Medical Deportations and Racial Narratives of the Burdensome Migrant

Abstract

Hospitals across the U.S. are quietly removing severely injured and chronically ill migrants to other nations. It is a reality that exists in practice but not in policy and is experienced by hundreds, potentially thousands, of low-income uninsured migrants. There is no formal accounting or regulation of this practice and federal immigration authorities remain silent regarding this practice despite the fact that alien removals, or deportations, are solely within their jurisdiction. Focusing on a case study, this paper analyzes migrant narratives embedded within news media accounts and legal analyses of medical deportations to address how this controversial practice is rationalized by health care providers. In these accounts, a racialized narrative of migrants as public burdens was clearly evident. This paper argues that such narratives have the power to transform actions legally defined as illegal—such as medical deportations—into a reasonable practice. In this way, social “cost” is racialized into individual debt, allowing for seemingly extraordinary disciplinary actions that are contrary to normative policy and ethics.

Hospitals across the U.S. are quietly removing severely injured and chronically ill migrants to other nations. It is a reality that exists in practice but not in policy and is experienced by hundreds, potentially thousands, of low-income uninsured migrants. There is no formal accounting or regulation of this practice and federal immigration authorities have remained silent regarding this practice despite the fact that alien removals, or deportations, are solely within their jurisdiction.

Various terms are used—“medical removal,” “medical repatriation,” medical deportation,” “medical rendition,” and international patient dumping—to describe the practice of forcibly removing low-income, uninsured migrant patients to other countries. Medical deportations are one of the more unique methods among the increasingly varied efforts in immigration enforcement. In this paper, I argue that racialized narratives of burdensome migrants are embedded within this practice and function to rationalize the actions of hospital administrators as within their purview as health care providers. In other words, racial formation of migrants as public burdens enables medical deportations.

Racialization of Public Burden into Individual Debt

For migrants, the condition of being a public burden is felt as a form of individual, irrevocable indebtedness. Drawing from Ethnic Studies, Critical Race Studies, and Critical Migration Studies, wherein the lived experience of those deemed burdensome has been a persistent focus of scholarship, it is evident that the concept of debt has multiple meanings. Debt takes on different forms and can reinforce positions of power as well as subjugation. The construction of migrants as public burdens illustrates the imbrication of the moral with the financial, with its attendant expectations of individual accountability.

For instance, going beyond the context of a financial economy, Jodi Kim (2018) argues that debt can signal a figurative economy or even a narrative structure. In other words, the relationship between debt and debtor articulates something much more than the sum of money owed. In fact, debt can inhabit two seemingly opposing forms at the same time. Debt can be both a source of strength and weakness—depending upon the person or institution and context (Kim, 2018). For instance, the United States—the world’s greatest debtor—is able (thus far) to convert indebtedness into a position of strength. Given the central financial role of the U.S., its default of this massive debt could radically destabilize the entire global economy. This possibility functions to anchor U.S. imperialism. This same debtor nation then exerts the authority to compel indebted nations and individuals to conduct themselves in particular ways that maximize the likelihood of repayment; at times, through violent disciplinary means (ibid). In this way, indebtedness is not simply the act of owing money; but a particular condition of being. And, race and racism have been convenient tools for determining these conditions. In other words, indebtedness has served as a very effective form of racialized domination.

Saidiya Hartman’s (2007) work has made important contributions in our understanding of this form of racialized domination. In particular, she shows how the substantive possibility of freedom after emancipation was fundamentally diminished as the U.S. required newly freed slaves to repay their “emancipators” as racially and economically “indebted” subjects entangled in a coordinated system of exploitative labor contracts and criminal codes (p.125). In this way, those “liberated” are forced into conditions of indebtedness and, subsequently, the experience of freedom is one of unending gratitude. Aaron Carico’s (2020) careful historical accounting of freedom after 1865 shows that the gift of freedom for those enslaved was “a Trojan horse that trapped such persons with the liability for a financial debt they literally incarnated.” (p. 21) Carico explains that after abolition, white Southern planters and merchants found themselves deeply in debt without the commodity of slaves. In response, the state through state and federal legislations on crop-lien and bankruptcy, respectively, were passed to ensure that these former slave owners retained their land and wealth by allowing cotton planters to secure credit from merchants based on their workers’ future labor and expunging their existing debts. The workers’ labor upon which the planters secured credit were the same people laboring under slavery. Carico writes, “At once contriving the consent of the freed and encumbering them with debt, the contract system reanchored the value of the slave’s body in the freed’s person” (p. 21). In this way, credit for the former slave owner is derived through the enforced indebtedness of the former slave. And, while both credit and debt indicate money owed, each suggest the opposite moral character. Ironically, credit is imbued with good moral character (i.e., slave owner) and debt is considered a sign of weakness and lack of self-control (i.e., slave).

