Rocio, a Mexican woman living in Norristown, is scheduled to have her second baby, a boy, by cesarean section next Sunday at Montgomery Hospital.
At that point, Medicaid, the federal and state insurance program for the poor, will pay for her hospital care and that of her baby, who will be an American citizen.
In the meantime, Rocio, whose full name is being withheld by The Inquirer, is among an increasing number of illegal immigrants getting prenatal care at clinics run by Norristown's two hospitals.
Federal Medicaid won't pay for that unless there's an emergency.
This quirk in the government's insurance program - a sign of the country's ambivalence toward its burgeoning population of illegal immigrants - leaves hospitals and doctors in a quandary: Subsidize prenatal care they believe is essential, or risk confronting much bigger problems when the women arrive in their emergency departments with labor pains.
By law, hospitals must care for women in labor.
The small but increasing number of pregnant, undocumented women in Philadelphia and in pockets of the suburbs is adding a financial stressor to the region's already strained maternity-care system, health leaders said. Since 1997, 14 area hospitals have stopped delivering babies. The big problems are inadequate payments from Medicaid and high malpractice-insurance costs, hospital leaders say, but poor funding for undocumented women, who often cannot afford care themselves, is rising in importance.
"There is a problem with underreporting of how many undocumented women there really are, and they're putting a huge strain on all of the safety-net systems," said Natalie Levkovich, executive director of the Health Federation of Philadelphia. "We're all in the same miserable, leaky boat."
Undocumented women constitute 60 to 65 percent of about 3,000 prenatal patients treated at city health clinics yearly, said Kate Maus, the Philadelphia Department of Public Health's director of maternal, child and family health. Eight years ago, she said, "all of them were insured."
Prenatal care at the clinics, which don't charge uninsured patients, is provided by doctors and nurses from four city health systems. They work on a contract basis, and some say they're getting paid practically nothing.
Even the Federally Qualified Health Centers, which were established so the uninsured and those on Medicaid could get low-cost care, are suffering as the proportion of undocumented patients rises, said Levkovich, whose group is a coordinating agency for the centers. They provide prenatal care in the city - uninsured patients pay on a sliding scale - but not in most suburbs, she said.
The centers, like hospitals, get substantially more money from Medicaid patients than from the uninsured. At one operated by Delaware Valley Community Health in Philadelphia, Medicaid pays $119 per visit. Most undocumented women pay only $15.
Pregnant women typically get about a dozen prenatal visits and a couple of ultrasounds, said Barbara Hand, infant health coordinator for the Montgomery County Health Department.
Illegal immigrants may receive prenatal care through a mishmash of programs subsidized to varying degrees by hospitals, obstetricians and governments in the region. Everyone thinks someone else ought to pay more.
In Philadelphia, Drexel University College of Medicine is using medical school tuition to keep its obstetrics program afloat as it staffs city health clinics, said Owen Montgomery, chair of the OB-GYN department. "I'm paying very well-trained providers to take care of patients for free in a city health center," he groused.
Jack Ludmir, chair of obstetrics and gynecology at Pennsylvania Hospital, said the physicians group that provided the most care to poor and undocumented women was losing $1 million a year. He's exploring outside donations to cover the uninsured. "We're losing an arm and a shirt on this group," he said.
In the suburbs, where hospital-operated clinics for low-income women are more common, Chester County Hospital in West Chester charges clinic patients $1,000 for prenatal care, requires its doctors to work there without extra pay, and says it still loses money.
In Norristown, the county Health Department is using $285,600 in state funding to help defray costs. Montgomery Hospital charges women who can't get the state money $1,350 - the equivalent of Medicaid reimbursement - but most pay less than half that.
St. Mary Medical Center in Bucks County offers free care to uninsurable women at its Mother Bachmann Maternity Center, which loses $685,000 a year on charity and Medicaid-funded care.
