When Hospitals Act Like ICE

This article was produced in partnership with The Nation, with support from the Gertrude Blumenthal Kasbekar Fund and the Fund for Investigative Journalism. Liset Cruz was a 2023-2024 Ida B. Wells Fellow at Type Investigations.

Junior found himself facing an impossible decision. One morning soon after Christmas in 2022, his wife, Soledad, had woken up feeling dizzy and nauseous; Junior hurried her to an emergency room in Allentown, Pennsylvania, where doctors determined that the 45-year-old had suffered a cerebral aneurysm and quickly ordered her to be transported to nearby Lehigh Valley Hospital, where she underwent a series of surgeries. The operations were successful, but there were complications. Soledad was left in a medically induced coma.

Eight weeks later, administrators at Lehigh Valley presented Junior with three options, none of them good: He could pay $500 a day to rent medical equipment so Soledad could continue treatment at home; he could find another facility to admit her; or he could agree to have her flown to a hospital in their home country, the Dominican Republic.

“My wife is still in a coma, and you’re telling me she’s ready for discharge?” Junior said he asked the hospital officials. (Because of their immigration status, both Junior and Soledad have been given pseudonyms in this article in order to protect their identities.) Before migrating to the United States in 2022, Soledad had worked as a psychologist and led a Bible study group. Junior described her as positive, easygoing, and determined. “She liked to work a lot,” he said. In Allentown, Junior found a job as an industrial mechanic. Together they had raised two sons, now adults, who had traveled with them to the United States.

Junior is active and strong-willed, but he didn’t have the money or the medical skills to care for Soledad himself. And he feared what would happen if she were transferred out of the United States. “If my wife boarded a plane,” Junior said, “that’s how she’ll die.”

As Soledad hovered near death, she had entered a hidden medical netherworld, one where the failures of our healthcare system meet the cruelties of our immigration system. Even before President Donald Trump made hospitals a locus of his mass deportation agenda, lifting the federal restrictions that had discouraged government agents from arresting undocumented immigrants in “sensitive areas” like schools, churches, and medical facilities, hospitals had become risky spaces for undocumented immigrants like Soledad—places where a serious illness, a slow recovery, or the need for long-term care could put them on a path to deportation. 

The problem begins, as it so often does in the United States when healthcare is concerned, with money. Federal law requires hospitals to provide lifesaving care to anyone who enters an emergency room, regardless of their immigration status or whether they have health insurance. But hospitals have long sought to limit their costs by discharging patients as soon as they’re in stable condition—particularly when a patient doesn’t have health insurance, as was the case with Soledad. In their rush to send patients on their way, hospitals have been known to pressure undocumented patients and their families to consent to transfers back to their home countries. Lawyers and immigrant rights advocates call this practice “medical deportation.”

Now, as the Trump administration steps up its immigration enforcement measures, the number of people facing medical deportation is likely to grow.

“We have noticed that under the Trump administration, hospitals are getting more comfortable with threatening medical deportation,” said Adrianna Torres-García, the deputy director of Free Migration Project, a Philadelphia-based nonprofit that provides legal assistance to immigrant communities and works to stop deportations. “Hospitals are taking this opportunity—this anti-immigrant climate—to become a little more bold about not wanting to work with immigrants who don’t have health insurance.”

The scale of the problem is not easy to track. Hospitals and the companies they hire to facilitate such removals are not required to report international transfers to state or federal regulators. However, interviews with patients, immigrant rights advocates, lawyers, and other experts, along with an analysis of news articles and academic studies, suggest that medical deportation is a frighteningly common occurrence that has likely affected thousands of patients. And given the current political realities, transfers that might once have been surreptitious affairs may now happen more openly.

“We know that it’s a real problem,” said Torres-García. “We’ve had people from Wisconsin, Indiana, and DC reach out to us for help.”

Under the Trump administration, hospitals are getting more comfortable with threatening medical deportation.

Adrianna Torres-García, the deputy director of Free Migration Project

Under Trump’s presidency, undocumented immigrants have become more concerned about their safety in hospital settings. A recent survey by KFF, a health policy research nonprofit, found that many undocumented immigrants said they would avoid seeking healthcare out of fear of being detained by US Immigration and Customs Enforcement agents.

Yet even before Trump’s return to the White House, the threat was significant. For Junior, the hospital’s efforts to transfer Soledad left him terrified for her health and scrambling for a solution. “They gave me an ultimatum,” Junior said. “They said, ‘We send her to the Dominican Republic, or you take her home.’”

Even without the prospect of deportation, the treatment for Soledad’s aneurysm was traumatic. Junior recalls surgery after surgery, during which doctors shaved her head, removed a piece of her skull, and placed her on a respirator so she could breathe. “She had so many devices connected to her,” he said.

