Undocumented immigrants and emergency car

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The Bush administration has set aside $1 billion to pay hospitals and doctors for providing emergency care to undocumented immigrants through 2008. Horizonte talks to John Rivers, President and CEO of Arizona Hospital and Healthcare Association about how this plan addresses the undocumented immigrant healthcare challenge and the impact of immigration on healthcare resources in Arizona.

José Cárdenas:
Good evening. I'm José Cárdenas. Tonight on Horizonte, undocumented immigrants and healthcare. There is a plan to help hospitals get reimbursed for emergency care. We'll talk about how it will affect Arizona. And an advertising campaign to attract tourists south of the border. Plus, in Horizonte Sounds of Cultura, S.O.C., it's one of the top Hispanic places to eat in the country. What do a cowboy movie star and Los Dos Molinos restaurant have in common? The answer may surprise you. All coming up next on Horizonte.

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José Cardenas:
Providing medical treatment costs huge amounts of money. Healthcare providers have an obligation to offer that care, but they also worry about the overall financial burden. In 2003, President Bush signed into law the Medicare Prescription Drug Improvement and Modernization Act of 2003, section 1011. The federal reimbursement of emergency health services furnished to undocumented immigrants. Section 1011 provides $250 million per year for 2005-2008 for payments to eligible providers for emergency health services provided to undocumented immigrants and other specified immigrants. Here tonight to talk about this issue and plan on Arizona's healthcare system is John Rivers, President and CEO of Arizona Hospital and Healthcare Association. John, you've been a guest before. Good to have you back.

John Rivers:
Thank you.

José Cardenas:
Tell us a little bit about the association, so people know what it is.

John Rivers:
We're what's called a trade association. We represent hospitals throughout the state of Arizona. We provide them with political advocacy, regulatory advocacy, communications, data services and so forth. I would say our bread and butter is political advocacy, which is how we got involved in the development of what came known as Section 1011.

José Cardenas:
We want to get into some specifics. But tell us what's the scope of the problem that Section 1011 was designed to deal with?

John Rivers:
Well, we can't measure it precisely. We did a survey of hospitals in Arizona about two years ago asking them to estimate the costs of providing care to undocumenteds. The estimate that we got back from them was about $150 million per year. We know that's a conservative estimate. We know it's nothing more than a good guess. And the reason we have to guess is because people are not asked about their immigration status when they present in a hospital emergency room. So we have no coding system set up to identify who's here legally and who's not. So the best estimate we can come up with is probably somewhere between 150 and $250 million per year.

José Cardenas:
For the state of Arizona alone?

John Rivers:
For Arizona alone.

José Cardenas:
Now, the last time you were here we were talking about one of these specific legislation. That was sometime ago. Why is it only now going into effect?

John Rivers:
Well, CMS, the federal agency that administers this program had to develop regulations on how to implement it. What determines who's going to get paid, for example, for what services provided to what undocumented immigrants. What sort of documentation are hospitals supposed to provide to CMS in order to make sure these claims are paid. There were all kinds of operational issues that had to be sorted through between the federal government and hospitals and other healthcare providers to determine how and when the dollars were actually going to flow.

José Cardenas:
Tell us a little bit about Section 1011, how it works and how Arizona will benefit from this.

John Rivers:
Well, basically 1011 as you indicated at the outset is about $250 million per year over 4 years. That's for all states nationally. Arizona's share of that, based on the formula in the legislation, will be about $45 million a year. In other words, hospitals, physicians, ambulance providers and other people in healthcare delivery will in total receive about $45 million a year beginning this year. Hospitals without question are the biggest piece of that. But essentially it just reimburses hospitals and other providers for care that they were providing before for which they were receiving no payment. And now they'll at least get some payment for those services. So it's a very good thing for Arizona, a very big thing for Arizona.

José Cardenas:
And the process of seeking reimbursement is exactly what?

John Rivers:
Well essentially when anybody walks into a hospital emergency room, regardless of who they are or their immigration status, there are certain basic demographic information that's requested of each patient. What's your name, what's your age, are you on any medications and so on and so forth. If the questions are answered in a way that suggests to a hospital admitting person that the person might be here illegally, they'll pick up another form. It's called a Section 1011 form. It's the same demographic information that's asked of everyone. And the services are provided to that patient, a copy of that 1011 form will be attached to the bill and submitted to what we call a third-party administrator to pay the claim. That's basically how it works and the claims are paid on a first come, first served basis.

José Cardenas:
Well, does the admitting person specifically ask for legal status?

John Rivers:
No.

José Cardenas:
And why is that?

John Rivers:
Well, in I guess what I would have to call the negotiation between the federal government and the hospital community primarily over this issue, hospitals very strongly resisted efforts to make us ask what the immigration status of someone was. Our concern was that if we were asking for immigration status, that would deter some people were seeking care in an emergency room who should be seeking care. In other words, we saw it as a barrier to care.