This contradictory duality of debt is central in Mimi Thi Nguyen’s (2012) analysis of The Gift of Freedom, in which freedom is understood as a gift that is both precious and poisonous. Focusing on those made into refugees by the U.S. war in Vietnam, Nguyen argues that in understanding freedom as a gift, a debt is incurred in which the recipient is obliged to repay. However, its poison is derived from the vast inequality of this contractual relationship; entered into not out of choice nor with consent, and without end. In this way, refugees are deemed “rescued” by the very forces that created the circumstances for their migration. ² And, for this, refugees are expected to be forever grateful.

Migrants racialized as outsiders are part of a similar structure that perpetuates conditions of indebtedness into subsequent generations. Asian Americans, for instance, have been useful in playing the role of the perpetual foreigner/victim who must be rescued, welcomed, and domesticated again and again in a patriotic drama of US exceptionalism (Park, 2008). Erin Khuê Ninh (2011) argues that such debt functions to produce generations of docile subjects. And, Aihwa Ong (1987) makes an important point that the power of such disciplinary measures is its stealth nature in which unequal institutionalized power relations are surreptitiously embedded in the “normal” order of things (p. 5). ³

Deportation by Hospitals

In 2008, the California Medical Association was the first state medical association to pass a resolution opposing deportations of patients (Smith, 2010). Then, in 2011, the American College of Physicians (2011) published a position statement arguing that “Physicians and other health care professionals have an ethical and professional obligation to care for the sick. Immigration policy should not interfere with the ethical obligation to provide care for all” (p. 12). ⁴

Evidence suggests that these resolutions and statements have not hindered deportations by hospitals. What we know thus far is that most cases involve migrants from Latin America. However, there are known cases of medical deportations to countries around the world, including South Korea, Philippines, Ukraine, and Poland (Seton Hall, 2012). And, while most of the known cases of medical deportation involve undocumented migrants, this is not always the case. Lawful permanent residents (those with green cards), temporary visa holders, and U.S. citizens born to parents who do not have legal documentation status have been involuntarily repatriated (Park, 2018).

In fact, in a report released in December 2012 by the Seton Hall University School of Law and the New York Lawyers for the Public Interest documented over 800 migrant patients who have been involuntarily repatriated from hospitals in 15 different States in the U.S. This is assumed to be a severe undercount given that there is no legal requirement that hospitals report medical deportations. One hospital in Phoenix alone reportedly repatriates approximately 100 patients a year (Seton Hall, 2012).

These deportations carried out by hospitals are conducted without the procedural protections required under international law and the U.S. constitution. Until recently, certain procedural protections were provided in formal removal proceedings when initiated by the federal government. ⁵ However, in my research, I found hospital administrators independently deporting patients with minimal risk of legal repercussions and no formal systems in place to regulate such practices. And, because this process is outside of the federal immigration process, there are no avenues for redress even for those who can prove that the hospital failed to obtain consent to transfer the patient abroad.

This paper shows how the entrenched narrative of migrants as inherently burdensome to the nation and its citizens functions in such powerful ways that it disrupts otherwise accepted notions of legal logics and medical ethics. And while this narrative of the burdensome migrant has a long history in the U.S., contemporary formations of race and racialization has been instrumental in this disruption. Using the case of medical deportations, the overwhelming costs of health care, rather than a societal burden requiring structural change, is transformed into individual debt incurred by individuals racialized as burdensome outsiders that is unfairly shouldered by citizens.

In reality, the crisis of medical costs in the U.S. has very little to nothing to do with undocumented or documented migrants. Instead, the powerful racializing narrative of the burdensome migrant has produced a sense of indebtedness among migrants—the vast majority of whom are ethnic minorities—that has functioned to discipline them into specific roles essential to the nation’s economy. Medical deportations of particular migrants no longer able to fulfill this role lays baer the reality of medical costs and the significance of narratives of racialized migrants as public burdens in obscuring the true costs and culprits of this reality.

