L.A. County estimates that ER and subsequent inpatient care for the illegal annually cost it $340 million. Others call the figure unreliable.

By Lisa Richardson
Times Staff Writer

Los Angeles County's financially imperiled health department estimates that it spends $340 million annually to treat illegal immigrants who seek
emergency and follow-up care, a figure that is fueling the long- standing debate over who should bear such costs.

The estimate arrives as the county Department of Health Services is cutting services and preparing to close hospitals in anticipation of a
$265-million shortfall by fiscal year 2006. The gap will grow if lawsuits block the department from shutting down Rancho Los Amigos National
Rehabilitation Center in Downey and reducing the number of beds at County-USC Medical Center near downtown L.A.

"With our health-care delivery system on the verge of collapse the issue of illegal immigrants impacts our ability to balance our budget," said
Mike Antonovich, the county supervisor who requested that health officials produce the estimate.

"We have no control over their breaking the law, entering the country illegally and ending up in our medical centers and hospitals," he said,
adding that the responsibility for dealing with the associated costs rests with the federal government.

But community health care advocates call the estimate unreliable, because the county has no accurate system for determining patients'
immigration status. They also worry that the estimate will unfairly blame illegal immigrants for the health department's overall budget crisis.

"Any responsible discussion of solutions has to deal with the true nature of the health-care crisis in L.A. County. It is outrageous that you can
have people working full time to be self-reliant and self-sufficient, but when their child gets sick, they cannot afford to take their child to the
doctor," said Yolanda Vera, an attorney at Neighborhood Legal Services.

Indeed, some experts say undocumented immigrants are not the biggest drain on hospitals; legal residents with no insurance are. A UCLA
Center for Health Policy Research survey found that of 1.3 million uninsured adults in the county, about 390,000 are illegal immigrants.

E. Richard Brown, the center's director, said the larger problem is that many employers don't pay for immigrants' health coverage — whether their employees are
here legally or not.

"These are people who may work in restaurants, as gardeners, in service sector jobs, as nannies or washing cars, and we're the beneficiaries of their services,"
Brown said. "We get cheap labor, but we're expecting somebody else to pay for the medical care."

The county estimates that about 11.5% of patients seeking care at county-run emergency rooms are illegal immigrants. Officials calculate that County-USC Medical
Center treats the highest percentage — a fifth of its overall patient population — followed by Women's and Children's Hospital (9.8%), which is one of its units, and
Harbor-UCLA Medical Center near Torrance (6.9%).

The health department arrived at its $340-million estimate by analyzing patients' ability to pay for emergency and subsequent inpatient services at County-USC,
Olive View-UCLA, King/Drew and Harbor UCLA medical centers, said Chief Medical Officer Dr. Thomas Garthwaite, director of the department.

Indigent patients who neither had private insurance nor were eligible for Medi-Cal because of unclear citizenship status were deemed likely to be illegal immigrants,
he said.

Garthwaite emphasized that the cost estimate is rough, but Vera and some other health-care advocates say determining a patient's legal status is so difficult that they
would not use the figure for policy discussions

"I think that number is suspect, because the county has never really tracked what patients' status is," she said. "And if you're presenting in an emergency room and
you're unconscious, they can't wait until you awake to take up your passport and check."

Los Angeles County officials say they are largely required by federal regulations to treat everyone who needs emergency care, even if they are here illegally and lack
public or private health insurance.

"The federal government has decided everyone is entitled to emergency care if they're really sick. They are to be evaluated and stabilized," Garthwaite said. "For the
County of L.A. [that] runs four hospitals with emergency rooms, that means we screen and evaluate any individual" who needs treatment.

A 1986 federal law requires that anyone who seeks treatment in an emergency department be provided with "an appropriate medical screening examination" to
determine if there is an emergency. So the hospital is obligated to treat and stabilize the patient. Also, pregnant women who arrive in labor must be treated.

But the federal definition of "emergency medical condition" leaves room for interpretation.

Los Angeles County takes a broader reading of the regulations than some other counties on the grounds that providing some preventive care to illegal immigrants is
more humane and economical than waiting until patients are in full-fledged medical emergencies, Garthwaite said.

"Take droopy eyelids, which happens to people as they get older," he said. "Is operating on you cosmetic if you can't see? If you're almost blind?

"Or if I'm a kid; I'm an undocumented immigrant, I don't have insurance and I'm not getting any care for my asthma. I miss school and go to the emergency room.
Well, without any monitoring and medicine, then I'm destined to be back in that emergency room again and again."

The situation is different, for example, in San Diego County, which has no public hospital. Instead, it contracts with UC San Diego Medical Center to care for
indigents. Since 1993 the county has not paid to provide emergency care for illegal immigrants, shifting the cost to the hospital.

"What San Diego does — that threshold is somewhat less than we would be comfortable providing," Garthwaite said.

Denver, which has a public hospital, also is stricter than Los Angeles County. The Denver Health and Hospital Authority requires proof of residency in the city or
county, although not proof of citizenship.

The growing burden on local governments in Southern California has further stoked opposition to illegal immigration.

"Dr. Garthwaite is absolutely right. He can't turn people away," said Barbara Coe, president of the California Coalition for Immigration Reform and coauthor of
Proposition 187, the 1994 ballot measure that would have denied many social services and public education to illegal immigrants.

"But the solution very is simple: What has to happen is that the illegals get out and are kept out," she said.

Antonovich believes that the problem should be addressed at the federal level. He said it is incumbent on U.S. officials to find ways of either paying for care or
stemming the flow of illegal immigrants into L.A. County hospitals.

One possibility would be offering guest worker permits that include health care coverage, he said. Another would be financing a system of clinics on the Mexican
side of the border, staffed jointly by U.S. and Mexican physicians.

"At this end we're making suggestions about what to do. If Congress recognizes the problem, they have the ability to solve it," he said.

Some lawmakers are seeking federal relief. Last month a senator and congressman from Arizona, working with Sen. Dianne Feinstein of California and a coalition of
representatives of other border states, submitted a bill that would provide $1.4 billion annually for five years to states, counties and hospitals with large populations of
illegal immigrants.

The bill, introduced by U.S. Sen. Jon Kyl and Rep. Jim Kolbe, is backed by the California congressional delegation and delegations from states with similar
expenses, the American Hospital Assn. and U.S. Border Counties Coalition, among others.

The proposed legislation faces long odds, however.

For a time there seemed to be growing political will to address the issue, but that interest waned after the terrorist attacks of Sept. 11, said Jan Emerson of the
California Healthcare Assn. Discussions between Mexico and the United States about easing immigration took a backseat to security concerns.

"As far as I can see, they're stuck," said Robert Blendon, professor of health policy and management at Harvard University, about L.A. County and other areas with
large populations of illegal immigrants.

"You can see that the problem is [that] the national government — and it's bipartisan — is abrogating its responsibilities," he said. "These costs should be subsidized
very heavily by the federal government, but other states are busy struggling with their own problems."

Dan Stein of the Foundation for American Immigration Reform, a nonprofit organization that favors curtailing immigration, argues that a surtax ought to be leveled on
everyone who employs illegal immigrants.

"The system of illegal immigration is really about trying to pass on to the community the cost for dependence on illegal foreign labor," Stein said. "This $340-million
figure represents this philosophy that's been adopted by the agricultural, food processing and hospitality industry for some time. I'd say, 'You wanted them here. In
many cases you bring them here, and so we're not going to ask the middle class to pick up the tab.' "