For three weeks, doctors kept her on a sedative in the hopes that it would allow her body to heal. At the end of January 2023, they gradually took her off the medication, but instead of waking up, Soledad remained unresponsive.

It was during this time, Junior said, that his meetings with hospital staff became increasingly fraught as they began to inquire about her immigration status. Then, during a meeting with Lehigh Valley administrators and staff from the medical transport company Med­Escort in early February, Junior said they raised the possibility of transferring Soledad to the Dominican Republic.

For Junior, the idea was a nonstarter. He felt that hospitals in the Dominican Republic wouldn’t be able to provide the level of care that Soledad needed. Indeed, the lack of adequate healthcare was one of the reasons they had sought a new life in the United States.

“I wasn’t going to sign any kind of document to authorize it,” Junior said of the transfer.

Medical records obtained by The Nation and Type Investigations suggest that Lehigh Valley continued to make plans for Soledad’s transfer, however, despite Junior’s repeated objections. According to these records, the hospital first documented its plan to send Soledad to the Dominican Republic on February 8, 2023, after meeting with MedEscort two days earlier. Over the next three weeks, doctors regularly evaluated whether Soledad’s condition made her stable enough for discharge, while MedEscort worked to coordinate the transfer and connect with a hospital in the Dominican Republic that could accept her.

Lehigh Valley Hospital did not respond to multiple requests for comment on Soledad’s case.

Under the federal Emergency Medical Treatment and Labor Act, passed in 1986, hospitals are required to ensure that medical transfers meet certain conditions designed to safeguard patients. Such transfers—whether to a domestic facility or an international one—must involve minimal health risks and be carried out via an appropriate mode of transportation, such as an ambulance or a private plane outfitted with medical equipment. The receiving facility must have both the space for the necessary treatment and personnel who are qualified to provide it.

Beyond these immediate requirements, discharge plans must be consistent with a patient’s health goals and treatment preferences as well as designed to reduce factors that could lead to a preventable hospital readmission. In Pennsylvania, hospitals must also ensure that patients are informed about follow-up care and are given guidance on accessing financial assistance for their hospital bills.

Finally, the US Department of Health and Human Services’ regulations dictate that patients, or their representatives, have a right to participate in “planning for care after discharge.” And hospitals are required to provide information in a patient’s native language. The idea is that hospitals must engage in a process that allows for “informed consent.” In Soledad’s case, however, as in many cases of medical deportation, the question of consent soon gave way to pressure.

“That’s the crux of the issue and what differentiates medical deportation from medical repatriation,” Torres-García said. Patients may consent to medical repatriation for any number of reasons: An executive who falls ill while traveling abroad for business, for example, or a tourist on vacation who has an accident might prefer to receive medical care in their home country. These patients elect to be treated outside of the country where they were injured. But in cases of medical deportation, Torres-García said, “people are not given that choice.”

Toward the end of February 2023, doctors determined that Soledad was medically stable, but they were not ready to sign off on sending her to another hospital in the Dominican Republic, according to her records. Then, at the beginning of March 2023, Lehigh Valley Hospital declared that Soledad’s time was up and that MedEscort was moving forward to facilitate the transfer. 

Founded in 1986 and based in Allentown, MedEscort says it has repatriated over 6,000 patients to more than 100 countries. And it expects the demand to increase. “As immigration policies and healthcare priorities evolve, American hospitals are likely to experience a higher volume of cases requiring tailored care discharge plans for uninsured and/or undocumented patients,” Med­Escort’s website states. A 2022 version of the site put it more bluntly: MedEscort’s services, it said, are designed to help hospital CEOs and CFOs who are “looking to solve the problem of unfunded Foreign Patients in American Hospitals.” Top destinations for the company have included Mexico, Haiti, and the Dominican Republic.

“Hospitals have scarce resources. When a patient is stable or only needs custodial care, the hospital has an obligation to consider lower-­cost settings,” said Mark Weller, an attorney and spokesperson for MedEscort. “Perhaps that could be having a patient go back to their home country.”

Weller said the company follows the American Medical Association’s guidelines on safe discharges, including requiring that a patient is stable, that a discharge plan is in place, and that the receiving facility has the resources to meet the patient’s needs. “We do not support or engage in involuntary discharges,” Weller said. He said MedEscort relies on hospitals to obtain the necessary consent from patients. 

Weller declined to discuss Soledad’s case but said that MedEscort exists “to help hospitals do this the right way”—something, he acknowledged, that might not be true of other companies. “Unfortunately, some vendors remove patients from US facilities without any assurance of continued care, putting both patients and hospitals at risk,” he said.

When Lehigh Valley Hospital decided it was time for Soledad to move on, it informed Junior, despite his repeated objections, that her transfer to the Dominican Republic would happen in less than a week. The date was set for March 8.