Data and Methods

This paper emerged out of a larger study on the health care safety-net for undocumented migrants in four U.S. States along the southern border between 2014 and 2016. The sources for the analysis in this paper derive from court transcripts, ⁶ published legal analyses, and news media reports on the case of Luis Alberto Jimenez, first reported in The New York Times in 2008 (Sontag, 2008). The larger research project is based upon 86 interviews with key hospital administrators, health care providers, and community health advocates in Houston, TX; Phoenix and Tucson, AZ; and San Diego, CA., 104 news media articles from 2003 to 2019 that substantively focused on medical deportations, 90 published law reviews and legal analyses since 2008 that specifically addressed medical deportations, and available court transcripts of specific cases that challenge forced removals of migrant patients. ⁷

In this paper, I center the experience of Luis Alberto Jimenez, whose case set not only legal precedence but also illustrates how the practice of medical deportation—despite its serious ethical, legal, and medical implications—continues to operate unabated. Over one hundred legal articles and media stories from 2008 to 2015 have mentioned this specific case. As larger context, I will begin by discussing the “Medical Cost Crisis” in the U.S., and its implications for low-income migrants’ health care access. Then, I will show how migrants are racialized as public burdens who are understood as already, irrevocably indebted to the host nation upon their arrival, and subsequently perceived as irresponsible and ignorant for being so. Jimenez’ case shows the power of racial knowledge in transforming actions legally defined as illegal into a reasonable practice. In this way, social “cost” or public burden is racialized into individual debt; allowing for seemingly extraordinary disciplinary actions that are contrary to social norms.

Social Costs of Health Care

“Cost” is by far the most frequently cited reason for medical deportations. Although there are multiple solutions recommended in response to the complex problem of medical deportation by legal analysts, journalists, and medical personnel, the cause is singularly understood as one of cost. In most written mentions about medical deportation, the high cost of migrant health care is treated as given, or background information, to the contested issues at hand. This section considers the presumptions embedded in this causal explanation, as well as what is obscured.

According to the Department of Health and Human Services, U.S. health care spending reached $3.5 trillion, or $10,739 per person, in 2017. ⁸ This amounts to an overall share of gross domestic product (GDP) of 17.9%. And, these health care costs are covered by 1) private health insurance (34%); 2) Medicare (20%), a public health insurance program for elderly, disabled, and those with end-stage renal disease; 3) Medicaid (17%), a public health insurance program for eligible low-income residents; and 4) Out-of-pocket (10%) (ibid). These figures all combine to reinforce the fact that the United States spends more on health care than any other country, and at the same time, Americans actually use less health services. In fact, U.S. spends almost twice as much on health care, as a percentage of its economy than other advanced industrial countries (Frakt & Carroll, 2018).

At the same time, many U.S. residents struggle with health care related costs. A study of bankruptcies filed between 2013 and 2016 found that a majority of these cases attributed medical costs as central to their financial straits (Himmelstein et al., 2019). These results are consistent before and after the implementation of the Affordable Care Act in 2014. In 2019, 29 million people remained uninsured; and even for those with health insurance, out-of-pocket co-payments and deductibles was unaffordable for many (Himmelstein et al., 2019). In addition, few people have adequate disability or long-term care coverage that will financially sustain them through catastrophic injuries or chronic illness.

In the midst of such serious constraints, quality health care appears increasingly out of reach for many. Health care is understood as a finite and fragile resource perpetually on the brink of collapse—a frightening proposition for an institution that performs a central role in sustaining the individual life of U.S. residents as well as upholding a national reputation for scientific advancement. In this context of precarity, migrants can serve as easy targets (Park, 2011). Migrants are viewed not only as undeserving burdens upon an already broken system but the cause of its downfall.

This is despite the fact that migrants, especially those undocumented, use disproportionally fewer medical services and contribute less to health care costs in relation to their population share (Goldman et al., 2006). Multiple studies have shown that foreign-born nonelderly adults have better relative health and use significantly less health care services than native-born citizens (Berk et al., 2000; Goldman et al., 2006; Mohanty et al., 2005). "One-quarter never had a medical checkup, and one in nine had never visited a doctor—rates twice those of the native-born” (Goldman et al., 2006, p. 1705.) And, among undocumented men, only 2% had any hospitalizations. In terms of medical costs, undocumented immigrants comprised 1.5% of total national medical costs in 2000, which is half as large as their 3.2% population share. And, of this 1.5% (or $6.5 billion), only 17% (or $1.1 billion) is paid for by public sources (ibid).

