Immigrants Hit With Pressure to Repay Benefits

In a practice of questionable legality, federal and state authorities from California to Florida--as well as U.S. consular officials abroad--are pressuring immigrants to repay health and welfare benefits that they legally were entitled to receive.

In some cases, immigrants who left the United States temporarily have been prevented from returning until they agreed to pay off their “debt� to the government. In other instances, immigrants have been told they could improve their odds of obtaining visas or green cards, either for themselves or for family members, if they reimbursed past benefit payments.

Frequently, immigrants have been pushed to repay benefits received under Medicaid (Medi-Cal in California), the federal-state health program for the poor and disabled. The subsidized care often was provided to their children, who are U.S. citizens if born in this country.

Until recently, the practice was largely ignored by authorities in Washington, who say it appears to have been implemented on a piecemeal basis in certain states and U.S. missions overseas.

The phenomenon is spreading fear through immigrant communities and alarming health care providers, who say that wary immigrant families are withdrawing from coverage for which they qualify or that they are declining to enroll. Health officials fear a surge in emergency room visits and delays in treating infectious diseases.

Extensive interviews and government documents show that officials with the Immigration and Naturalization Service and the State Department, federal immigration judges--who are Justice Department appointees--and numerous state agencies have pushed for repayment of benefits, either explicitly or implicitly. The actions appear to violate the stated policies of the INS and the State Department.

This month, both the INS and the State Department sent directives to field offices and missions reminding officials that they have no legal authority to demand aid reimbursement in most cases.

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The practice is the subject of two federal class-action lawsuits in California alleging that thousands of immigrants may have been illegally coerced into dropping medical coverage.

The issue has generated concern within the federal Department of Health and Human Services, where officials see a potential collision of immigration law and sensible social policy. They have raised questions about whether it is legal to request repayments, even implicitly, and whether the practice violates the privacy rights of immigrants. Department administrators have concluded that neither state nor federal authorities have the right to collect Medicaid reimbursements in the absence of a finding of fraud or overpayment.

“There are significant public health concerns for those families and kids who are legally in the country and guaranteed coverage,� said Michael Kharfen, a Health and Human Services Department spokesman in Washington.

Last summer, Martha Torres, a legal immigrant from Mexico, decided to visit her ailing mother in Acapulco.

Torres, a mother of four who lives in a cramped one-bedroom apartment in the gritty Los Angeles suburb of South Gate, took along her two youngest children, Cassandra, 5, and Luis, 2. Both were born in the United States and are citizens.

Upon their return to Los Angeles International Airport on Aug. 12, an INS inspector asked Torres if she had ever received Medi-Cal benefits. When she replied yes, Torres said, the agent took her travel documents.

Torres said she was then questioned by an investigator from the California Department of Health Services, who warned her she could be deported. Torres was directed to phone a state office to discuss her case.

“She [the investigator] said I could lose my residency if I did not call the next day,� Torres said.

Terrified that she might be separated from her children, Torres made the call. She said she was told by a state investigator that she had to cancel her Medi-Cal coverage and make arrangements for reimbursement.

Hours later, she called her welfare case worker and canceled her family’s Medi-Cal participation and monthly food stamp allotment, benefits to which she was entitled because her family of six subsists on her husband’s $200-a-week salary at a meat-processing plant.

Larry Malm, investigations branch chief for the Department of Health Services, denied any wrongdoing in the case of Torres and tens of thousands of other immigrants interrogated upon their arrival at airports and the U.S.-Mexico border about receiving public benefits.

Torres’ children remain uninsured.

California officials defend the practice, saying it is designed to encourage voluntary repayments by immigrants who received benefits legally, or to recapture benefits obtained fraudulently. California recouped more than $1 million last year from such repayments.

“All too often individuals who are not entitled to state benefits simply come across the border and utilize health care services that are otherwise denied to working-poor Californians,� said Sean Walsh, a spokesman for Gov. Pete Wilson, whose administration has been in the forefront of the controversial practice.

But critics say many--possibly most--of those affected are not short-term visitors but permanent residents of the United States and their citizen children, like Torres and her family, who received benefits legally.

At the heart of the issue are long-standing laws requiring federal officials weighing visa requests to consider whether an immigrant is likely to become a “public charge� if allowed to take up residence in the United States. Applicants deemed to be likely future aid recipients could be barred from entry.

The underlying idea, whose origins date to the early years of the republic, is that the United States does not welcome immigrants who will depend on government benefits instead of their own labor and the support of relatives or guardians.

Last year’s sweeping welfare reform law reinforced the doctrine, requiring relatives and other sponsors to sign legally binding affidavits pledging to support any newcomers they bring into the country. Those new rules became effective Friday.

The agencies principally responsible for screening immigrants are the State Department, at overseas consulates, and the INS, at U.S. ports and borders and in the nation’s interior.

Past receipt of benefits is regarded as one of several possible indicators of future government dependency.

“This is just one of the things we look at,� said James Ward, U.S. consul general in Ciudad Juarez, Mexico, across the Rio Grande from El Paso. Ward’s office processes all immigrant visas from Mexico. “This is not a requirement that says, ‘You don’t pay up, you don’t get your visa.’ �

Added Maria Rudenski, a State Department spokeswoman in Washington: “We are not in the business of debt collection.�

The State Department’s involvement in checking benefit histories intensified in 1995, after about 50 Air Philippines flight attendants entered the country briefly to have babies at U.S. hospitals, according to Bruce Byers, spokesman for the U.S. Embassy in Manila. Now, 16 consulates from Juarez to Manila to Seoul have formal information-sharing agreements with agencies in 12 states.

