Six months ago, a Hispanic immigrant named Ana went to a clinic at a private Montgomery County hospital seeking prenatal care.
But the clinic was full and officials referred Ana, a Silver Spring resident, to a private clinic in Adams-Morgan.
"I was so depressed," recalled Ana, 24, an illegal immigrant from the Dominican Republic who does not want her full name used. "I didn't know if the clinic would take me."
The District clinic, Columbia Road Health Services, treated Ana throughout her pregnancy and arranged for her to have her baby at a private hospital in the District at a cost of $600, much less than the average $1,800 fee charged by private hospitals. Ana, who is unemployed and depends on her husband's salary as a gardener's assistant, even was allowed to pay the bill in weekly installments.
In what local health officials say is an alarming problem, a growing number of illegal Hispanic immigrants from suburban jurisdictions are seeking health care at District clinics established to aid low-income residents. That influx is straining the 15 government clinics and other nonprofit, private health facilities in some parts of the District, especially Adams-Morgan, that are overloaded with indigent cases in their own neighborhoods, officials said.
The number of Hispanics crossing jurisdictional borders is difficult to determine because so many are illegal immigrants and seek to hide their identities by giving false addresses, but District health care officials said that the majority of non-District residents appears to be from Montgomery County. Despite its affluence, Montgomery has no public hospital and has only five public health clinics for low-income residents.
Immigrants are attracted to the clinics in the city because they offer the easy availability of health services at reasonable prices and often provide Spanish-speaking professionals, District officials said.
Hispanics in Montgomery complain that when they call a county health clinic they frequently are told, "Sorry, no Spanish." Most of the staff members at health clinics in Adams-Morgan, an area where a large number of Central American refugees have settled, speak Spanish, said District clinic officials.
Until last year, a sign at Montgomery County's Silver Spring Health Clinic, where about40 percent of the clients are Hispanic, asked persons who could not speak English to bring interpreters. The sign was in English.
Dr. Donald Swetter, chief of the Montgomery County Health Department, said he ordered the sign removed last year when he learned that it was there. The clinic now has a Spanish-speaking receptionist.
"Obviously, the sign was very offensive to me," he said.
Montgomery County Council member Scott Fosler, when asked about Hispanics being forced into the District for health care, said he had not known that they were receiving health services in the District.
"There is no reason why Montgomery County residents should be going to the District for necessary services," said Fosler, a member of the council's health and human services committee. He subsequently asked Swetter to look into the problem.
Montgomery Council member Rose Crenca, chairman of the health and human services committee, said the reason that Hispanics from the county are going to the District for health care is not because the county doesn't provide such services.
"If there is a problem, it seems to be cultural," she said. "They have ties to Adams Morgan because that's where they came from originally or they have relatives there."
District health officials said they know many Hispanic immigrants are coming to them from the suburbs, and suspect that most of them give false addresses.
"I'd say it's a significant problem," said D.C. Commissioner of Public Health Andrew McBride.
In a random sample of 6,237 bills mailed to health clinic patients in the District, 781 were returned because of incorrect addresses, said Gladys Chinn-Mitchell, a payment and collection officer with the District's office of the controller. Of those returned, 613 had Hispanic names, she said.
Last year the District government spent$21 million for health services to indigents, said Peter Coppola, deputy administrator of ambulatory health care for the District. He said there is no way to determine how much went to serve patients who do not live in the District.
Columbia Road Health Services, the clinic that treated Ana, recently decided to stop taking new patients temporarily because of its overwhelming caseload, officials said.
"We found we were having to turn some of our local population away because we had so many Spanish-speaking pediatric patients," said Ellen Farrior, a social worker at the clinic.
Of about 7,500 patients seen by Columbia Road Health Services in the past two years, 1,082 said they lived outside the District, clinic director Sallie Holdrich said. More than two-thirds, or 660 of them, were from Montgomery County. The rest were from Prince George's and Fairfax counties and other surrounding jurisdictions.
Twenty-three percent of the Hispanics who went last year to the Spanish Catholic Center Inc. in Adams-Morgan, a social and health services agency run by the Catholic Archdiocese of Washington, were from Montgomery County, and 11 percent were from Prince George's, said the center's executive director, the Rev. Kevin Farrell. Only 3 percent were from Fairfax, he said.
Officials at District clinics said they did not know why the largest number of nonresident patients are from Maryland and specifically Montgomery County, but they pointed to the growing number of illegal Central Americans moving to southern Montgomery and northern Prince George's counties. They noted that there are fewer Hispanics in Virginia. And Arlington County, which has a large number of Hispanic immigrants, recently beefed up its health services for Hispanics.
While District-run health clinics serve adults and children, Montgomery County health clinics provide care only to pregnant women, senior citizens and children, said Jay Josephs, an administrative services coordinator in the Montgomery Health Department.
Social workers at Spanish Speaking Community of Maryland Inc., a private, nonprofit organization in Takoma Park that serves local Hispanics, said they refer about six adults every month to health clinics in the District for such problems as broken bones and tooth extractions, because county clinics do not provide that type of treatment.
Some suburban Hispanics go to District clinics because they are familiar with the services.
Lucia, 37, from El Salvador, did not know that Montgomery County has a health clinic not far from where she has lived in Gaithersburg for the past year with her husband and two sons, aged 3 and 2, according to her husband, Sebastian.
He said that his wife gave birth to their third child a week ago in the back seat of a friend's car as they sped toward D.C. General Hospital. She did not receive prenatal care except for a visit to a private doctor when she was two months pregnant, said Sebastian, a dishwasher.
The language barrier remains a major problem in trying to reach Hispanics, officials said. They said that only one doctor out of 14 in Montgomery County's Health Department and 10 of 140 nurses speak Spanish.
Swetter said the county will hire three Spanish-speaking staff members for its health centers this year: a nurse, a community service aide and a public health adviser.
In the past, he said, the county has had trouble finding Spanish-speaking health professionals for county jobs.
"The solution is to continue our efforts to establish better communication with Spanish-speaking groups . . . and keep a constant eye on population shifts and beef up services when they are needed in a a particular area," Swetter said.
The surge of poor, suburban Hispanic patients in District clinics has prompted a search for answers among local health agencies. A Commission on Black and Minority Health, created by Maryland Gov. Harry Hughes, is exploring the problem. The commission will submit its recommendations to the governor in December.
"I see no need for the District to be subsidizing Montgomery County," said Rudy Arredondo, a health consultant from Takoma Park and member of the commission. "We are perfectly capable of taking care of our residents."