At the same time, researchers have shown that undocumented and documented migrants, given their relative young age and high employment levels, contribute far more to Medicare than they receive. A 2013 study (Zallman et al., 2013) argued that migrants disproportionately subsidized the Medicare Trust Fund, which supports payments to hospitals and institutions and thereby contribute significant benefits to the US. From 2002 to 2009, they estimated a contribution of $115.2 billion more than they took out as a result of their disproportionately high numbers of working-age taxpayers (Zallman et al., 2013, p. 1154).

Overall, it is clear that migrants, and undocumented migrants in particular, play little to no role in the overall “medical cost crisis.” Meaning, even if undocumented migrants used no health care at all, struggles over health care costs in the U.S. will continue.

Case Study: Luis Alberto Jimenez

And yet, the narrative of migrants as public burdens remains as strong as ever. This is evident in the case of Luis Alberto Jimenez. On February 28, 2000, Jimenez was a 28-year-old landscaper getting a ride home after work when he was hit head-on by a drunk driver in Stuart, Florida. Two of his co-workers died instantly and Jimenez suffered severe injuries. He arrived by ambulance at Martin Memorial Medical Center, unconscious, in shock, with extensive bleeding, two broken thigh bones, broken arm, multiple internal injuries, lacerations across his face, and a severe head injury. Doctors did not expect him to survive. The drunk driver who caused the crash walked away uninjured, and was found to have stolen the van and had no car insurance (Sontag, 2008).

Luis Alberto Jimenez is from a remote indigenous Mayan community in the highlands of Guatemala. He arrived in Florida a little less than a year prior, drawn to the area for its many golf courses and gardens that need tending, and a community of Guatemalan workers including his cousin. He quickly found work as a landscaper and sent money to his wife and two sons in Guatemala (Sontag, 2009). Like many migrants, Jimenez planned to work in the U.S. long enough to pay off his debt to the smugglers who brought him, buy land of his own in Guatemala, and return to his family. At the time of the crash, Jimenez was undocumented, uninsured, and without financial resources.

Martin Memorial is a nonprofit community hospital located in a small, up-scale town north of Palm Beach, an area nicknamed the Treasure Coast for its historical past as the location of multiple shipwrecks and appropriate in describing the current affluence of its residents. The medical personnel at Martin Memorial were able to save Jimenez’ life but after he was determined to be medically stable, the hospital could not find a rehabilitation center or nursing home to accept him as a long-term patient. At first, they were able to place him in a nursing home when an insurance payout seemed a possibility. However, the drunk driver was uninsured and it became clear that there would be no reimbursement for Jimenez’s care. It was also apparent that the quality of care by the nursing home was sub-par, if not criminal. Previously described as “husky” and an “industrious laborer” who loved to play soccer, Jimenez arrived back at Martin Memorial near death. The doctors found him emaciated, with an infection over-taking his body, and “suffering from ulcerous bed sores so deep that the tendons behind his knees were exposed” (Sontag, 2008).

For over a year, Jimenez remained in the hospital in a vegetative state, coiled in a fetal position. Montejo Gaspar Montejo, a cousin by marriage served as his guardian during this time. Montejo described Jimenez as unrecognizable from the man he was but nonetheless alive. Then, in a stunning turn of events, Jimenez slowly gained consciousness and began to communicate (ibid).

For nearly 3 years, Jimenez stayed in the hospital ward. Martin Memorial Medical Center calculates their services for Jimenez at $1.5 million. Of this amount, they were reimbursed $80,000 by emergency Medicaid. ⁹ A news article reports that the average stay at Martin Memorial is usually a little over 4 days at an estimated cost of $8188 (Sontag, 2008).

A hospital representative is quoted as saying: “I don’t want to sound heartless. A community hospital is going to give care. But is it the right thing? We have a lot of American citizens who need our help. We only make about 3% over our bottom line if we’re lucky. We need to make capital improvements and do things for our community” (ibid).

As a non-profit, community hospital, Martin Memorial is tax exempt and required to dedicate some part of its services to charity care. In 2006, Martin Memorial provided $23.9 million worth, or 3%, to charity, which was the average in the state of Florida. That same year, it reported earning 6% over its bottom line. It also reported assets of $270.6 million and its senior executives earned more than $4 million in salaries and benefits (ibid).

