They knew that she had been born in Mexico, was a 15-year-old student at a Dallas high school and had gone to her prenatal checkups. They knew she was scared about giving birth.
What the hospital staff did not know, because they did not ask, was whether Ms. Domínguez was an illegal immigrant.
“I don’t want my doctors and nurses to be immigration agents,” said Dr. Ron J. Anderson, the president of Parkland.
Patients like Ms. Domínguez — uninsured Hispanic immigrants with uncertain immigration status — have flocked in recent years to public hospital emergency rooms and maternity wards in Texas, California and other border states. Their care has swelled costs for struggling hospitals and increased the health care bills that fall to states and counties, giving ammunition to opponents of illegal immigration who complain of undue burdens on local taxpayers.
As a result, health care has become one of the sorest issues in the border states’ debate over illegal immigration. Facing harsh criticism from residents, public hospitals are confronted with an uneasy decision: demand immigration documents from patients and deny subsidized care to those who lack them, or follow the public health principle of providing basic care to anyone who needs it.
In Texas, two of the biggest public hospitals chose differently.
The Parkland Health and Hospital System, which serves Dallas County, offers low-cost care to low-income residents with no questions asked about immigration status.
“We decided that these are folks living in our community and we needed to render the care,” Dr. Anderson said.
In Fort Worth, in neighboring Tarrant County, JPS Health Network requires foreign-born patients to show legal immigration documents to receive financial assistance in nonemergencies, like elective surgery and the treatment of routine or chronic illnesses. Executives said that their first responsibility was to legal residents, but that they were uncomfortable about having to make such distinctions.
“I don’t think you should ask the hospital to make moral decisions for the State of Texas or, for that matter, for the United States,” said Robert Earley, a senior vice president of JPS.
To some Fort Worth residents, the hospital — which does provide emergency and maternity care to illegal immigrants — has nonetheless sent a message that illegal immigrants are not welcome.
“Whenever immigrants go to the hospital, the first thing they are asked is, ‘Who are you and where are your immigration papers?’ ” said José Aguilar, a leader of Allied Communities of Tarrant, a coalition of church-based community groups that has pressured the JPS board to reverse its policy. “They are being scared away.”
Across Texas, the debate over illegal immigration has spilled into county commission hearings and hospital board meetings. A study ordered by commissioners in Harris County, which includes Houston, found that about one-fifth of the patients in its health system last year were immigrants without documents, most of them from Mexico. Their numbers had increased 44 percent in three years, the study found, and their care had cost the county $97.3 million, about 14 percent of the health system’s total operating costs.
“We have a lot of United States citizens that need our help in health, and we should pull them up before we pull up someone here illegally,” said Tim Gallagher, 45, a software salesman from Plano, north of Dallas, who in an interview expressed views widely shared in the state. Mr. Gallagher said he favored deporting illegal immigrants who sought care from public facilities, even if the patient was a mother who gave birth to an American citizen.
“If somebody here needs health care, they should get it, and then if they are illegal, they should go bye-bye,” said Mr. Gallagher, who wrote a letter on the subject to The Dallas Morning News.
In California, hospitals spent at least $1.02 billion last year on health care for illegal immigrants that was not reimbursed by federal or state programs, according to federal government estimates. Hospital officials there said the ailing health care system was being pushed to its limit.
“Emergency rooms and hospital doctors are forced to subsidize the lack of immigration enforcement by the federal government,” said C. Duane Dauner, president of the California Hospital Association. “It amounts to an unfunded mandate for us to treat everybody.”
California received $66 million in federal money in 2005, the first year of a four-year national program to help pay for emergency care for illegal immigrants. But it was “not even a down payment” on the total cost, Mr. Dauner said. With more than 1.4 million of California’s residents uninsured and more than half of California’s hospitals operating in the red, Mr. Dauner warned that care for illegal immigrants could tip some hospitals into bankruptcy.
Even so, the surging numbers of illegal immigrants in the health care system have fed some misconceptions, hospital administrators said.
While Texas border hospitals often get “anchor babies” — children of Mexican women who dart across the border to give birth to an American citizen — most illegal immigrants who go to major hospitals in Texas can show that they have been living here for years, said Ernie Schmid, policy director at the Texas Hospital Association. Many immigrant families have mixed status; often a patient with no documents has a spouse or children who are legal.
Most immigrant patients have jobs and pay taxes, through paycheck deductions or property taxes included in their rent, administrators at the Dallas and Fort Worth hospitals said. At both institutions, they have a better record of paying their bills than low-income Americans do, the administrators said.
The largest group of illegal immigrant patients is pregnant women, hospital figures show. Contrary to popular belief here, their care is not paid for through local taxes. Under a 2002 amendment to federal regulations, the births are covered by federal taxes through Medicaid because their children automatically become American citizens.
These cases are not affected by new regulations that went into effect on July 1 requiring Medicaid patients to provide proof of citizenship, Texas health officials said. They said they believed that only small numbers of illegal immigrants had received other Medicaid benefits.
Administrators at Parkland said the hospital delivered 11,500 babies last year to mothers who were probably illegal immigrants, representing at least 56 percent of its maternity patients.
One was Ms. Domínguez, whose family brought her to Dallas from Mexico 11 years ago. Guided through Parkland’s prenatal care, the frightened teenager had an unexceptional labor and a robust baby girl.
Many immigrants have sought low-cost care by going to Parkland’s emergency room, where, by federal law, they must be examined and treated, as is the case in any emergency room. Leticia Martínez, 24, walked into the emergency room one morning weak with cramps, fearing a miscarriage in her two-month pregnancy.
Ms. Martínez said she had been sure she would get care at Parkland because her first baby had been born there. “They help economically,” she said. “They don’t ask the immigration question.”
Dr. Anderson fiercely defends Parkland’s open policy. “It’s much wiser to render care than to wait until they are very sick,” he said.
In Fort Worth, JPS Health Network also provides low-cost prenatal care and delivery for illegal immigrant mothers. It does not offer them help for other nonemergency care.
In January 2004, the JPS board of managers voted to offer its financial assistance program to all Tarrant County residents, legal or otherwise. But eight months later, with illegal immigrants starting to fill the hospital, the managers reversed course in a meeting where they agonized over their votes, the minutes show.
The policy has given the hospital a mixed reputation among Hispanics in Fort Worth.
Edy Patricia Rodríguez, 18, an illegal immigrant whose husband is an American citizen, cuddled her newborn recently in a private, state-of-the-art room at the JPS hospital. The child, Pablo F. Ibarra, born June 28, thrived in the network’s care, and his mother was satisfied.
But misunderstandings about immigration status clouded the case of Victoria Canales, a Mexican immigrant who had sought care for advanced liver disease, said her husband, Jesus Canales, 36.
Mrs. Canales was a legal resident and a member of the JPS network’s low-income program. But hospital staff members seemed confused about her case, Mr. Canales said, and twice sent her home when she had gone to seek relief from the liquid filling her body.
Humiliated, Mrs. Canales was reluctant to return to the hospital until she could no longer manage at home, Mr. Canales said. She died June 26.
JPS officials say they do not refuse care to people who need it, but are wrestling with the demands of county residents and changing state laws.
Mr. Earley, the JPS vice president, said, “We have been bounced around like a basketball on this issue.”
