By David Montgomery
Washington Post Staff Writer
Monday, November 16, 2009; A03
The 31-year-old woman creeping gingerly into Adventist HealthCare's free-standing emergency department in Germantown was obviously in pain, and physician Orlee Panitch quickly diagnosed the problem: gallstones.
The case wasn't an emergency -- yet -- but the woman, who is an illegal immigrant, didn't know where else to go for care.
"Her inability to access care is a problem," Panitch said. "At some point, untreated, she'll need emergency surgery to deal with this."
That question of access to care for some immigrants, and who should pay for it, could well become one of the most contentious sticking points in the coming weeks as members of Congress sit down to reconcile the health-care bill passed by the House on Saturday with the yet-to-emerge Senate version.
The controversy centers largely on whether illegal immigrants should benefit at all under a revised health-care system. Democratic leaders had vowed that only legal residents would receive subsidies to buy insurance. And after Rep. Joe Wilson (R-S.C.) famously shouted "You lie" at President Obama when he made that vow to Congress, both the White House and the Senate Finance Committee went a step further. They pledged that undocumented workers would be barred not only from receiving subsidies but also from buying insurance through federally sponsored exchanges -- even if they used their own money.
Last week, when some House Democratic leaders pressed to match the Senate Finance Committee version, Hispanic lawmakers threatened to revolt and ultimately prevailed: Under the bill approved by the House, illegal immigrants would not be barred from the exchanges.
That stark debate, however, has largely obscured the distinct challenge raised by immigrant families as reformers try to provide coverage to as many Americans as possible. Because so many of the nation's 38 million immigrants -- legal and illegal -- live in households that include both categories, families must often rely on a patchwork of care and funding. And while the legislation could have a significant impact on how millions of immigrants obtain care, it is clear that large gaps in coverage will remain, not only across immigrant communities but also even within individual families.
Maria Salmeron, for example, is a legal resident from El Salvador who has insurance through her job in the kitchen of a nursing home. But her husband, a construction worker who is trying to legalize his status, has no insurance. Their youngest child, Isabella, a 2-year-old citizen in pigtails, requires a ventilator to breathe. Her medical needs are covered by state and federal programs.
On a recent fall day, Salmeron took Isabella to a pediatric clinic in Falls Church, where a bilingual pediatrician, Albert Brito, checked her for a cold and helped her mother make an appointment with a kidney specialist for the child.
Meanwhile, the nurse who comes to the family's home to help take care of Isabella has no insurance. J. Katan, a legal resident from Nigeria, said she cannot afford the premiums for the plan offered by her nursing agency.
"If I need to see a doctor," she said, "I go myself, and I pay."
Locally and nationwide, roughly two-thirds of working-age immigrants who are legal residents are insured, and more than one-third of illegal immigrants also have insurance, according to a new study by the Migration Policy Institute, a Washington think tank. The group estimates that as many as 2.8 million uninsured legal residents of working age could benefit from reform, by qualifying for expanded Medicaid or proposed subsidies to purchase insurance. Nearly 1 million uninsured legal immigrants also work at firms that could be required to provide insurance. And 1.8 million uninsured illegal immigrants work for firms that may be required to provide insurance, according to the institute.
Even as lawmakers remain divided over how far to extend the new safety net, some health providers already have fashioned multi-layered systems to match care with the mixed needs of immigrant families.
The Falls Church pediatric clinic that treated Isabella was created by the Inova Health System, part of a cluster strategy that includes a maternity clinic for uninsured women, a nutritionist, a low-cost pharmacy, a lab, classrooms and social workers to help families navigate the system.
"We're basically a community safety net as well as a medical safety net," said Geoffrey DeLizzio, director of the clinics.
Ramiro Herbas, who came from Bolivia eight years ago, recently brought his son, Demothi, 2, for a checkup and a flu shot to the Falls Church pediatric clinic. American-born Demothi qualifies for Medicaid. Herbas said he has a work permit, but his construction jobs don't offer insurance. If he gets sick he visits a doctor's office in Seven Corners, where discount practices cater to immigrants, $40 a visit.
For some, the emergency department will remain the only option -- especially for patients like Susy, the illegal immigrant with gallstones, who would be excluded from subsidies.
"The pain is strong," said Susy, a babysitter who came from Peru six years ago. Because of her immigration status, she spoke on the condition that her last name not be published.
As Susy lay on a bed, Marcos Pesquera, executive director of Adventist's center on health disparities, picked up the phone and made an appointment for her with a surgeon, who, two weeks later, removed her gallbladder at Shady Grove Adventist Hospital.
Susy said she was initially asked to make a deposit of $3,500 to the hospital. Ultimately she made a deposit of just $100, she said, but she added that she may be asked to pay more.
The surgeon declined to comment, but his colleague, Jason Brodsky of Inpatient Surgical Consultants, said in an e-mailed statement: "We are pleased to provide this care regardless of a patient's insurance status."
Most of the cost of Susy's care will end up being absorbed by Adventist.
Like Inova, Adventist HealthCare, a $1.2 billion nonprofit provider, has stitched together services on its Germantown campus with a cluster of clinics and emergency care, paid for by an array of public and private players.
Next door to the emergency department where Susy was treated, Monica Peñaherrera, 53, sat in an examination room at a clinic operated by the nonprofit Mobile Medical Care. Peñaherrera is an American citizen but has had no health insurance since her husband's construction business declined. When she felt a pain in her breast recently, she came to the clinic she had heard about at her church.
"I'm comfortable here," Peñaherrera said after she was examined by nurse practitioner Marylynn Gonsalves. "I think of her as my family doctor."
For Peñaherrera's visit, she pays $30. Montgomery County pays $62. "That is way less than half what our costs would be," says Bob Spector, executive director of Mobile Med. The rest comes from cash and diagnostic support from Adventist, plus Mobile Med's own fundraising and reliance in some cases on donated medical expertise.
The patchwork of services is also paid for by taxpayers and people with insurance.
"We have to try to cover for those who can't pay or won't pay with the revenues that come from people who can and do pay," says Bill Robertson, president of Adventist HealthCare, which provided about $51 million in uncompensated care -- to poor, uninsured patients like Susy -- in their two local hospitals last year. The hospital covers the gap with money from other patients' insurance plans that pay more than cost.
Downstairs from Mobile Med is a maternity clinic for uninsured women, where Socorro Almejo, 38, an immigrant from Mexico, brought her 17-year-old daughter, Reina, who is pregnant, for a routine prenatal exam. Reina is receiving a full range of pregnancy checkups for $450 through a county-subsidized program. Almejo herself has no insurance and goes to another clinic when she is sick. "I'm glad at least my children have [coverage], even if I don't," she said.
Dianne Fisher, the county health department's nurse administrator for women's health services, said the goal was to ensure healthy pregnancies and births. "Otherwise," she said, "they would show up in the emergency room, with more problems."