With mounting expenses associated with Jimenez’ care, Martin Memorial sought ways to remove him from the hospital. An attorney representing Martin Memorial argued, “…the government should step in and otherwise exercise its authority for deportation or whatever it wants to do” (ibid). In making this point, the hospital framed Jimenez as an immigration problem, rather than a medical problem to distance their involvement. But, when no other entity “exercised their authority,” Martin Memorial administrators-initiated deportation actions on their own. As part of this process, they contacted the Guatemalan health minister, who wrote a letter stating they would accept and care for Jimenez in Guatemala.

Jimenez’ guardian, Gaspar Montejo, refused to consent to the discharge plan given his knowledge of the public health system in Guatemala. Montejo believed the Guatemalan health system to be inadequate in providing the kind of long-term rehabilitative care that his cousin needed. Martin Memorial took Montejo to court to override his decision as the court appointed guardian. In other words, when Montejo would not consent to the deportation, the hospital asserted their role as an “interested party” and used their medical expertise in a court of law to argue that forced removal was in the best interest of the patient.

Circuit Judge John E. Fennelly agreed with Martin Memorial Medical Center. Judge Fennelly’s decision included as fact that Jimenez is cognitive of his surroundings and stated, “[t]he Ward is unhappy and misses his family; he often says he misses his wife and children” (ibid). In opposing Gaspar Montejo’s position, the Judge asserted the voice and supposed wishes of Luis Jimenez and discredited Montejo, the legal guardian, by describing him as having a sixth grade education.

The court document, however, fails to mention that Jimenez’ traumatic brain injury has left him with the mental age of a child, incomplete memory, rudimentary verbal ability, unable to walk, and racked with violent seizures, which occur regularly and leave him unconscious (ibid). Instead, Judge Fennelly ordered Gaspar Montejo to consent and “fully cooperate in and refrain from frustrating the Hospital’s discharge plan to relocate the Ward back to Guatemala under the authority and guarantee of the Guatemalan Ministry of Health” (Sontag, 2008). And, in his decision, the Judge portrayed the financial concerns of the hospital as pivotal in allowing a private deportation against the wishes of a legal guardian.

Montejo and his attorneys were stunned by this decision. They immediately filed a notice of appeal and asked for a stay of the court’s order while the appeal was pending (Sontag, 2008). In response, the Judge requested a response from the hospital by 10a.m. on July 10, 2003. But, while the court was waiting for this response, Martin Memorial personnel secretly placed Luis Jimenez on an air ambulance at 7:30a.m. that morning and transported him to Guatemala. No one was notified, including his guardian. Montejo found out only when he arrived at the hospital and found an empty bed.

The appeal case moved forward nonetheless. Almost a year after Jimenez’s forced removal, the fourth District Court of Appeal of Florida reversed the earlier Circuit Court decision based upon the fact that: “(1) there was no competent substantial evidence to support Jimenez’s discharge from the hospital, and (2) the trial court lacked subject matter jurisdiction to authorize the transportation (deportation) of Jimenez to Guatemala.” ¹⁰

The letter from the Guatemalan official, which served a key role in the earlier decision to discharge and deport Jimenez, was determined to be “inadmissible hearsay” and “not specific enough to satisfy either the federal regulations or the hospital’s discharge procedure.” ¹¹ The only admissible evidence, according to the Appeals Court, as to whether appropriate care would be available in Guatemala was the testimony of Dr. Miguel Graces, an expert in the Guatemalan public health system who stated that there were no public facilities providing traumatic brain injury rehabilitation. ¹² The Circuit Court judge had disregarded this testimony. And, the Appeals Court decision repeatedly cited the fact that trial courts do not have jurisdiction to authorize the forced removal of an individual to another country. The transportation of Jimenez was defined as a deportation, which is solely within the purview of federal immigration agencies.

Upon his deportation to Guatemala, Luis Alberto Jimenez was allowed to stay at the National Hospital for Orthopedics and Rehabilitation for a few weeks. The hospital then transferred him to another public hospital when they needed his bed. When Jimenez’s brother came to visit him at his new hospital, he found him “lying in the hallway on a stretcher, covered in his own excrement.” He said, “So we cleaned him up and we brought him home” (Sontag, 2008).

