DES MOINES, Iowa (AP) -- Days after they were badly hurt in a car accident, Jacinto Cruz and Jose Rodriguez-Saldana lay unconscious in an Iowa hospital while the American health care system weighed what to do with the two immigrants from Mexico.
The men had health insurance from jobs at one of the nation's largest pork producers. But neither had legal permission to live in the U.S., nor was it clear whether their insurance would pay for the long-term rehabilitation they needed.
So Iowa Methodist Medical Center in Des Moines took matters into its own hands: After consulting with the patients' families, it quietly loaded the two comatose men onto a private jet that flew them back to Mexico, effectively deporting them without consulting any court or federal agency.
When the men awoke, they were more than 1,800 miles away in a hospital in Veracruz, on the Mexican Gulf Coast.
Hundreds of immigrants who are in the U.S. illegally have taken similar journeys through a little-known removal system run not by the federal government trying to enforce laws but by hospitals seeking to curb high costs. A recent report compiled by immigrant advocacy groups made a rare attempt to determine how many people are sent home, concluding that at least 600 immigrants were removed over a five-year period, though there were likely many more.
In interviews with immigrants, their families, attorneys and advocates, The Associated Press reviewed the obscure process known formally as "medical repatriation," which allows hospitals to put patients on chartered international flights, often while they are still unconscious. Hospitals typically pay for the flights.
"The problem is it's all taking place in this unregulated sort of a black hole ... and there is no tracking," said law professor Lori Nessel, director of the Center for Social Justice at Seton Hall Law School, which offers free legal representation to immigrants.
Now advocates for immigrants are concerned that hospitals could soon begin expanding the practice after full implementation of federal health care reform, which will make deep cuts to the payments hospitals receive for taking care of the uninsured.
Health care executives say they are caught between a requirement to accept all patients and a political battle over immigration.
"It really is a Catch-22 for us," said Dr. Mark Purtle, vice president of Medical Affairs for Iowa Health System, which includes Iowa Methodist Medical Center. "This is the area that the federal government, the state, everybody says we're not paying for the undocumented."
Hospitals are legally mandated to care for all patients who need emergency treatment, regardless of citizenship status or ability to pay. But once a patient is stabilized, that funding ceases, along with the requirement to provide care. Many immigrant workers without citizenship are ineligible for Medicaid, the government's insurance program for the poor and elderly.
That's why hospitals often try to send those patients to rehabilitation centers and nursing homes back in their home countries.
Civil rights groups say the practice violates U.S. and international laws and unfairly targets one of the nation's most defenseless populations.
"They don't have advocates, and they don't have people who will speak on their behalf," said Miami attorney John De Leon, who has been arguing such cases for a decade.
Estimating the number of cases is difficult since no government agency or organization keeps track.
The Center for Social Justice and New York Lawyers for the Public Interest have documented at least 600 immigrants who were involuntarily removed in the past five years for medical reasons. The figure is based on data from hospitals, humanitarian organizations, news reports and immigrant advocates who cited specific cases. But the actual number is believed to be significantly higher because many more cases almost certainly go unreported.
Some patients who were sent home subsequently died in hospitals that weren't equipped to meet their needs. Others suffered lingering medical problems because they never received adequate rehabilitation, the report said.
Gail Montenegro, a spokeswoman for U.S. Immigration and Customs Enforcement, said the agency "plays no role in a health care provider's private transfer of a patient to his or her country of origin."
Such transfers "are not the result of federal authority or action," she said in an email, nor are they considered "removals, deportations or voluntary departures" as defined by the Immigration and Nationality Act.
The two Mexican workers in Iowa came to the U.S. in search of better jobs and found work at Iowa Select Farms, which provided them with medical insurance even though they had no visas or other immigration documents.