Alexandra Santos, an attorney with Free Migration Project, attended several meetings between Junior and hospital staff. She said that, despite state and federal regulations requiring informed consent from patients, hospital administrators told Junior, “We don’t need your consent.”

There is no official data on medical deportations, but researchers and immigrant rights advocates say the practice is surprisingly common. In 2012, researchers at Seton Hall University School of Law and New York Lawyers for the Public Interest released a report documenting more than 800 cases of successful or attempted medical deportation in the United States between 2006 and 2012. It remains one of the most significant reports on the practice to date.

The report is filled with horror stories: a 19-year-old girl who died shortly after being transferred from Arizona to Mexico; a victim of a car accident in Las Vegas who died after being left on the tarmac at a Guatemala airport; a baby, born with Down syndrome and a heart condition, whose transfer from an Arizona hospital to Mexico was halted at the 11th hour.

In one case from 2008, a hospital in New Jersey, seeking to transfer a stroke victim to Guatemala, contacted the man’s sister there. When she refused to give her consent, the hospital falsely led her to believe that her brother was near death in order to convince her to agree to his transfer. The following year, a man who suffered a stroke and brain hemorrhage in North Carolina was also transferred to Guatemala, where no arrangements for his continued care had been made. He spent one night in a hospital
before he was taken to his family’s home, where he died about two weeks later.

The report is scathing in its assessment of hospital practices in the United States. “There is enough information to establish that the US is in systematic violation of its human rights obligations under a variety of treaties that the US has signed and/or ratified,” the authors wrote.

John Sullivan, a former Fulbright scholar in Mexico, said he tracked nearly three dozen cases of medical deportation during a research project on the issue in 2013 and 2014. In one case, a 28-year-old man who had been left in a vegetative state after a physical assault was sent from Chicago to Mexico City, where medical personnel left him on a makeshift bed in his sister’s apartment. Sullivan said he did not know what ultimately happened to the man, but the fact that he was not transferred to a healthcare facility shows how medical deportation can leave patients in dire straits. “Medical repatriation shifts the burden of care onto families with few resources,” Sullivan said. “Patients and their families struggle to find adequate and affordable treatment.”

Sullivan also noted that, in the cases he studied, elderly parents typically, and unexpectedly, were the ones who took on the role of caretaker for their ill adult child, who had often been the family breadwinner. These children had traveled to the United States not only to secure their own livelihoods but also, in many cases, to support their families back home. 

There have been more recent stories as well. In 2020, the case of an undocumented patient at Philadelphia’s Jefferson Torresdale Hospital sparked a local outcry. The man, known as A.V., was walking from his apartment to a nearby grocery store when he was struck by a motorcycle, leaving him with multiple fractures and severe brain injuries. A few weeks later, A.V.’s niece, Claudia Martinez, received a call from a social worker at the hospital inquiring about his immigration status. When the worker learned that A.V. was undocumented, she informed Martinez that her uncle would be transferred to Guatemala later that month.

“How is that possible?” Martinez recalls asking.

She said the hospital told her it had obtained the consent of A.V.’s wife, Juanita, an assertion that both women dispute. Juanita said she never received a call in 2020 regarding her husband’s transfer.

“It’s like they took advantage of the situation,” Martinez said. “They could say they received authorization from his wife…but that was a lie.” Martinez said that a hospital official continued to pressure her into agreeing to the transfer, threatening to simply drop her uncle off at her home. “He told me, ‘If you don’t sign for us to remove him, we’re going to leave him on your doorstep. You’ll wake up one morning and just see him outside your house,’” she recalled. “I didn’t know what to do. It drove me crazy.”

A.V.’s story might have ended there, like those of so many other seriously ill undocumented immigrants. But in June 2020, medical students at Jefferson Torresdale Hospital circulated a public petition highlighting the health risks that A.V. could face if he were transferred to Guatemala. “As healthcare professionals, we are taught to ‘First, do no harm.’ This much is egregiously clear—when you deport a medically at-risk, disabled individual to a country which may not have the means to care for them, you are doing harm,” the petition said.

Free Migration Project also organized a protest to keep A.V. in the country. Dozens of people gathered outside the hospital to raise awareness of the case, linking arms and vowing to block any ambulance that attempted to take A.V. to the airport. Soon, local media arrived, putting Jefferson Torresdale in the spotlight. 

Finally, in the face of this growing opposition, the hospital canceled the transfer and kept A.V. in its care until alternate plans could be made. He was eventually discharged to a nursing home. 

He told me, ‘If you don’t sign for us to remove [your uncle], we’re going to leave him on your doorstep.’

Claudia Martinez

Jefferson Torresdale Hospital did not respond to requests for comment about A.V.’s case.