José Cardenas:
So the specific question is never asked.

John Rivers:
The specific question is not asked. And I hope never is asked of anyone.

José Cardenas:
Well, how does the federal government ensure that these moneys are being used as intended? As I understand it, the actual problem with uninsured people seeking services and the hospitals not getting paid for, that the percentage of that is for undocumented immigrants is probably relatively small. Am I right?

John Rivers:
It's certainly not a huge number. There's no question about that, Jose. The Saint Luke's health initiative did a study of emergency room patients in Arizona a few months ago. They determined that about 85% of the people who show up in our emergency rooms are people with insurance. So even though there's a public myth out there that our emergency departments are being overrun with undocumenteds and overrun with uninsured, the facts really don't square with that. I'm not saying that the uninsured isn't a problem because it is. We have over a million people in Arizona who have no insurance. Many of those people are undocumenteds. They still need healthcare. They still show up on our emergency room. So it is in total dollars I guess I would say in terms of the total dollars involved it is a big problem. But when you look at it as a percentage of the total volume that flows through emergency rooms, it's a smaller problem than many people would think.

José Cardenas:
Will there be any temptation, so to speak, for the hospitals to decide that somebody is here without the proper documentation because that means they'll get reimbursed for expenses where as if they didn't make that determination they would?

John Rivers:
I really don't think so. Because hospitals are only going to be reimbursed for a percentage. And it's not going to be a big percentage of the total care they're providing to undocumented immigrants. They're going to be reimbursed depending on how you want to estimate this, anywhere between 10 and 25%, maybe, of the costs of the total amount of care they're providing. So even if their estimates of who's undocumented and who's not are a little bit off, it's going to work out to be the same at the end of the day. They're still going to get reimbursed just a piece of it. That's the flip side.

José Cardenas:
You did say the estimates are $150 to $200 million and Arizona is only going to get $45 million. Is this really effective?

John Rivers:
I think it is. I mean, $45 million isn't chump change no matter what kind of business you're in. You can provide a lot of help here to a lot of people for that kind of money. So we think it's very significant both in terms of the actual dollars involved. But it's also significant because it represents the first time that the federal government has assumed a responsibility, a financial responsibility for care that we're legally and morally obligated to provide anyway, regardless of a person's immigration status, ethnicity or anything else. The important thing is for people to know that we have always been there for them when they need healthcare. We are there for them now and we always will be there for them. People should not have any fear about walking into a hospital emergency room for fear that their immigration status is going to be disclosed or they're going to be deported. They are now and always going to be treated court justly and conscientiously and given the care that they need.

José Cardenas:
As I understand it, Arizona fares well. California is out front as you might imagine. But then you have Arizona and Texas roughly about the same, $45, $46 million and then a drop-off to $12. The next state would probably be a surprise to some people is New York. Why is it? What is there about the calculations that treats Arizona so well?

John Rivers:
Well, the formula that determines how this money gets allocated among the states. It favors states that have a higher percentage of apprehensions around the border. So even though California has probably 5 or 6 times as many people as we have living here in Arizona, and I would guess Texas is about the same, we have more border apprehensions than those states. Many more border apprehensions as a percentage of our total population. So we do well under this formula. And that formula is in the statute. And it favors Arizona. And frankly, that's because of the championship and the leadership that Senator Kyle showed in getting this measure enacted in the first place. Nothing happens in congress without a champion and without a leader. And frankly, John Kyle, Senator John Kyle, deserves the credit for having gotten out in front on this issue. He has said it's not right for the federal government to require that hospitals provide this care and then not pay them anything for it. It was his leadership that got this done.

José Cardenas:
What kind of opposition did he face? Why would anybody in congress be opposed to this other than perhaps spending money?

John Rivers:
Well, part of it was that. Part of it was that there's a resistance on the part of some people to spending money for anything. And I think frankly -- I don't think it's any well-kept secret that in certain pockets of this country there's a lot of anti-immigrant sentiment. Even though except for Native Americans I think we are all offspring of immigrants. Which is another story. But despite that fact, there is today a lot of anti-immigrant sentiment in some parts of the country. And some of that is reflected in congress, just like it is everywhere else. No one expresses it that way there. But that is the underlying -- that's part of the underlying thing that John Kyle faced when he tried to get this enacted into law.

José Cardenas:
At least a portion of that anti-immigration sentiment you're referring to is directed at the federal government for not helping the border states deal with these issues. Do you think this will change the tone of the discussion?