His home, since then, has been a small, one-room brick house on a steep mountainous slope in Guatemala where he lives with his elderly mother. He received no medical care or medication since he arrived at his mother’s home in 2003 (ibid)

Back in Florida, Montejo followed the favorable Appeals Court decision with a personal injury lawsuit against Martin Memorial Center. His new attorneys initiated a false imprisonment action by identifying Jimenez’s deportation as a kidnapping and likening the process to a medical rendition (ibid). Given that medical deportations do not exist as a categorical legal entity, Montejo’s attorneys argued that Jimenez’s confinement in the ambulance and private airplane amounted to “false imprisonment.” ¹³ The lawsuit sought nearly $1 million to cover the estimated lifetime costs of Jimenez’s care in Guatemala, as well as damages to discourage other hospitals from doing the same (Associate Press, 2009; Wides-Munoz, 2009).

Martin Memorial administrators were infuriated (Sontag, 2008). They contested the false imprisonment charge; and in July of 2009—5 years after his deportation—a jury in Stuart, Florida assessed “whether Martin Memorial’s actions were unwarranted and unreasonable under the circumstances.” ¹⁴ In court, the question of false imprisonment was narrowly focused on this question. Prior court decisions had already determined that Martin Memorial detained Jimenez against the will of his guardian and without the legal authority to do so. Now, the question posed to the jury was whether this was warranted and reasonable. In fact, in his instructions to the jury, the presiding Judge reiterated that it was already “a matter of law” that the patient, Luis Alberto Jimenez, had been unlawfully detained and deprived of his liberty (Sontag, 2009).

After deliberating for little over a day, the six all white, non-Hispanic, jury found the unlawful actions of Martin Memorial Medical Center warranted and reasonable under the circumstances; and therefore, the Medical Center did not engage in false imprisonment.

This precedent setting legal case, one of the very few on medical deportations, raises numerous questions; as is evident by the slew of subsequent publications of legal, medical, and media analyses that parsed various implications and suggested a range of policy recommendations. In closing arguments, the lawyer representing Montejo and Jimenez, Jack Hill, argued that the central and only reason for the hospital’s unlawful deportation was cost. Given that the deportation was already established as unlawful, Hill could not base his argument on a tautology in which the unlawful deportation is “unreasonable” because it is unlawful. The legal framing of the problem at hand required a separate, different reason why this unlawful action was “unreasonable.” In invoking cost as the sole motivating factor, the contention was that the hospital’s action was unreasonable for a health care provider. The inference was that rather than functioning as a medical institution and upholding the Hippocratic Oath of “first, doing no harm,” Martin Memorial went against their own creed and moral obligations as a community hospital and harmed one of their patients to save money.

For the jury, it seems the cost of care was a greater violation than the illegal act of a hospital secretly deporting a severely ill and disabled patient. As an undocumented migrant, Jimenez is understood as undeserving of any care, much less $1.5 million worth. And, from the hospital’s point of view, the amount of care they provided prior to the deportation absolves them from their responsibility in conducting unlawful actions.

Debt, Race, and Health Care

This case illustrates how those appointed to uphold the law can make an unlawful act reasonable. Here, the incurring of costs by an unauthorized migrant for using a public good for which it is intended is a crisis of such magnitude that violation of federal law is warranted. This case also shows that it is not costs alone that allows the violation of fundamental tenets of law. It is costs associated with particular racialized bodies.

For many migrants, hospitals and doctors are hostile places to avoid unless at the brink of death (Park, 2011). And, while financial debt from unpaid medical bills can be a source of great stress for any individual, there are added consequences for migrants. This is because migrants are understood as already indebted to the host nation before they access any service or program, regardless of whether or not they are legally eligible to participate. This debt is assumed upon arrival and without the possibility of recompense. In this way, migrants are made into debt-producing subjects wherein one’s mere existence produces harm to the host nation; a drain upon the system. To then accept assistance or charity is viewed as a sign of weakness in character and fortitude—an insult to the generosity afforded in allowing their presence in the first place.

