> Published Sunday, August 13, 2000, in the Miami Herald
>
> Health clinics accused of immigrant bias
>
> Miami-Dade trust comes under fire
>
> BY ANDRES VIGLUCCI
> aviglucci at herald.com
>
> Miami-Dade's vast system of public health care is coming under increasing
> fire for charging high fees to poor undocumented immigrants, a practice
> that critics say is discriminatory and effectively denies treatment to some
> of the county's neediest residents.
>
> Under long-established but little-noticed procedures, foreign-born patients
> who cannot produce immigration papers have been denied the reduced rates
> given to other poor county residents at
> Jackson Memorial Hospital and a far-flung network of primary care clinics,
> both run by the Miami-Dade Public Health Trust.
>
> Even indigent immigrants who would otherwise qualify for free care must pay
> fees or cash deposits
> before they can see a doctor in non-emergencies, and are subsequently
> billed at the system's highest rates, advocates for immigrants and the poor
> say.
>
> The consequences: Some immigrants who cannot afford the cost let medical
> conditions go untreated until they need expensive emergency care. And
> contagious diseases can pose a public health threat.
>
> Complaints over the practice have become increasingly common in the last
> two years as the trust has taken over operation of several formerly
> state-run clinics in immigrant-heavy neighborhoods.
>
> When her 9-year-old daughter was diagnosed with leukemia in 1995,
> Nicaraguan immigrant Mar=EDa
> Morales spent countless hours at Jackson, missing work, while she persuaded
> officials to reduce a $75 clinic fee every time doctors needed to see the
> girl.
>
> A DEPOSIT
>
> A bone-marrow transplant the girl needed was put off until Morales could
> pay a deposit. Morales never tallied the bills she later received for two
> years of treatment, saying she could not pay them.
>
> ``The doctors are very good. I have no complaints about them or the
> clinic,'' said Morales, who was here illegally at the time, but has
> recently obtained U.S. residency. ``But to get her seen, I had to go
> through a thousand difficulties for two years. It's unfair.''
>
> LAWSUIT PLANNED
>
> Lawyers at Florida Legal Services and the American Civil Liberties Union's
> Florida chapter are preparing to file a civil-rights complaint with the
> U.S. Department of Justice, contending that it is illegal for the trust to
> provide free or discounted care to one group of county residents while
> denying the same benefit to another -- even if they are undocumented.
>
> The advocates say the issue of access to public health care is critical in
> a county where about 500,000 people, many of them immigrants, have no
> medical insurance. They say the undocumented deserve equal treatment for
> several reasons:
>
> First, illegal immigrants who live and work here pay sales taxes that
> support the trust's operations. Second, getting people into preventive care
> early saves money in the long run by reducing the need for expensive
> emergency care, which the county must by law provide to all who require it.
>
> HEALTH THREAT
>
> Also, people with contagious or infectious diseases who go untreated pose a
> threat to public health.
>
> ``To deny them primary care or to throw up these barriers hurts their
> health and is a huge risk to public health,'' said legal services attorney
> Miriam Harmatz. ``The policy excludes undocumented immigrants who are
> living here, working here, paying taxes, and when they get sick, are
> classified as non-county residents and charged the highest fee.''
>
> Trust officials insist that no one is denied care because of inability to
> pay or lack of immigration status. They say they do not want to discourage
> the poor and sick from seeking care.
>
> ``We need people to come and get preventive care. We want them to show up
> at primary care centers,'' said trust spokeswoman Conchita Ruiz-Topinka.
> ``We don't want them to show up in the emergency room if it can be
> avoided.''
>
> REIMBURSEMENT
>
> The Miami-Dade County attorney's office, while conceding that no law
> requires trust officials to ask for immigration documents, contends that
> the policy is not discriminatory because the papers are used only to check
> whether patients qualify for government reimbursement.
>
> But trust officials acknowledge that its written policy can be read to
> require immigration documentation to determine eligibility for discounted
> fees. Advocates say that has been the common practice.
>
> ``The policy was not intended to happen that way, but it might have,'' said
> Maria Dominguez, a specialist on immigration law and a member of the
> trust's board of directors who has been appointed
> to review the policy. ``What we need to do is fine-tune the policy.''
>
> But advocates who have been pressing the trust to rescind the practice for
> months say officials have
> yet to formally rewrite the policy.
>
> Interviews with social workers, neighborhood advocates and patients suggest
> the practice is in fact commonplace, and has earned Jackson and the
> trust-run clinics a reputation as immigrant-unfriendly.
>
> To be seen, uninsured patients undergo a complicated application process
> that comprises verification that they are county residents, followed by an
> income review to determine whether they qualify for free or discounted
> care.
>
> Most of the difference is absorbed by taxpayers: Jackson spends about $350
> million a year on indigent care that is unreimbursed, about $200 million of
> that from a half-penny sales tax, trust officials said. The trust garners
> millions of dollars more in reimbursement for care from state and federal
> programs.
>
> Advocates argue that the trust is flush enough, with cash reserves of about
> $300 million and an operating surplus of about $5 million, to provide care
> to the undocumented poor.
>
> ``They're a little too interested in their own finances, more than they are
> in their public service, which is to take care of people who need it,''
> said Dr. Joe Greer, founder of free clinics at Camillus House and St. John
> Bosco Catholic Church in Little Havana.
>
> THE DOCUMENTS
>
> Yet the trust requires foreign-born patients, in addition to proof of
> county residency, to provide one or more of a series of immigration
> documents that show they are here legally, or have applied for legal
> status. In practice, many advocates and patients said, intake workers have
> treated those who cannot produce papers as non-county residents, meaning
> they are not eligible for free or discounted care.
>
> So when they apply for a clinic card to be seen by a doctor, they pay $75,
> the highest fee in the system's scale. Until a recent policy change -- also
> prompted by advocates' complaints -- indigent patients paid $10; now they
> pay nothing. Those persistent or savvy enough can get the fee reduced or
> waived. But the undocumented are in addition billed for other services,
> such as lab work or hospitalization, at the highest, non-resident rates.
> Indigent legal residents, in contrast, are not billed.
>
> Some patients, fearful of being reported to immigration authorities or
> simply unable to pay, leave when intake workers ask for immigration
> documents or cash, advocates who have compiled scores of complaints said.
> Some wait until they are so sick they need expensive emergency care.
>
> When his doctor at the free, charity-run Camillus House clinic sent him to
> Jackson's pharmacy last
> month to pick up discounted prescriptions for arthritis and a chronic sinus
> condition, Jose Mej=EDa, 37, a Honduran immigrant, said his immigration
> status posed a problem.
>
> INTAKE WORKER
>
> After examining his temporary immigration papers, an intake worker
> scornfully -- and erroneously -- informed Mej=EDa that they were about to
> expire, he said. She filled the prescription for $12, but told Mej=EDa he
> would pay full price -- about $72 -- when time came for a refill.
>
> Mej=EDa, who has no health insurance at his insulation-installation job,
> skipped his follow-up visit to
> Camillus, figuring doctors would only send him back to Jackson for
> medication he could not afford. He said he would never return to Jackson if
> he could help it.
>
> ``They treated me with disrespect,'' Mej=EDa said. ``At a public hospital,
> there should be better treatment, and it should not matter whether you are
> undocumented or not.''