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Charity health care hard to come by for undocumented immigrants

Eduardo Franco Ramirez was attacked so viciously by muggers near his home in Aurora in September 2013 that the police on the scene thought he had died.

The Guatemalan construction worker was rushed to the emergency department of the University of Colorado Hospital, less than a mile away. Doctors there saved his life. They removed a quarter of his skull to relieve the swelling and cared for him during his 16-day coma, then more than a week after that.

And then he was discharged. Franco was told to return for surgery to reattach his bone after his brain had a chance to heal. That’s when his trouble deepened.

Franco is an undocumented immigrant. Without insurance or a large amount of cash, he had no way to pay for the surgery he needed to reconstruct his skull.

Left out of health-care reform and ineligible for Medicaid, undocumented immigrants have few options for coverage and are dependent on charity care from hospitals for urgent medical needs.

At Mercy Regional Medical Center in Durango, anyone who needs emergency attention or other nonelective, medically necessary care will receive it, spokesman David Bruzzese said.

In cases in which reimbursement for service to Medicaid or Medicare patients doesn’t cover the cost, the medical center absorbs the difference, Bruzzese said.

Accessing specialty care can be daunting in the best circumstances. The expansion of Medicaid and private insurance have swelled wait lists and strained specialty clinics, while high co-pays and deductibles can add up quickly.

For those who remain without insurance, the barriers can be even higher.

State laws require that each institution’s financial assistance policies be posted publicly and that hospitals offer discounted care to low-income patients. But the policies are sometimes opaque and are fraught with loopholes.

A 2012 law intended to provide charity care to uninsured patients, for example, applies to patients only in emergency care or admitted to hospitals – not those seeking admission for surgery or follow-up care, said state Sen. Irene Aguilar, D-Denver, a physician who pushed for the expansion in discounted care.

But none have it harder than undocumented immigrants when it comes to accessing low-cost specialty care. The state health insurance exchange sells only to legal residents, and insurers often have their own restrictions. Meanwhile, a confusing raft of state and federal laws and hospital policies can conspire to shut people out from even what charity care is available.

Dr. Jim Williams heads a safety-net clinic in Westminster called Clinica Colorado. He primarily serves uninsured patients, many of whom are undocumented.

Most of them need no more than the primary care available at Clinica Colorado. But when Williams has patients who have suffered trauma, he struggles to find specialty care for them. He has found Exempla Saint Joseph Hospital to be a willing partner in offering his patients surgery or other specialty care at discounted rates. But Saint Joseph’s can’t always help.

“My undocumented patients who can’t get specialty care deal with it just the way they would deal with it if they were living in Mexico – they just put up with it,” Williams said. “Even when it’s life-threatening.”

Except in emergency cases when a patient likely is to die within 24 to 48 hours, undocumented immigrants over age 18 are excluded from most charity care at University Hospital. The ban makes University different, even in the realm of restrictions, caveats and limitations by other hospitals.

The general exclusion – which does allow for public health services, including immunizations and prenatal care – is a result of a 2006 state law that restricts the use of public benefits for undocumented immigrants. Because University Hospital’s doctors are on the faculty of CU School of Medicine, their charity services are defined as a public benefit.

“We are prohibited by the state from doing any nonemergency care for undocumented patients,” said Christina Finlayson, a surgical oncologist put forward by University Hospital as a spokesperson. She said the law puts doctors there in a bind.

“If you talk to any one of us individually, if you talk to our administrators individually, we all have a vested interest in that. We are all wanting to provide as much care as we can,” she said.

The restriction can play out in cruel ways, for doctors and their patients.

Aurora grandmother Luz Macias, an undocumented immigrant from Mexico, already had visited three different emergency rooms when she showed up for a specialist appointment at University Hospital on Dec. 16.

During those ER visits, three doctors told her that she had an ovarian tumor, gave her prescription medication to address her crippling pain and advised her to seek a diagnosis and get the tumor removed.

Finally in the door at University Hospital, Macias was weighed, given a flu shot, then told that because she didn’t have insurance or ability to pay, there would be no visit with the gynecologist, no diagnosis and no surgery.

The hospital declined to comment on Macias’ case, citing patient privacy laws, but reiterated that undocumented immigrants by state law do not qualify for charity care.

Some critics question the hospital’s policies. University Hospital is an independent nonprofit with its own stream of private funding, and administrators point out that it is not the state-supported institution that its name implies.

Joan Fitz-Gerald, a former Democratic state senator, co-sponsored the 2006 bill limiting the use of public benefits for illegal immigrants. She believes University Hospital’s use of the law to deny charity care is a stretch.

“This interpretation is pretty much beyond the boundaries of what we had envisioned,” Fitz-Gerald said. Given the hospital’s access to nonstate funding, “they could figure out to be more comprehensive if they so choose,” she said.

Hospital spokesman Dan Weaver stood by University Hospital’s interpretation of state law, saying that the hospital is defined as a “political subdivision” of the state, and its doctors are supported in part by state funds.

Other hospitals in the state aren’t bound by the same rules. Still, access at those hospitals also can be daunting.

Macias, the woman with the tumor, eventually found help. But it wasn’t simple. She found her way to Caritas Clinic, a safety-net clinic affiliated with Saint Joseph Hospital.

A week later, surgeons at Saint Joseph removed her tumor, which turned out to be benign.

Franco has not been so lucky. Now a year and a half out from the assault, his life has shrunk down to his bare apartment

He wears a cheap white bike helmet to protect his head. Beneath it, his black hair has grown over a dent the size of a man’s fist. He takes the helmet on and off compulsively, his hand creeping to the soft spot.

“I am frightened,” Franco said. His vision has been fading. Without the surgery, he can’t work to support himself or his family, including a 4-year-old daughter who is paraplegic. And returning to Guatemala is out of the question.

“I can’t go back,” he said. “I’ll starve to death along with my family. I can’t work. How are we going to live?”

The Durango Herald provides this report in partnership with Rocky Mountain PBS I-News. Learn more at rmpbs.org/news. Contact Kristin Jones at kristinjones@rmpbs.org. The Durango Herald contributed to this report.



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