As Marta Berrera received emergency dialysis treatment recently at University Medical Center, the 34-year-old illegal immigrant said she wouldn't want to be sent home to Mexico for treatment.
Las Vegas is now home for her and her four school-age children, she said through an interpreter.
"I like it here. People are so nice. I am so thankful to this hospital for doing this for someone who is not a citizen."
Weary from her two-year battle with failing kidneys -- a fight she wages by receiving costly treatment through the UMC emergency room two or three times a week -- Berrera says she has never thought about returning to her homeland for health care to keep her alive.
But as health care costs spiral out of control in the United States, many Americans think illegal immigrants like Berrera should not only think about repatriation, they should be forced to leave.
Hospitals in other states, including Arizona and Florida, have sent patients back to their home countries despite objections of either the patients or their families.
In 2008, St. Joseph's Hospital and Medical Center in Phoenix sent an average of seven patients a month to their native countries for treatment, according to Sister Margaret McBride, an administrator there.
"We always try to get their agreement, but sometimes we can't," she said.
The cost to arrange medical transport of an illegal immigrant back to a home country ranges from $35,000 on the low end up to $200,000. That's not cheap, but it's far less than the $1 million per patient the nonprofit Phoenix hospital estimated it was spending for ongoing dialysis treatment.
The transportation costs can include providing equipment, such as ventilators, if they are not available in the patient's native country.
A medical vehicle is chartered, and medical personnel sometimes is needed to accompany a patient.
And although Arizona sees the vast majority of its illegal immigrants coming from Mexico, repatriation can be to anywhere. One patient was flown to South Korea, McBride said.
In Florida, in what legal experts believe was the first case of its kind, a jury found that a hospital there did not act unreasonably when it chartered a plane six years ago to fly a brain-injured Guatemalan patient home for care.
The hospital had provided Luis Alberto Jimenez $1.5 million in long-term care for several years until forcing his repatriation in 2003.
After learning that cash-strapped UMC had provided more than $20 million in dialysis services for uninsured illegal immigrants in the current fiscal year, Clark County Commissioner Steve Sisolak said more effort must be made to send foreign nationals back to their home countries for treatment.
But Sisolak did not advocate forced repatriation, suggesting instead that the hospital work more closely with the Mexican consul of Las Vegas, Mariano Lemus Gas, to come up with a solid voluntary plan. Gas said he is contacting authorities in Mexico to see if he can have them help pay for repatriation.
Brian Brannman, UMC's chief financial officer, said he is aware of four cases in which the hospital was able to convince illegal immigrants to receive continuing care in their country of origin. That's more likely to happen when the extended family is in the home country, Brannman said.
Last Sunday, the Review-Journal reported that UMC is treating 80 illegal immigrants who require costly and repeated emergency dialysis. Hospital officials say the majority of those patients are Mexican, though they note a wide array of nationalities, from Canadians to Pakistanis, have received care.
Under federal law, anyone who shows up at an emergency room for a medical condition must be given an appropriate medical screening to determine whether there is an emergency. If there is, treatment must be provided regardless of a patient's ability to pay or citizenship.
Dialysis, which must be done two or three times a week on patients, is almost four times more costly when done through the emergency room than through the usual doctor-guided treatment at a dialysis center.
Emergency room treatment would normally be billed out at up to $18,000 per visit, in part because of required testing and costly in-patient critical care to keep someone alive.
Dr. Dale Carrison, head of emergency services at UMC, said illegal immigrants with failing kidneys have figured out doctors will treat them if they go to the emergency room in bad enough shape.
"They don't have insurance and they can't get Medicare because they're illegal, so all they can do is use the emergency room to stay alive," Carrison said.
UMC, which provides the vast majority of health care for illegal immigrants in the Las Vegas Valley, does not engage in repatriation, spokesman Rick Plummer said.
Health care professionals want to help people, not be an arm of immigration enforcement, he said.
"We don't have the appetite to force people to leave. That's not what health care workers want to do. They go into their profession wanting to help people. ... Immigration authorities know where these people are all across the country."
Plummer noted that litigation costs for hospitals in forced repatriation cases could wipe out the initial savings realized by shipping someone to a country of origin.
He also said some believe forced repatriation constitutes kidnapping.
The Florida legal case involving Jimenez lasted more than five years. The hospital, Martin Memorial Medical Center, has not disclosed how much its legal costs were to defend its actions in a civil lawsuit brought by his family.
