In an emergency, hospitals, by law, must treat any patient in the U.S. until he or she is stabilized, regardless of the patient's immigration status or ability to pay.
Yet, when it comes time for the hospitals to discharge these patients, the same standard doesn't apply.
Though hospitals are legally obligated to find suitable places to discharge patients (for example, to their homes, rehabilitation facilities or nursing homes), their insurance status makes all the difference.
Several years ago I began caring for a man who'd been in our hospital for more than three months. He was in his 50s and had suffered a stroke. Half his body was paralyzed and he couldn't swallow food. After weeks of intensive physical, occupational and speech therapy, he regained his abilities to eat, drink and walk with only minimal help. But he still wasn't well enough to live on his own, prepare food or even get to the toilet by himself.
Ideally, we would have discharged him from the hospital to a rehabilitation facility so he could continue therapy and make more progress toward his prestroke state.
But our plan faced insurmountable barriers. First off, the patient was an immigrant who had entered the country illegally. Second, he didn't have insurance.
Because he lacked health coverage, no other facility would accept him. His immigration status meant that we couldn't find an outside charity that would cover the costs of his care or pay for insurance.
Our comparatively expensive acute care hospital was therefore compelled to hold him — with the meter running. After another month, it began to seem that he'd become a permanent resident of our hospital ward.
"Could he go back to Mexico?" our case manager asked.
We were startled. No one on my team had ever experienced a situation like this, so we began researching the possibility. As it turned out, it's a murky legal and ethical area that drew some public attention after an expose in The New York Times in 2008.
Nevertheless, our hospital faced a real financial burden, and the case manager pressed on. After reaching the patient's family in Mexico, and discussing issues with the Mexican consulate, the case manager began making travel arrangements to a rehabilitation hospital in Mexico.
Medical air transport to another country is an expensive proposition — roughly $50,000, depending on the equipment needed and the distance to the receiving facility in the patient's home nation.
From the hospital's point of view, it was easy to see that this large one-time expense would be worthwhile. The transfer to Mexico would put a stop to the indefinite, uncompensated costs of continued hospitalization. Further, the transfer would open up the patient's bed to a new (and presumably insured) patient.
After several meetings between our medical team, case management services, and a hospital administrator, I reluctantly agreed to sign off on the transfer.
Though the discharge plan left me feeling uncertain, I became more comfortable with the idea because our patient had the capacity to make his own decisions. He consented to return home to Mexico because it was clear that he was no longer physically able to work, and his family was also on board with the plan to help him.
A few weeks later the transfer was completed. The last I heard about the man, he had successfully arrived at the rehabilitation hospital near his hometown in Mexico.
I hadn't thought of this case for years until the combination of a recent Shots piece about dialysis and the heated rhetoric of the election season about immigration caused the memory to bubble back up into my consciousness.
Reflecting on the man's case, I began to wonder all over again: Who were we to send him back to Mexico? On the other hand, what alternative did we have for a safe and reasonable discharge?
I also hoped to understand if our experience was part of a broader trend or a sporadic occurrence. I could only find estimates of the number of so-called medical deportations because there isn't any required reporting or specific oversight. It's a murky area that falls in the gap between federal health and immigration regulations.
The best estimates suggest dozens or maybe a few hundred cases occur each year. I called several air ambulance companies to gauge the demand for such services, but none was willing to provide numbers or even go on record to discuss the practice in general.
One group that has studied the phenomenon offered a conservative estimate of 800 cases of medical deportation over a period of six years. "We field calls from across the country, so it is a national problem and not confined to border states," Lori Nessel, director of the Center for Social Justice at Seton Hall University School of Law, told me in an email.
Even in the absence of hard numbers, the medical community has responded to the investigative reporting and advocacy around the practice. In 2012, the American Medical Association added an opinion to its Code of Medical Ethics that states, in part, a "discharge plan should be developed without regard to socioeconomic status, immigration status, or other clinically irrelevant considerations."
A 2014 piece in The New England Journal of Medicine concluded with the opinion that doctors "...are uniquely equipped to display the moral courage necessary to advocate effectively for patients by calling attention to the profound ethical issues raised by repatriation," using a slightly fancier word for deportation.
Health care for immigrants is a hot button issue. Though the Affordable Care Act excludes immigrants who entered the country illegally from the mandate to purchase health insurance, many U.S counties have taken steps to provide preventive and chronic care for them. The obvious rationale is that this care saves money and prevents suffering in emergency situations.
I'm confident that the transfer home of the Mexican man who'd had a stroke was both consensual and sensible. But given reports of patients being transported without their consent, this practice needs legal clarity to match the ethical aspirations of my profession.
One thing is clear: Without a policy change, hospitalized people who entered the country illegally and who don't have insurance will remain vulnerable to the seemingly irreconcilable conflict in our society between commerce and medicine.
John Henning Schumann is a writer and doctor in Tulsa, Okla. He serves as president of the University of Oklahoma, Tulsa. He also hosts Public Radio Tulsa's Medical Matters. He's on Twitter: @GlassHospital.