John Rivers:
I really don't know the answer to that Jose, because aside from what we've been talking about which is healthcare provided to people who are here and undocumented and presumed illegal status, there's the whole issue of immigration reform, which is a much broader issue. And people have a lot of different opinions about how that should be approached. So I really don't know how the broader discussion on immigration reform is going to have an effect on this kind of a -- on this kind of federal legislation going forward. Obviously the longer it's in place and the more it's accepted, I think the debate in future years is not whether the federal government should be funding this portion of its responsibility, the debate is more likely to be at what level should they be funding it. And I think that's a good thing if you're from Arizona or if you're from any other state on the Mexican border.

José Cardenas:
We just have a few seconds left. Overall this is a benefit I assume not simply to the hospitals but also to the citizens, taxpayers of Arizona?

John Rivers:
Yes. Well, it will be. It's a return of a lot of taxpayer dollars that are being sent to Washington right now. One way of looking at it. But also physicians who provide services to undocumented, paramedics, ambulances services are all going to be able to receive at least a portion of the cost of providing this care under Section 1011.

José Cardenas:
John Rivers, CEO Arizona Healthcare and Hospital Healthcare Association. Thank you for joining us.

John Rivers:
Thank you, Jose.

José Cardenas:
Hope to see you again soon. Last week we told you about Los Dos Molinos making Hispanic Magazine's list of the top 50 Hispanic restaurants to eat in the country. Tonight Nadine Arroyo walks you through the history of the property the restaurant was built on.

Nadine Arroyo:
For more than a decade, valley residents and visitors have enjoyed the traditional food of the nationally acclaimed Los Dos Molinos Restaurant in South Phoenix. The restaurant has been recognized as one of the best in the country by Hispanic Magazine and they are currently listed in the annual guide of 100 Great Places to Eat in AZ. But there's more to this dining location. The property has exchanged owners for decades. The earliest data to the property goes as far back as 1953 when Phoenix began zoning the areas residential and began providing numerical addresses to homes. At that time the one-acre property was in an apartment building. As years past the building was turned into a funeral home and ultimately the restaurant it's known for today. But the interesting part of this property is in the years prior to the 1950s, a time where very little concrete information is found. Many say the original 1920s home belonged to silent cowboy movie star Tom Mix. During the 20s Mix spent many years in Arizona. He made films in the Grand Canyon and throughout the state. But many others like Los Dos Molinos Proprietor Victoria Chavez says the home belonged to a friend of Tom Mix and often visited.

Victoria Chavez:
The original, original owner of this house and land was Mr. Parker. And I don't know his first name, but I know that it was Parker. He was very -- a very prominent man. He was an old, an old-timer. Say 1926, 1923, whatever, that they started the house. But he owned sections of land there.

Nadine Arroyo:
Los Dos Molinos restaurant continues to be considered Tom Mix's residency by several local agencies, like the tourism bureau. Some say it makes for good publicity. And others say it really doesn't matter. It's what's there now that counts.

José Cardenas:
Tom Mix died in 1940, just outside Florence, Arizona. If you're looking for a great place to get away you might want to head to the border. Traveling to Sonora is now easier than ever. There is a campaign to lure tourists south of the border. Take a look.

Commercial announcer: Las playas de Sonora, Mexico are located on the Sea of Cortez and offers something to everyone: beautiful sand beaches, spectacular diving, snorkeling, kayaking, and offshore fishing, eighteen-hole championship golf course, tennis courts, a bowling alley, and numerous gift shops and galleries for shopping and browsing. There's something for everyone. Experience the ambiance and relaxing lifestyle of Mexican's seaside resort. A generous community is eager to share its wonders and beauties. Come home to Sonora, Mexico. Beyond your expectations.

José Cardenas:
Joining us to talk about the campaign is Keith Rosenblum, Director of Sonora Tourism. Keith, welcome to Horizonte.

Keith Rosenblum:
Thank you.

José Cardenas:

Tell us a little bit about Sonora. We saw a variety of different images.

Keith Rosenblum:
That's probably part of a misconception is that you go to Sonora just for beaches. Actually it's appropriate probably coming on the heels of a hospital administrator that you have an awful lot of people who now look at retiring to Mexico because your medical costs are a fraction of what they are in the states, and in Sonora you have a state that is every bit as diverse as Arizona. You have mountains there, snow, they have the same snow this year as in Arizona. You have the colonial cities to which you alluded. Alamos, Rio Sonora, villages in the mountains in the center of the state, then you have this incredible development going on all along the entire coast. Sonora has 500-miles of coast. It actually is from Nogales to Estación Don southern limit of Sonora is actually just 350 or 400-miles. But you have a coast that zigs and zags everywhere. And as a consequence, these last couple of years you've had an amazing boom at Puerto Peñasco Rocky Point. And as you go further south along the coast you have large developments plans of Caborca and Puerto Libertad region Guaymas and San Carlos have also gone through a boom of their own. Bahía de Kino or Kino Bay. Mexico generally is doing quite well. Sonora in particular has been a beneficiary of both American tourists that are going down, the Anglo market, the Mexican American market going home sometimes to visit and also with increasing purchasing power and buying second homes or condos. And so the last couple of years you've seen this just amazing boom next door.

