The U.S.-Mexico border is a jagged 1,956-mile line that defines a simple dichotomy. On the north side of the line is the world's premier economic and military superpower. On the south side is a relatively poor country with a promising economy and a fitfully improving democracy, struggling to climb out of the shadow of its northern neighbor.
For hospital executives who work just north of the line, however, the border's effects are anything but simple.
Close proximity to the line casts hospital executives into a figurative Rio Grande of swift-moving economic, political and cultural currents-poverty, immigration policy, treating the uninsured, a bilingual culture. All those factors compound the already tough fight to keep a hospital's fiscal head above water.
"We're operating at about a 10% loss for the year," says John Grah, administrator of 173-bed Scripps Memorial Hospital Chula Vista (Calif.), about a 15-minute drive south of San Diego. Scripps Chula Vista, part of the five-hospital Scripps Health system, San Diego, is the closest hospital to the Interstate 5 border crossing, the world's busiest. That kind of loss is unsustainable, he says.
The federal government, which has restricted payments to hospitals facing a disproportionate share of charity care, needs to pick up a greater share of the burden, Grah says, because of its responsibility for policing the border and the mandate it imposes to provide emergency treatment even to illegal immigrants: the 1986 Emergency Medical Treatment and Active Labor Act.
Border crossers seeking care in the U.S. include both illegal immigrants and Mexican nationals with work visas or other clearances to enter the country. Contrary to popular belief, many can and do pay for part or all of their healthcare, especially if they have jobs on the American side of the border.
Grah estimates that as many as 7% of the patients at Scripps Chula Vista are border crossers, and poverty isn't their only disadvantage.
"The biggest problem is delay of access," says Ahmed Calvo, M.D., the hospital's medical education director. "By the time they get treatment (here), they're just sicker."
In recent years, those higher-acuity patients have boosted the admission rate for Scripps Chula Vista's emergency department to 17% from its historic average of 11%, says Mel Ochs, M.D. Ochs is the medical director for San Diego County's emergency medical services division and an emergency department physician at Scripps Chula Vista.
Overall, 43% of the hospital's patients are at or below the poverty line, and about 17% of the hospital's patients lack health insurance, which is lower than the countywide average of 25%, Grah says.
Moreover, San Diego County is the only county in California that does not run a public hospital focusing on indigent care. The County Medical System is a health plan offering some coverage for uninsured residents, but it does not cover border crossers.
U.S. border poverty
As difficult as the situation is in San Diego County, the area is relatively affluent for a border region. It is the only one of 24 border counties in Arizona, California, New Mexico and Texas that has a lower percentage of residents living below the poverty line than the U.S. average of 13.1%, according to the U.S./Mexico Border Counties Coalition. Taken as a whole, 25.5% of 6.3 million border county residents have incomes below the federal poverty limit, the coalition reported in February.
The Southwestern border counties have far fewer economic resources to deal with the costs of immigration, including healthcare, than most of the rest of the U.S., said Sharon Bronson. She is president of the border counties coalition and a Pima County, Ariz., supervisor whose district spans the county's 131-mile border with Mexico.
HHS considers all 24 Southwestern border counties as "medically underserved." The agency's Health Resources and Services Administration noted last month that "if U.S. territory within 100 kilometers of the border were a state, its 11 million residents would rank last in access to healthcare, second in deaths due to hepatitis and third in deaths related to diabetes."
Relative to the rest of the country, communicable diseases run rampant in the border region, the HRSA says, with six times the number of cases of tuberculosis and twice the incidence of measles and mumps.
In its February report Illegal Immigrants in U.S./Mexico Border Counties: The Costs of Law Enforcement, Criminal Justice and Emergency Medical Services, the coalition estimated the costs of immigration on local taxpayers at $108.2 million for 1999, including $19.1 million for emergency medical service.
That estimate, however, does not include the cost of uncompensated care borne by hospitals other than county-run facilities. Another study, funded by a grant from the Centers for Medicare and Medicaid Services, will attempt to determine the total cost of border crossers on the healthcare system in the region. The results may be available in late March 2002.
"We want reimbursement from the federal government for costs that are a direct result of federal policies that our taxpayers have to bear," Bronson says. "The costs of federal policies should not be borne by those communities least able to bear it."