Though a Florida appeals court ultimately ruled that Jimenez had been unlawfully detained and deprived of his liberty, that ruling came too late for Jiminez, who already had been sent back to Guatemala.
Despite the Florida jury's initial finding, Sonal Ambegaokar, a health policy attorney at the National Immigration Law Center in California, predicted more lawsuits will be filed against hospitals engaging in forced repatriation.
She said in most cases it is doubtful hospitals are providing a safe discharge for patients.
"In many cases, the hospitals can't guarantee that the proper level of care is continued," Ambegaokar said. "Basically we think these hospitals are acting as a government agency without proper (due process) procedures in place."
When hospitals force an individual to leave family in the United States, Ambegaokar said, an argument can be made that constitutes a kidnapping which tears at the family's emotional fabric.
But McBride said St. Joseph's is breaking no laws when it arranges with health care professionals or facilities in other countries to provide continuing care for a patient. She said the hospital's legal responsibility, regardless of what the patient's family wants, is simply to provide a safe discharge. About seven other hospitals in the Phoenix area also repatriate, she said.
Suzanne Pfister, a spokeswoman for St. Joseph's, acknowledges the hospital's discharges have drawn criticism. In 2008, the Arizona Republic newspaper reported that an 18-year-old who was sent back to a hospital in Mexico died there of a highly curable form of leukemia.
Pfister wouldn't talk about specific cases.
"These are heart-wrenching cases," McBride said, adding that the hospital must make difficult decisions to stay financially solvent.
"We do everything we can to work with families and consulates. But it is something that we must do in order to be able to continue to offer care."
St. Joseph's is a trauma center which treats people who have been in serious accidents. Many who are stabilized at a cost of hundreds of thousands of dollars need long-term care that the hospital cannot provide for financial or licensing reasons, she said.
For-profit institutions, which are licensed for long-term rehabilitation in Phoenix, generally refuse to take patients without insurance, McBride said.
Plummer said there have been trauma cases involving illegal immigrants that have cost UMC hundreds of thousands of dollars.
"We're basically warehousing them for months," he said. "For-profit rehab centers don't want to take them."
The four cases in which illegal immigrants willingly returned to their homelands involved patients who needed long-term continuing care, Brannman said.
"We'll spring for the plane ticket. It's a lot cheaper than running up a bill for hundreds of thousands of dollars."
Brannman said UMC social workers continually work with patients to explain their options. He hopes that building a closer relationship with foreign consuls also can help convince patients that they're better off where they were born.
Gas, the Mexican consul, said he wants to help UMC and does not want to encourage illegal immigrants to come to or stay in Las Vegas.
But, he said, "many of these people don't want to go back to a place that they no longer know very well. Much of their family is here, and it is very emotional."
Many factors to blame
What is happening to health care in Las Vegas and around the nation isn't surprising to Mark Krikorian, executive director of the Center for Immigration Studies, a nonpartisan research group that supports immigration reform.
He said it's sad that hospital officials are put in a position where they must deport someone because immigration authorities and politicians don't have the will to enforce the law.
"This is what happens that society faces when it doesn't enforce immigration laws adequately," he said. "American hospitals can't give costly medical care to everybody in the world."
Jan Emerson, a spokeswoman for the California Hospital Association, cautioned people not to put too much blame on illegal immigrants for health care problems in the United States.
Emerson said she often hears from "people that don't care about facts" who say treatment of illegal immigrants has been responsible for the closing of 70 hospitals in that state since 1996.
"That's just not true," she said. "They contribute to the problem, but they're not the main reason."
Emerson said about 10 percent of the $11.3 billion in uncompensated care provided by California hospitals in 2008 is related to illegal immigrants.
She said underfunding of Medicare and Medicaid programs is responsible for nearly three quarters of the uncompensated care, which hurts hospitals' bottom lines.
"There is so much emotion on this topic, and too many people don't want the facts to get in the way," she said.
Still, Emerson agrees that the question of health care reform in the United States can't be addressed without a discussion of illegal immigrants.
Ten percent of the problem is not insignificant, she noted.
After the Florida jury found that Martin Memorial was justified in shipping Jimenez back to Guatemala, hospital CEO Mark E. Robitaille noted that none of the proposed national health care reform bills being debated in Congress address illegal immigrants.
"That means there are still cases like Luis Jimenez's in hospitals across the country, Robitaille said. "And there will continue to be cases like Luis Jimenez's."
Contact reporter Paul Harasim at firstname.lastname@example.org or 702-387-2908.