José Cardenas:
Well, you made some reference to the fact that Arizona-Sonora were once part of the same state in Mexico when you referred to people going home, for example. There's a lot of cross border traffic. A lot of ties families on both sides of the border.

Keith Rosenblum:
This is something that the Mexicans themselves have sought to do. You always want to go after the kind of mainstream Anglo households but there's also plenty of immigrant community in the United States. And in that immigrant communities is a very influential and affluent Chicano or Mexican American community. And there are attempts both with this website -- this website is www.gotoSonora.com or its Spanish language counterpart www.sonoraturismo.gob.mx and the same information provided to people both in English and Spanish. Years ago, I believe it was Alvaro Obregon who is the Minister of Tourism for the state of Sonora said ‘you'll never see Sonora or any of the beach places become similar to an Acapulco or Manzanillo or places like that'. He said, ‘the climate is just too oppressive'. Well people probably said the same thing about Arizona. You'll never see that kind of growth. But for people who haven't been to Rocky Point, Puerto Peñasco for a couple of years…what you see now is one high rise after another and housing prices that are still a fraction of what it would cost in California or Oregon or along U.S. coasts. But for Mexico they're appreciably higher.

José Cardenas:
Mexicans living in the United States, Mexican Americans who have cultural ties to Sonora might feel comfortable going there. But what about people who don't have those connections? I assume it can be a little intimidating for them.

Keith Rosenblum:
I've been going to and from for 30-years. I've been blessed with the opportunity working in media and then on my own to be able to go to villages to places like Yécora, or Badispe, or Cumpas along the Rio Sonora to cities such as Alamos or Navojoa, Hermosillo. And yes, the U.S. in many ways is one of the last great islands. We speak one language, or most of our country does. We're not big travelers in comparison with a lot of other foreign communities. And so people do have that you can call it a trepidation or a phobia of going to Mexico. That they may be fearful of the legal system, fearful of--

José Cardenas:
What are the Sonorans doing to deal with those fears?

Keith Rosenblum:
There's a number of them, a number of fronts things that have been started 10 and 15 years ago and things that have been started yesterday. One is that Mexico both by design and by circumstance has become almost a bilingual nation. You have English mandatory at the elementary level in Sonora. You have a Mexican population that more and more can talk to visitors, not just Americans, obviously, but English speakers from anywhere in the world. You have a country or state I should say, in Sonora that's much more hospitable toward foreigners. You have the Ford Motor Company plant, which now has increased -having a third shift. We have 3,000 people working there while Ford has been laying people off in the U.S. You have a general--

José Cardenas:
And a plant that I understand earns a high quality of--.

Keith Rosenblum:
Oh it's one of the highest in all of the Lincoln mercury staffing assembly plants they have an autotive rate that you can rate vehicle to vehicle and company to company, and this was one of the second or third most productive and least error prone in the entire system.

José Cardenas:
Keith, how hard is it for Americans to go into Mexico?

Keith Rosenblum:
It used to be really nasty. Used to be Mexico itself was synonymous with can you show me more papers or finding something that was wrong with your paperwork. Or you'd bring down a copy of your birth certificate instead of a certified copy or instead of the original document. And what's happened and this was in particular under Governor Boors. It was started years ago under Governor Beltranes and previously, but under Governor Boors you have looking to break down one barrier after another. I would venture to say it's a lot easier to travel to Mexico now, and Sonora in particular, than it is for Mexicans or foreigners to come to the U.S.

José Cardenas:
As I understand, one significant change made by the current governor is the extension of the free zone.

Keith Rosenblum:
I'm glad you brought that up. That's a main stay of this most recent advertising program. What Governor Boors has done is to declare what is in Spanish is a zona libre vehicular which means that you can go to Rocky Point, you can go to the border cities, you can go to Naco, Agua Prieta, Nogales, Sasabe, and without any permits. Without any immigration documents.

José Cardenas:
Let me do this because I want to make sure we talk about the website. Tell us about the website and how useful it is.

Keith Rosenblum:
The website is the whether it's bicycling, hunting, whatever it is, go to that website and you'll learn about the state in either language.

José Cardenas:
Keith, thank you for being on our show and talking about Sonora. For more information on Horizonte just log on to our website, azpbs.org and click on Horizonte. Next week on Horizonte, learn about Ballet Arizona and meet some of their top ballet dancers from Latin America. That's our show for tonight. I'm Jose Cardenas. For all of us at Horizonte have a good week and have a good night. ¶¶[Music]¶¶

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John Rivers: President and CEO, Arizona Hospital and Healthcare Association;

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