The HRSA's border programs funneled $280 million to the region between fiscal 1998 and fiscal 2001, which ended Sept. 30. But those programs don't cover the costs of treating Mexicans who are injured or become ill while attempting to cross the border in remote desert regions, for instance. And more of those crossings have been attempted since the Immigration and Naturalization Service's border patrol began concentrating more agents and other resources in urban areas, including the crossings in El Paso, Texas, and San Diego, where enforcement was stepped up in 1993 and 1994, respectively, the General Accounting Office reported in August.
The GAO report INS' Southwest Border Strategy found that concentrating agents in an area has the effect of shifting border crossings to other areas. For example, the report shows that apprehensions of illegal immigrants in the San Diego area fell by 71% to 151,681 in fiscal 2000 following a seven-year period in which the number of border patrol agents more than doubled to 2,215. During the same time period, apprehensions skyrocketed nearly 700% in the border patrol sector based in El Centro, Calif., directly east of the San Diego area, to 238,126 in 2000. Fewer agents were added in that area.
David Selman, chief executive officer of 107-bed El Centro Regional Medical Center, about 15 miles from the border, has seen the effects of this shift. Undocumented border crossers now make up 2% of the hospital's patient population, and from calendar 1998 to 2000, the hospital wrote off $3 million in charity care for border crossers. In terms of patient counts, the hospital treated 76 border crossers in 1998, 282 in 1999 and 502 in 2000. Selman estimates the hospital will treat 658 border crossers this year.
Many of those patients are turning up in El Centro Regional's emergency room with severe injuries directly related to dangerous attempts to cross the border in the desert, Selman says. Some have multiple fractures sustained while trying to climb the border fence or in car accidents that occur while trying to elude border patrol agents. Others suffer from multiple organ failures related to heat exposure and dehydration. River crossings are no safer, as high water pollution has led border crossers to contract polio and meningitis, among other diseases, Selman says.
The GAO report notes that the border patrol has been increasing the number of agents in all nine of its Southwestern border sectors, but the INS hasn't been able to recruit enough agents to fill all of the positions that its strategy calls for. The hiring has been limited by both budget concerns and the tight labor market of the late 1990s, the report says.
The INS isn't the only border employer having trouble with recruiting. Border hospitals, too, face added challenges in hiring and keeping workers.
The El Paso region, which includes about 1.5 million people from Mexico, New Mexico and Texas, has fewer than 850 physicians, or about half as many physicians per 100,000 residents as the rest of Texas, says Irene Chavez, vice president of business development for Sierra Providence Health Network, a three-hospital system in El Paso owned by Tenet Healthcare Corp., Santa Barbara, Calif.
Both cultural and economic factors limit the number of physicians who would even consider practicing in El Paso, Chavez says. Not everyone is interested in living in a bilingual desert community. And, "If we find a physician who is interested in the city and the culture and the opportunity to practice medicine here, the next hurdle is: How does he make a living?" she asks. Some doctors are quickly turned off by the high percentage of charity care offered at El Paso's hospitals, she says. El Centro Regional's Selman agrees; every doctor he recruits raises the same issue.
Cultural hits and misses
Border hospitals also have adapted culturally to the Hispanic populations they serve. At 306-bed Sharp Chula Vista Medical Center, which is part of four-hospital Sharp Healthcare, San Diego, 28 new intensive-care rooms are being designed with more space for visiting family members, says Debra Holly, a registered nurse and the hospital's acute-care director. "We really find a lot of our patients like to have a lot of family around. That's not normally the way ICU rooms are run."
On a tour, a visitor sees an example of what Holly is talking about: a patient with eight family members visiting-four sitting inside, one leaning in the doorway and three against the wall outside the room.
Scripps Chula Vista participates in a federal effort, locally known as Project Dolce, to train Hispanic community members to teach their neighbors about diabetes-prevention strategies. Helping leaders emerge from within the community overcomes some of the lack of trust of English-speaking authorities, Grah, the Scripps administrator, says. "Instead of a white guy going and teaching a class that no one attends, and they're very suspicious, (instead), it's their sister leading the class," he says.
Other cultural differences are not so easily overcome. Grah recounts a recent case in which a doctor from Spain had trouble communicating with a South American patient because a single word had different meanings in their respective Spanish dialects.
James Packer, M.D., the medical director of Sharp Chula Vista's emergency department, says that even with plenty of translators available among employees, English-speaking doctors can have difficulty relating to Spanish-speaking patients with psychological problems. "It's hard to get across the nuances of what you're saying," Packer says.