This is a well-worn moral narrative that is intimately felt by many migrants throughout U.S. history. It is ingrained in both formal policy and informal practice. Most notably, for over a century, the administrative policy of public charge has remained constant within immigration law. Since its earliest iteration in the U.S., paupers or “persons likely to become a public charge” has been a persistent rationale for the exclusion of “undeserving” or “defective” migrants. The Immigration Act of 1882, passed swiftly after the Chinese Exclusion Act a few months prior, formally permitted the federal government to prevent any person “unable to take care of himself or herself without becoming a public charge” from entering the country (U.S. Citizenship and Immigration Services). ¹⁵ And, still today, it remains one of the most common grounds for immigrant inadmissibility (ibid). Also persistent throughout its existence is the largely discretionary nature of determining an individual’s potential to become a public burden. ¹⁶ However, migrants’ potential health care costs are one of the most frequently cited sources of this burden.

More recently, the Trump administration implemented a drastic new definition of public charge in which migrants can be denied permanent legal status if they use or are likely to use public benefits like Medicaid, food stamps, and housing vouchers (Liptak, 2020). This is a vast expansion of the public charge rule, which had narrowly applied to those receiving sustained cash assistance or long-term use of institutionalized care for decades prior. The new rule punished documented migrants for using even modest or temporary amounts of benefits that are designed to promote health or economic stability. In this way, age-old political disputes concerning migrants and their associated economic and social costs to the nation have set the stage for informal practices such as medical deportations.

Some have argued that social relations produced through indebtedness are particularly valuable during moments of welfare state retrenchment and increased precariousness of labor markets (Joseph, 2014). The passage of Prop. 187 in California, which restricted migrants’ access to publicly funded programs and institutions, including education, welfare benefits, and health care, was based upon the nativist position that migrants are a burden on the state. And while this state proposition was deemed unconstitutional and never implemented, a spate of major federal legislations in 1996 reinforced the “personal” debt owed by immigrants. The Illegal Immigration Reform and Immigrant Responsibility Act of 1996, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, and the Antiterrorism and Effective Death Penalty Act of 1996, entrenched familiar nativist ideas that migrants are taking jobs away from native-born citizens; that migrants place a strain on public services; and that they threaten the cultural fabric of the nation by introducing new languages, religions, and new racial/ethnic political power blocs. It is noteworthy that these heightened calls for migrants to take “personal responsibility” took place when migrant employment rates were higher than those native-born. And, each of these legislative efforts significantly restricted migrant access to health care services (Park, 2011).

In the case of Jimenez, Martin Memorial Hospital administrators tightened the boundaries of their community by restricting their patient population to “American citizens.” There was no evidence that Jimenez’s care forced the hospital to turn away any other individual nor did Jimenez negatively impact the care provided to other patients. However, his presence was perceived as a serious drain on the institution. Rather than a seriously injured patient in need of care, Jimenez was treated as a waste of valuable community resources and an unruly one at that. His guardian, Montejo, was one of the very few migrants to launch a serious legal challenge against a hospital. The presumption of negligent costs imposed by migrants obscures the structural gaps in health care coverage for low-income migrants and their providers that is produced by a combination of retrenchments in health care, immigration, and welfare legislations.

For instance, the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA), which was passed in response to public outrage over alarming reports of hospitals “patient dumping” uninsured individuals, mandates hospitals to “stabilize” an emergency medical condition and they can only transfer or discharge patients to an “appropriate” medical facility. ¹⁷ However, once a patient is stabilized, federal funding to cover uninsured low-income unauthorized (meaning undocumented and new arrived documented) migrant patients end and, at the same time, nursing homes and rehabilitation centers for those patients in need of long-term care are under no obligations to accept patients without insurance. There is no health care safety-net for undocumented migrants. In fact, the passage of the Affordable Care Act hinged upon the explicit exclusion of undocumented migrants. This structural exclusion has made migrants a high-risk population to avoid and exacerbated the narrative of migrants in general as burdens.

The very people excluded from health care and welfare safety nets are scapegoated as irresponsible and ignorant. Chakravartty and da Silva (2012) argue that this process is produced through the historical construction of “raciality.” or racial difference, which constructs racialized minorities and migrants as outside society (or unrooted strangers) and without self-determination (as illegitimate juridical, economic, and ethical beings). In this way, racism enshrines unequal differentiation of human value to produce the inequality that capitalism requires (Melamed, 2015). ¹⁸ For example, this was evident in the predatory loans of Wall Street, which induced the Great Recession of 2007–2008 (Mahmud, 2012). In the Subprime Mortgage Crisis, Wall Street bet on and profited from low-income Black, Latinx, and low-income migrant’s inability to pay unpayable debts. Then, Wall Street was bailed out with a massive debt forgiveness program funded by public dollars—and, in the end, escaped the disciplinary consequences endured by those they targeted (Chakravartty & da Silva, 2012). This feat was accomplished not only through the sheer power of financial capitalism but, just as importantly, with racial power/knowledge, which marks particular populations as inherently incapable of meeting the economic, legal, and moral demands of society on their own.

