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.
Every year hundreds of immigrants are sent home through this little-known removal system known formally as "medical repatriation."
The obscure system allows hospitals seeking to curb high costs to put patients on chartered international flights, often while they are still unconscious. Hospitals typically pay for the flights.
A recent report compiled by immigrant advocacy groups determined at least 600 immigrants were removed from the country over a five-year period through this system, though there were likely many more.
"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.
Patients are frequently told family members want them to come home. In cases where the patient is unconscious or can't communicate, relatives are told their loved one wants to return, De Leon said.
Sometimes they're told the situation is dire, and the patient may die, prompting many grief-stricken relatives to agree to a transfer, he said.
Some hospitals "emotionally extort family members in their home country," De Leon said. "They make family members back home feel guilty so they can simply put them on a plane and drop them off at the airport."
The American Hospital Association said it does not have a specific policy governing immigrant removals, and it does not track how many hospitals encounter the issue.
Nessel expects medical removals to increase with implementation of health care reform, which makes many more patients eligible for Medicaid. As a result, the government plans to cut payments to hospitals that care for the uninsured.
Some hospitals call immigration authorities when they receive patients without immigration documentation, but the government rarely responds, Nessel said. Taking custody of the patient would also require the government to assume financial responsibility for care.
The American Medical Association's Council on Ethical and Judicial Affairs issued a strongly worded directive to doctors in 2009, urging them not to "allow hospital administrators to use their significant power and the current lack of regulations" to send patients to other countries.
Doctors cannot expect hospitals to provide costly uncompensated care to patients indefinitely, the statement said. "But neither should physicians allow hospitals to arbitrarily determine the fate of an uninsured noncitizen immigrant patient."
Arturo Morales, a Monterrey, Mexico, lawyer who helps Cruz and Rodriguez-Saldana with legal issues, is convinced the men would have been better off staying in Iowa.
"I have no doubt," he said. "You have a patient who doesn't have money to pay you. You can't let them die."
Based on reporting by The Associated Press.