John A. Guest: Caring for a city of immigrants, Feb 4 2002, in Modern Healthcare

This is a reproduction of an article published in Modern Healthcare in 2002. I'm reproducing it here, because it gets at why health systems in just about any country should provide care, or at least certain kinds of care, without regard to immigration status: it's the right thing to do, and providing preventive care means you avoid more costly conditions later. The article doesn't deal with one other factor: if an immigrant community has as outbreak of an infectious disease, like AIDS, the flu, or SARS, you absolutely need to offer treatment, or else your citizens get sick, too.



In December the Harris County district attorney in Houston announced he was ''shelving'' his criminal investigation into the Harris County Hospital District's provision of discounted, nonemergency care to undocumented aliens residing in our county. Now that nobody is talking about arresting me or other district officials, I feel free to speak out on this thorny issue, which has implications for providers and immigrants across the country.

While some have argued that this case is about providing free care to illegal immigrants, I look at it differently. What we have been doing is providing preventive care to our neighbors, who in many cases pay for part of their treatment. It's a lot better than everyone depending on emergency rooms as primary-care centers.


It is important to remember that Texas used to be part of Mexico. Today large numbers of people on one side of the border have family on the other side. Children visit their parents; cousins spend summers with aunts and uncles; even in-laws move in with one another for varying periods of time. Sorting out who belongs on which side of the border is next to impossible, particularly for a public hospital system with limited investigative powers.

Mostly, undocumented immigrants come to Texas to work. And it is often physically demanding work-mowing lawns, building houses and roads, picking crops, preparing and serving food. Federal law says we are not supposed to employ them, but they are here, working in our community.

While no generalization applies to all undocumented immigrants, for the most part they are young and healthy, necessary attributes for doing the kind of work they do. They also lack insurance and a regular doctor, so when they need healthcare, they use the emergency room. After all, hospitals cannot refuse to treat someone who is ill. But that is not the type of care most of them need. They need preventive care, ongoing care.

And when an undocumented immigrant couple gives birth to a child in the U.S., that child is automatically an American citizen. I think we would all agree that when it is time for a baby to be born, that child should be born healthy.

The cruel reality is that many immigrant children are not born healthy, in part because their mothers did not get early and adequate prenatal care. When she is ready to give birth, that's when sending her to the emergency room makes sense. But prenatal care needs to take place in other, more appropriate settings so the seriously ill or injured patients can be seen more quickly.

I didn't always think this way. When I was chief executive officer of the public hospital system in San Antonio in the mid-1980s, I thought it was inappropriate to provide care to undocumented immigrants who lived in the area unless it was an emergency or it was paid for. In 1989, the district board-over my objection-changed our policy. The board decided that neither citizenship nor immigration status should be used to determine if someone was a resident of Bexar County.

I expected an influx of new patients, but this did not occur. Emergency-room volume flattened out or dropped. Hospital district staff members who had spent considerable energy trying to determine immigration status now concentrated on determining who really lived in our community. And finding the best way to care for a family unit composed of American citizen children and working undocumented immigrant parents was no longer a problem.

When the 1996 federal welfare reform law made certain immigrants ineligible for some public benefits, the hospital district in San Antonio kept serving undocumented Bexar County residents. The board was right, and I had been wrong.

In Houston there are many more undocumented and legal immigrants than in San Antonio. This is a city of immigrants. They come here to work. Their children are entitled to a public education. They have made homes here, and many plan to live their entire lives here. They are in our schools, in our places of business and in our emergency rooms.

Like San Antonio, Houston needs to decide what makes the most sense. Should we exclude the undocumented and all other ''unqualified'' immigrants from certain services offered by the Harris County Hospital District? Will that encourage them to go away? Will we reduce the tax burden by leaving the emergency-room door open and closing all other services? Can we afford to serve people from everywhere?

My answer to these questions is ''no.'' The Harris County Hospital District cannot care for everybody. We can't take care of our neighbors from other counties or countries. But we can take care of people who live in Harris County, and that's really all I want us to do. If that's a crime, then someone should arrest me.