood out, since it so clearly illustrates the shortcomings of the health care system.
As the weeks went on, I spent more time with Pedro, learning about the death of his family members, his journey to the United States and the health problems he faces today.
Pedro shared that he has a Foley catheter, which helps regulate urine flow and ensures a functioning bladder. But by the time we became acquaintances, he was forced to change the catheter regularly because it leaks, leading to foul smells and potential contamination.
I asked him if there was any way to fix his underlying medical issue. Surgery, he said, was possible, but he explained he would be unable to undergo the procedure because he lacks a Gold Card.
Though the physical card no longer exists – it was phased out several years ago – the term refers to the Harris Health Financial Assistance program. The taxpayer-supported discount program offsets health care costs for individuals and families on a sliding scale of fees. It’s meant to supplement health insurance, but for those who lack insurance, it can also help reduce costs. It can only be used within the county’s Harris Health System, and eligibility is limited to those with household income at or below 150 percent of the federal poverty level.
While Harris County’s Gold Card program is not a form of health insurance, it has become the only means of granting indigent, uninsured populations some form of financial assistance to make health care affordable at little to no cost. In Fiscal Year 2015, it provided $626.2 million in charity care, according to Harris Health. But not everybody can enroll in the program: three proofs are required for a Gold Card. To get in the program, residents must show proof of income, proof of residency and proof of identification. Technically, undocumented immigrants aren’t banned from the program. But effectively, many are, because each of these requirements can be a serious hurdle.
Undocumented immigrants’ employers are often unable or unwilling to provide paycheck stubs. Many undocumented immigrants share housing or have living arrangements in which their names aren’t on the actual lease (and some are altogether homeless – which makes the process of providing proof of residency nearly impossible). Finally, though some “undocumented” immigrants really do have documents that prove their identity (e.g., passports, birth certificates or visas), others – like Pedro – may not have anything. As a result, they’re excluded from the only program in place that can help them access the health care safety net before resorting to the emergency room.
A more efficient system might recognize the benefits of allowing someone like Pedro to access the Gold Card program, documentation not withstanding. Of course, some skeptics question the merits of providing undocumented immigrants with access to a financial assistance program like the Gold Card. But, beyond the human rights argument, there’s a clear economic case to be made.
One of the most pervasive arguments about undocumented immigrants is that they take more than they put into the economy. But this is not true. Scholar James Cockcroft, in his book, “Outlaws in a Promised Land: Mexican Immigrant Workers and America’s Future,” is among the many researchers who dispel this myth. He argues that instead of draining the economy, undocumented immigrants subsidize it, contributing substantially to the U.S. economy while generally being denied public benefits that citizens are provided (e.g., health care).
And, of course, it’s commonly accepted that preventive medicine is less costly than emergency care. A decade ago, then-Texas Comptroller Carole Keeton Strayhorn released a report indicating that undocumented immigrants produced an estimate of $1.58 billion in state revenue and received $1.16 billion in state services. In terms of health care, her report revealed that 1 in every 5 patients within the Harris County Hospital District was an undocumented immigrant, accounting for $97.3 million or approximately 14 percent of the district’s total operating costs that would not be reimbursed. The majority of these expenditures come from high-cost emergency room services.
Pedro epitomizes the situation facing thousands of undocumented immigrants across the country, and he illustrates the dire domino effect of exclusion from the health care safety net. Pedro needs to see a primary care provider in order to get a referral for a specialist. But this is not possible because Pedro has no Gold Card; even if he did, his lack of identification would likely halt his movement through the long chain of health care bureaucracy. If Pedro can’t see a specialist, he is unable to schedule a surgery. Without the surgery, he essentially has to wait for his treatable bladder problem to escalate into a full-scale urinary tract infection and kidney failure. It is only at this point that Pedro might be able to be seen in a hospital’s emergency room under the Emergency Medical Treatment and Labor Act, if the hospital regards his situation as life-threatening emergency (though there is some definite discretion in this). At that point, the public would likely foot the medical bill, either through taxpayer costs or indirectly through insurance premiums.
Assuming he is seen, the hospital would be required to stabilize him, but after this, he would be on his own again, expected to pick up hospital costs for long-term care, such as his hospital stay or ongoing dialysis. Of course, he won’t be able to do this because he has no insurance – he’s ineligible for government-subsidized health insurance as an undocumented immigrant – and his earnings as a day laborer are unlikely to ever allow him to pay for this treatment out-of-pocket.
In all likelihood, Pedro will face one of two outcomes. One might be medical repatriation/deportation, the process by which some American hospitals repatriate sick immigrants – often without government oversight – since hospitals are obligated by federal law to arrange post-hospital care for patients, even though such care is difficult or impossible to find for those without insurance. As a result, they often choose another option: arranging for the immigrant to be sent back to his home country. Another possible outcome is that Pedro may die as a result of failing to treat his treatable medical complications.
He’s not alone. Kidney disease experts at Baylor College of Medicine estimate that 1,000 undocumented immigrants in Texas require dialysis. That treatment costs about $87,000 annually, but in many cases, if they don’t get the regular treatment they need, they must seek “emergent dialysis” at the ER. They only get it if their lives are truly at risk, and it costs more than three times the amount of typical dialysis. It’s more expensive, and it’s much less effective.
The Migration Policy Institute estimates there are more 373,000 undocumented immigrants in Harris County, which ranks it second only to Los Angeles County among counties with the highest concentrations of undocumented immigrants. Collectively, we’re paying a lot of money for some very poor health outcomes. Without access to preventative care, the result for undocumented immigrants like Pedro is a slow deterioration of health or death. And we’re paying for it – even if we think we aren’t.
* Pedro and Justicia y Paz are pseudonyms intended to protect the identity of the subject of this article.
Anthony Jimenez is a Kinder Scholar and doctoral candidate in University of Minnesota’s Sociology Department. He received his master’s degree in sociology from the University of Texas at El Paso.