President Barack Obama's health care law is putting new strains on some of the nation's most hard-pressed hospitals, by cutting aid that they use to pay for emergency care for illegal immigrants, which they have long been required to provide.
The federal government has been spending $20 billion annually to reimburse these hospitals most in poor urban and rural areas for treating more than their share of the uninsured, including illegal immigrants. The health care law will eventually cut that money in half, based on the premise that fewer people will lack insurance after the law takes effect.
But the estimated 11 million people now living illegally in the United States are not covered by the health care law. Its sponsors, seeking to sidestep the contentious debate over immigration, excluded them from the law's benefits.
As a result, safety-net hospitals said the cuts would deal a severe blow to their finances.
The hospitals are coming under this pressure because many of their uninsured patients are illegal immigrants, and because their large pools of uninsured or poorly insured patients are not expected to be reduced significantly under the Affordable Care Act, even as federal aid shrinks.
The hospitals range from public ones, like Bellevue Hospital Center in Manhattan, to neighborhood mainstays like Lutheran Medical Center in Brooklyn and Scripps Mercy Hospital in San Diego. They include small rural outposts like Othello Community Hospital in Washington state, which receives a steady flow of farmworkers who live in the country illegally.
No matter where they are located, all hospitals are obliged under federal law to treat anyone who arrives at the emergency room, regardless of their immigration status.
''That's the 800-pound gorilla in the room, and not just in New York in Texas, in California, in Florida," said Wendy Z. Goldstein, Lutheran's chief executive.
Lutheran Medical Center is in the Sunset Park neighborhood, where low-wage earning Chinese and Latino communities converge near an expressway. Hospitals are not allowed to record patients' immigration status, but Goldstein estimated that 20 percent of its patients were what she called "the undocumented not only uninsured, but uninsurable."
She said congressional staff members acknowledged that the health care law would scale back the money that helps pay for emergency care for such patients, but were reluctant to tackle the issue.
''I was told in Washington that they understand that this is a problem, but immigration is just too hot to touch," she said.
The Affordable Care Act sets up state exchanges to reduce the cost of commercial health insurance, but people must prove citizenship or legal immigration status to take part. They must show similar documentation to apply for Medicaid benefits that are expanded under the law.
The Affordable Care Act did call for increasing a little-known national network of 1,200 community health centers that provide primary care to the needy, regardless of their immigration status. But that plan, which could potentially steer more of the uninsured away from costly hospital care, was curtailed by congressional budget cuts last year.
That leaves hospitals like Lutheran, which is nonprofit and has run a string of such primary care centers for 40 years, facing cuts at both ends.
On a recent weekday in Lutheran's emergency room, a Chinese mother of two stared sadly through the porthole of an isolation unit. The woman had active tuberculosis and needed surgery to drain fluid from one lung, said Josh Liu, a patient liaison.
The disease had been discovered during a checkup at one of Lutheran's primary care centers, where the sliding scale fee starts at $15. But the woman, an illegal immigrant, had no way to pay for the surgery.
Another patient, a gaunt 44-year-old man from Ecuador, had been in New York eight years, installing wood floors, one in Rockefeller Center. The man had been afraid to seek care because he feared deportation. Finally, the pain in his stomach was too much to bear.
Dr. Daniel J. Giaccio, leading the residents on their rounds, used the notches on the man's worn belt to underscore his diagnosis, severe B-12 deficiency anemia. The woodworker had lost 30 pounds in a month, and his hands and feet were numb. Reversing the damage could take months.
''This is a severe case of sensory loss," Giaccio said. "Usually we pick it up much sooner."
In some states, including New York, hospitals caring for illegal immigrants in life-threatening situations can seek payment case-by-case, from a program known as emergency Medicaid. But the program has many restrictions and will not make up for the cuts in the $20 billion pool, hospital executives said.
Groups that favor more restrictive immigration policies said they agreed that the cuts in the $20 billion fund were a burden. They said hospitals obviously had a duty to provide emergency care for everybody, including illegal immigrants.
''I kind of like living in a society where we don't let people die on the steps of the emergency room," said Mark Krikorian, the executive director of one such group, the Center for Immigration Studies in Washington.
But he said the answer lies in enforcing laws, so that illegal immigrants leave the country, not in extending health coverage.
''There is no ideal resolution to the problem, other than reducing the illegal population," he said. "Incorporating illegal immigrants into health exchanges or directly taxpayer-funded health care legitimizes their presence."
The Obama administration said the Affordable Care Act supports safety-net hospitals in other ways, pointing to measures that raise payments for primary care and give bonuses for improvements in quality.
''We are taking important steps to make health care more affordable and accessible for millions of Americans," said Erin Shields Britt, a spokeswoman for the Department of Health and Human Services, in an email message. "Health reform isn't the place to fix our broken immigration system."
With illegal immigration an issue in the presidential campaign, many politicians continue to steer clear of addressing the cuts.
Hospitals in New York state now receive $2.84 billion of the nation's $20 billion in disproportionate share hospital payments.
That fund starts shrinking in 2014 under the law, and drops to $10 billion by 2019.
"It is a difficult time to really advocate around this issue, because there is so much antipathy against new immigrants," said Alan Aviles, president and chief executive of the Health and Hospitals Corp.
The corporation runs New York City's public hospitals, which treated 480,000 uninsured patients last year, an estimated 40 percent of them illegal immigrants. The same worries haunt tiny Othello Community Hospital, in Washington state's rural Adams County, where it is the only hospital for miles around.
Last year, the state began requiring that participants in a basic health plan that it offers prove that they are citizens or legal residents.
As a consequence, 4,000 out of the 4,400 patients at the nearby primary care center, mostly immigrant farmworkers, lost their coverage, leaving Othello more financially vulnerable when those people need emergency care.
In central California, Harry Foster, director of the Family HealthCare Network, another primary care center, called the Affordable Care Act "a double-edged sword."
Many low-wage earning citizens now lack employer-sponsored health insurance, and the health care industry is already competing for those who will gain coverage through the law. But no one is competing to treat those it leaves out, he said.
''We will receive more and more of those patients," he said, estimating that 40 percent of the area's residents were illegal immigrant farmworkers. "But financially, we can't take on all the uninsured patients in the area, to the exclusion of all the others, and survive."
In many ways Lutheran, a century-old hospital that refurbished a defunct factory to serve as its hub in the 1960s, has been a prototype of the law's new model: coordinating primary and preventive care to improve health outcomes while curbing costs. Yet it stands to lose $25 million from the cuts.
''This is an unintended consequence of the law," said the hospital's chief executive, Goldstein. "But so far, nobody is doing anything to resolve it."