New Jersey, where maternity-unit closings have not been a trend, is among five states that use their own money to fund Medicaid coverage for prenatal care for illegal immigrant women. But the $3.8 million - enough for 7,439 women - runs out after only about four months, according to a state Department of Human Services spokeswoman. Much of their care after that would likely be subsidized by providers, said Ron Czajkowski, spokesman for the New Jersey Hospital Association.
Just figuring out how many undocumented pregnant women there are is a challenge. Several hospitals and health centers said they didn't ask whether women were here legally, and know only whether they are uninsured. But, they said, there's no question the numbers are up.
In Philadelphia, the percentage of women who failed to supply Social Security numbers after giving birth - an indicator of illegal status likely to undercount the problem - grew from 4.8 percent in 2003 to an estimated 7 to 8 percent now, said Ludmir, also director of obstetrical services at the Hospital of the University of Pennsylvania. Total births during that time have hovered above 22,000 a year.
Thirteen percent of Pennsylvania Hospital's 5,207 births last fiscal year were to undocumented women, Ludmir said.
At Mother Bachmann, the proportion of patients who are illegal immigrants has remained steady at about a third, but the number of patients grew from 191 in 2001 to 337 last year. The number of undocumented women served at Montgomery Hospital's clinic more than doubled from 73 in fiscal 2003-04 to 154 in 2006-07.
Medicaid pays less than care costs, hospital leaders say. As a result, some argue, they can lose more money on a pregnancy that goes bad than on providing prenatal care below cost.
For example, Ludmir said, a pregnant illegal immigrant who had not had prenatal care went to one of his emergency rooms in 2005 with bleeding in her brain caused by preventable conditions. She needed three operations, and her baby was born early and sick. Their care cost the hospital $151,019, he said, but it got only $23,544.
Money aside, Drexel's Montgomery called universal access to prenatal care a "sign of a civilized society." Ludmir has spiral notebooks filled with the names of undocumented women he treated. With a smile, he said, "When I die, my children can say I did something right."
Doctors and midwives add that preventing physical and mental disabilities in the babies saves society money.
"You pay now, or you pay later," Hand said. Her agency gives Montgomery Hospital and Mercy Suburban Hospital grants of $800 per patient for pregnant women who can't get Medicaid - overwhelmingly that's illegal immigrants - until its money runs out. This year, there's enough for 357 Norristown women, more than twice as many as in 2005.
Philadelphia, which gets a smaller grant, has been paying doctors at city clinics $450 a patient until the money runs out.
Philadelphia's Maus said she knew the city's payments were too low, and she is working on a new system. The old one assumed Medicaid patients would subsidize the uninsured. Now almost all pregnant patients in some clinics are undocumented.
On a recent morning, Montgomery Hospital's clinic was crowded with proud, anxious mothers-to-be, a combination of local women on Medicaid and undocumented women, most from Mexico. On a typical day, about half the 40 to 50 patients are undocumented. Asked what they would do without the free care there, one said she would go without. Another said she would have returned to Mexico to have the baby.
Rocio, 23, a soft-spoken woman who has lived in Norristown three years and has a child in Mexico, had all the usual measurements taken. Obstetrician Jim Mollick listened to the baby's heartbeat. It was strong and steady. Rocio's ankles were swollen, so he suggested elevating her feet.
"July 15 is baby day," he told her with a smile.
Mollick provides care at a discount because he thinks it's the only way to keep the hospital's maternity program viable and make sure the women are safe. Without prenatal care, he said, "you're going to have a dangerous situation turn into a disaster."
By the Numbers
$15 Typical amount an undocumented woman
pays per visit to a Federally Qualified Health Center in Philadelphia.
$119 Amount Medicaid pays per visit for prenatal
care to the same health center.
13% Estimated percentage of Pennsylvania
Hospital's 5,207 births in the fiscal year ended June 30 to undocumented women.
$3.8 Amount in millions that New Jersey is
spending this year on Medicaid funding for prenatal care for illegal immigrant women.
SOURCES: Delaware Valley Community Health; Pennsylvania Hospital; N.J. Department of Human ServicesEndText