Medical deportation, then, becomes a solution for racialized migrants who no longer fulfill the role of the debt-bound worker. In this calculation, migrants already owe an immeasurable debt upon arrival. Their very life exists in debt to the U.S. and, once injured or rendered chronically ill, their value as precarious workers beholden to the U.S. is erased. They shift from being surplus labor to pure burden as their potential contribution to speculative capital diminishes. The costs of being human—of living, aging, dying—are not afforded to surplus populations whose existence is allowed to care for, or otherwise support, the capitalist institutions of the core. Instead, migrants become marked as irresponsible and irrational when they need care themselves. This is the story of Luis Alberto Jimenez and the source of the anger and exasperation expressed by Martin Memorial Medical Center in response to Jimenez’ guardian’s persistent legal effort to cover the cost of Jimenez’ health care.

At the same time, the power of debt is also in its ability to flatten differences and thereby obscure inequality between and across groups. The significant role of race in producing health disparities, for instance, disappears. Jodi Byrd and colleagues (2018), write: “Debt has been and remains a supreme technique of financial capital’s commensurate making. A kind of analytic trap, it produces a language of commonality, which constitutes a singular world-historic subject of debt and the debtor as a single political actor into which anyone can be slotted” (p. 9). Byrd et al. argue that such flattening of difference and its resulting inequality is essential in “economies of dispossession” so that disproportionate levels of poverty and debt is simply rendered an apolitical result of law and policy. The “differential devaluation of racialized groups,” as articulated by Lisa Cacho (2012), becomes useful in not only contributing to capital as an expendable and exploitable labor force but in serving as the cause of problems created by capitalism. In both circumstances, it is their racial formation, in conjunction with class and immigration status—or, racialization—which establishes their differential devaluation; and debt is an indispensable technique in enabling this systemic dispossession while obscuring the role of race.

Conclusion

The fixation on cost obscures other narratives with regard to immigrant health care. Migrants are rendered public burdens and the source of these costs, regardless of the actual financial structure of health care costs in the U.S. This narrative also obscures the powerful role of race in producing conditions of indebtedness.

Historically, hospitals, along with churches, courthouses, and schools, have been among the few designated “sensitive locations,” as defined by Border Patrol policy, where enforcement actions are discouraged. ¹⁹ A public health imperative shields the patients, endowing health care facilities and its providers the ability to grant a sanctuary of sorts. Certainly, this sanctuary is limited and increasingly so as governmental mandates create ever more stipulations in the care of low-income migrants. But, it is this current threadbare state of sanctuary and the fact that our public health is at stake that makes resistance to participating in medical deportations crucial. Hospitals that engage in this practice do so at their own peril. Medical deportations will not solve our long-term health care problem, and it goes against the central mission of the medical profession to provide care for those who are sick, regardless of immigration status.

In the case of Luis Alberto Jimenez, an act legally defined as illegal was found to be reasonable in a court of law. This case study graphically illustrates the power of the burdensome migrant narrative, racialized as irresponsible and ignorant, in justifying practices in direct contradiction to fundamental social policies, morals, and ethics. It also shows the deep engagement of hospitals in immigration enforcement, even when federal immigration authorities have no interest in doing so. It is particularly troubling that safety net hospitals—with an explicit mission and public funds to care for people regardless of their ability to pay—are participating in this practice.

But, this is nothing new for ethnic minorities in the U.S. For many migrants, life is comprised of contradictions and the accumulation of one layer of debt upon another. The history of Latin American migration is replete with arduous journeys and exorbitant costs through multiple national boundaries, guided by narratives of a better life. ²⁰ And, Asian American history begins with indentured servitude in the 19th century facilitating an Asian diaspora in the Americas by entering into contracts with labor recruiters in Hawaii and California (Wu & Agarwal, 2015). The monetary debts incurred in these migrations are just one small slice of the far greater costs and its attendant condition of indebtedness that follow. Going back to Mimi Thi Nguyen’s (2012) analysis of the “gifts of freedom,” it is evident that the impossibility of settling this debt is purposeful, and purposefully poisonous—not only for the migrant but also for the nation.