Mostly, the consulates receive information on use of subsidized health care by visa applicants or their sponsors. Legal immigrants are generally eligible for Medicaid, assuming they meet income guidelines and other requirements; their U.S.-citizen children face no bars based on nationality. Even illegal immigrants are eligible for emergency services and certain other medical treatments.

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Last year in North Miami Beach, Frantz Bien-Aime reluctantly agreed to give up his monthly food stamps and forgo subsidized medical care for his 4-year-old son, Washington.

Bien-Aime, a Haitian immigrant who became a U.S. citizen in 1988, did so in an effort to obtain visas for the five older children he had left behind in Haiti.

According to Bien-Aime and immigration lawyers familiar with his case, officials at the U.S. consulate in Port-au-Prince told his family that he had to repay past Medicaid benefits to the state of Florida before the children could emigrate legally. The state could not give him an accurate accounting for the amount he owed because there was no system for doing so.

Desperate to have his children rejoin him, Bien-Aime said he signed an agreement to repay the state $100 a month even though he did not know how long he would be making the payments. In addition, he dropped Medicaid coverage for his little boy.

“I will do anything to have my children with me,� said Bien-Aime, who is paid $6 an hour as a security guard. He said he barely earns enough to take his son to the doctor when he needs it and to send money to his children in Haiti.

“I feel they are holding them hostage,� he said.

While Bien-Aime’s older children remain in Haiti, his youngest is uninsured. Bien-Aime said he has stopped making payments to the state because he needs the money to take care of his son.

With word of the repayments spreading, officials in Washington are trying to clarify the ground rules.

Earlier this month, the State Department cabled all overseas posts to remind diplomats that demanding repayment of benefits is legally questionable. It noted that past receipt of aid does not automatically disqualify would-be immigrants from receiving visas.

“Under no circumstances should an officer instruct or request an applicant to repay previously received benefits,� the cable said.

The INS in Washington followed with a similar agency-wide memorandum.

“In the normal course of events, an immigration inspector shouldn’t get anywhere close to getting into a position of saying, ‘Repay the debt,’ � said Robert Bach, INS executive associate commissioner for policy and planning.

Bach acknowledged “problems� with the way the process is working at some airports and borders. At least until now, some INS field offices--notably the district office in Los Angeles, one of the agency’s busiest--seem to be using different guidelines.

“If they have received benefits, they have to satisfy us that the benefits have been repaid, that they are no longer receiving benefits and that they are not likely to receive those benefits again,� said Richard K. Rogers, INS district director in Los Angeles.

According to one INS form used in Los Angeles, green-card applicants should supply “a letter from the Department of Health Services investigations unit regarding receipt of Medi-Cal. Letter must indicate repayment agreement started.� (The form is now under review, INS officials in Washington said.)

The INS now screens new arrivals for use of public benefits at U.S.-Mexico border crossings in California and at Los Angeles International Airport and San Francisco International Airport, working with state investigators in a joint program launched by the Wilson administration.

In Florida, the governor’s point man on immigration issues, Mark Schlackman, portrayed his state’s repayment program as purely optional.

“Our position is we’re not requiring it. There’s no legal authority to require it,� Schlackman said. “But if someone is interested in voluntarily repaying or reimbursing the state of Florida . . . we certainly want to facilitate that kind of a decision.�

Likewise, administrators in California said they are merely giving people the opportunity to make “voluntary� payments to enhance their immigration status. “We don’t require repayment, but the INS may,� said Larry Malm, investigations chief for the Department of Health Services.

Until at least 1996, however, California was sending out letters telling some immigrants that they or their sponsors had an outstanding “debt� that had to be repaid.

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Maria, a native of Guatemala, arrived in the United States years ago and gave birth to five children while living in Southern California as an undocumented immigrant. (She and her husband asked that their full names not be used for privacy reasons.)

Under California law, illegal immigrant women are eligible for Medi-Cal prenatal care. As citizens, their children are eligible for full Medi-Cal coverage as long as the family satisfies the income guidelines.

Maria’s daughter Shirley, now 7, was born with cystic fibrosis. After Shirley entered public school, Maria visited her twice a day to provide the physical therapy--vigorous pounding on her chest to dislodge mucous plugs in her lungs--that allowed her to breathe normally and concentrate on her studies.

Maria returned to Guatemala in December 1996 to finish processing her residency application, which was filed by her husband, a U.S. citizen and construction worker.

In March of this year, consular officials in Guatemala City instructed Maria to obtain a letter from the state of California saying she did not owe any money “for the birth of her children or for any other help,� according to a consular document reviewed by The Times.

Her husband said he contacted the Department of Health Services and was told to terminate Medi-Cal for his children. He did so for four of the five, but not for Shirley, whose life depended on continued treatment.

Consequently, the state refused to issue a clearance letter for the embassy in Guatemala City, according to Marilyn Holle, a lawyer at Protection and Advocacy, a group that works on behalf of disabled immigrants.

In June, the state sent Maria’s husband a letter saying that Medi-Cal had spent $121,147 on behalf of the family and that if he wanted to repay it, he should do so by certified check or money order. No installment plans were available, the letter said.

By September, Shirley’s weight had dropped to 32 pounds. Because of esophageal problems, she could not keep down much food. Terrified for his daughter’s life, her father was forced to hospitalize her.

It took extraordinary intervention by lawyers in Los Angeles and Washington as well as doctors at Childrens Hospital in Los Angeles to convince the U.S. Embassy in Guatemala that the Medicaid benefits reflected the financial reality of an extraordinary illness.

Nine months after she returned to Guatemala, Maria was issued a visa and allowed to rejoin her family in California. After a long slide, Shirley’s health has begun to improve, and she continues to receive Medicaid coverage. Her four brothers and sisters remain uninsured.

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Rubin reported from Washington and McDonnell from Los Angeles.