At the nursing home, A.V.’s condition improved dramatically, but he still required help to perform daily functions. He remained at the nursing home for four years before ultimately consenting to an international discharge back to Guatemala last year. His care in the United States had allowed his health to improve to the point that he could manage the transfer, and in Guatemala he was able to reunite with his wife and continue his recovery.

A.V.’s story, and the advocacy around it, shattered the silence that had long surrounded medical deportations—and soon shook free other instances of families trying to keep their loved ones from being deported. Maripat Pileggi is a supervising attorney at Community Legal Services who worked on A.V.’s case. She said she’s worked on about 10 similar cases since then. “Most of them have occurred since A.V.’s case was publicized so widely in 2020, which tells me that this likely happens a lot more often than anyone knows,” Pileggi said. “People often don’t realize they have any right or power to fight against it.”

One of the people who’d heard about A.V.’s case was Junior. As his discussions with Lehigh Valley Hospital grew increasingly acrimonious, he connected with Free Migration Project and organized a local media campaign denouncing the attempted transfer. On March 2, 2023, dozens of protesters gathered outside the hospital’s main entrance. A second demonstration was held less than a week later.

In response to the outcry, the hospital backed down and allowed Soledad to remain in its care.

“I wouldn’t have thought another family was going to go through this again,” said Claudia Martinez, who began working with Free Migration Project as a volunteer after connecting with the organization through a social worker. “Especially not so close to home.”

To help make sure families are spared their own medical deportation horrors, Free Migration Project and other immigrant rights advocates came together to end the practice in Philadelphia. They drafted legislation to prevent hospitals from deporting patients without their consent, and the City Council passed it in December 2023.

The legislation, which is the first of its kind in the country, forbids hospitals to “engage in medical deportation, either directly or through a designated agent.” To that end, it designates oversight of medical repatriation practices to the Philadelphia Department of Public Health and the City Committee on Public Health and Human Resources, and it requires hospitals to report patient data, enabling city officials and others to track the prevalence of international transfers. The law also gives the city the power to fine hospitals that engage in the practice, and patients have the right to sue hospitals for damages.

“I am very happy that this bill was passed, and I am hopeful that it will help many families,” Martinez said.

Still, even as activists and lawmakers in Pennsylvania have succeeded in increasing protections for undocumented immigrants, the situation in other parts of the country is becoming more precarious. Trump has threatened to penalize states like California, New York, and Ore­­gon, which offer health insurance to undocumented immigrants, by reducing the federal Medicaid match dollars that help hospitals and medical facilities offset their care costs. Without these matching funds, states will be forced to shoulder the entire cost of care for undocumented patients—a situation that could strain their budgets and lead some states to cut health coverage for undocumented patients. And in July, the Associated Press reported that ICE officials will be given access to the personal data of 79 million Medicaid enrollees—to help agents track down undocumented immigrants.

“You will see more medical repatriations and more attempted medical deportations,” warned Charles Blatteis, a lawyer based in Tennessee who specializes in medical repatriation.

Some states are even proposing changes of their own to try to appease the president and head off his punishment. In May, California Governor Gavin Newsom proposed freezing enrollment for undocumented immigrants, ages 19 and older, in Medi-Cal, the state’s Medicaid program. All undocumented residents in the state would still be covered for emergency medical care—as is required under federal law—but adults who haven’t enrolled by January 2026 would not have access to basic health coverage. Without this coverage, immigrant rights advocates suspect, medical deportations will continue to increase.

Back in Philadelphia, with the battle against Lehigh Valley Hospital behind him, Junior is optimistic about Soledad’s recovery. At the end of May 2023, Soledad was moved into a nursing home, and she emerged from her coma shortly afterward. She is undergoing physical therapy to try to improve her condition and help her regain cognitive function and bodily autonomy.

“She’s still there, slowly getting better,” Junior said. “They’ve removed the endotracheal tube, and she’s able to articulate more words.”

Still, the danger for Soledad—as well as for Junior himself—has not disappeared: The Trump administration’s anti-immigrant agenda has trickled down to the Lehigh Valley. An administrator at the nursing home “asked me about my immigration status and noted my situation and the new administration,” Junior said. “I told them I wouldn’t answer any of their questions—this isn’t an immigration office. They told me my wife wasn’t good for their business.”

In Soledad’s room at the nursing home, a shelf holds a small boombox, which Junior has tuned to a gospel music station. On a visit to see her last year, Soledad lay in bed alert and aware, smiling often. Junior brushed her salt-and-pepper hair tenderly and secured it into a ponytail. He visits her every day, he said, often twice a day on weekends. Together they celebrated their 25th wedding anniversary in April. Despite the challenges of the past two years, their connection remains strong. As Junior entered the room to greet her, Soledad reached out to embrace him, whispering softly into his ear and pulling him closer.“She’s the love of my life,” Junior
said.