BORN IN THE USA

BIRTHS TO ILLEGAL IMMIGRANTS ON THE RISE

State-paid prenatal care for undocumented moms depends on residency

NANCY CLEELAND Staff Writer

20-Feb-1994

Alma Meza Gutierrez, 20 years old and pregnant with her second child, sleeps on a mattress crammed into her uncle's kitchen.

Undocumented, broke and new to San Diego, Meza plans to have her baby here. And she's asking the state of California to pay for it.

That's what brought Mark Miranda to her door.

Miranda, a Medi-Cal fraud investigator, spends much of his time interviewing women like Meza, who are suspected of cheating the system by crossing the border for free pregnancy care.

He and other investigators say hundreds, perhaps thousands, of Mexican residents have been drawn north by a 6-year-old Medi-Cal program that provides free prenatal care and delivery services for women who are not in this country legally. The program was intended only for long-term residents of California.

Prompted by investigators' impressions and media reports of widespread cross-border fraud, the Medi-Cal investigations unit in San Diego has adopted a tough -- some would say overly aggressive -- policy to rout it out.

In the last year, the staff of investigators has about doubled to 15, and all Medi-Cal eligibility workers have been trained to question residency claims and spot phony documents.

Since the "zero tolerance policy" was adopted, investigators have denied about 300 claims a month filed by women suspected of coming here only to have babies on Medi-Cal.

But the fluid nature of the border region, where languages, cultures and extended families span both countries, makes it difficult for investigators to know who's truly living here and who isn't.

Meza, like several other women Miranda interviewed on a recent day's rounds, seemed pushed by bad luck rather than drawn by state benefits. In fact, Meza said she had never heard of the Medi-Cal program until a community clinic worker told her about it in San Diego.

This is the story she told to Miranda, during a 20-minute interview in the one-bedroom apartment in Logan Heights that she shares with her uncle, aunt, their infant son and Meza's 3-year-old boy:

She'd become pregnant by a boyfriend in her hometown in the Mexican state of Nayarit, but he left her for another woman. Her uncle and aunt, visiting from San Diego, offered to take her home with them. She followed them on a two-day bus ride, her son in tow, then sprinted across the hills that span the border.

"Why did you come here?" Miranda asked in Spanish. Appearing exhausted and uncomfortable, Meza shrugged her shoulders and said she didn't know.

"What will you do after the baby is born?" Her answer was vague. "I don't know if I will go back or not," she said.

Irony of humanitarian plan

Meza was denied Medi-Cal benefits, but her case illustrates a difficult border paradox:

For pragmatic and humanitarian reasons, the state agreed in 1988 to fund prenatal care and deliveries for undocumented women who live here.

It was hoped the program would reduce the number of risky and expensive emergency room births in San Diego. Prenatal care also is said to reduce long-term health-care costs of the children -- who, if they're born on this side of the border, are born U.S. citizens regardless of the legal status of their mothers.

But some argue that the Medi-Cal program -- along with other advantages that come from births in the United States, including better medical care -- has become a magnet for pregnant women from other countries, many of whom move in temporarily with relatives and friends in order to qualify.

"They have uncles and aunts scattered all over," said Medi-Cal investigator John Fernandez. "That's what makes it so hard to prove someone came up from Tijuana (to give birth), even if you're 99 percent sure of it."

It's up to Fernandez, Miranda and other investigators to decide who legitimately qualifies for the Medi-Cal pregnancy program, and they have few guidelines to help them.

Applicants must provide some proof of residency -- a rent receipt, a driver's license, a car registration, or simply a note from a relative who provides a room. State law says the applicant also must be "physically present and living in California with the intention to remain."

Some cases -- such as Tijuana residents who use a relative's address as a front or who simply make one up for the Medi-Cal form -- are obvious frauds and are usually resolved with a quick inspection.

More often, however, investigators find applicants at the address they listed, though sometimes their living space is confined to a corner of a room. To distinguish who is a true resident and who isn't, they must rely on subjective clues -- a lack of clothes in the closet or photos on the wall, comments from neighbors and landlords, items found in a purse.

One of the few automatic disqualifiers is a border-crossing card, issued by the U.S. government to Mexican residents for brief visits to the north. Otherwise, the decision is largely intuitive.

Jim Mayfield, who supervises the fraud unit, said investigators find problems with about 60 percent of the cases they look into.

`They are so strict'

The 300 cases denied each month represent a potential cost savings of about $1 million, Mayfield said. However, because applicants can reapply after being denied benefits, and are sometimes denied several times, those numbers may be inflated.

Some health-care workers applaud the state's new aggressiveness, but others claim legitimate applicants are being denied benefits along with the cheats.

"They are so strict in terms of verification of addresses," said Linda Stende, a social worker at Sharp Hospital in Chula Vista. "I have seen women come in here to deliver with no prenatal care because they've been Medi-Cal-pending since their fourth month of pregnancy."

Nevertheless, a perception of widespread fraud is becoming a factor in some government decisions.

Gov. Pete Wilson has proposed that the prenatal program for undocumented immigrants be abolished.

The county Department of Health this month considered dropping a Spanish-language television campaign that urged San Diego residents to seek prenatal care, using government services if necessary. Some government officials feared the ads would attract women from Tijuana.

A county task force this month recommended that all Medi-Cal eligibility workers and investigators be required to turn over suspected undocumented immigrants to federal immigration officials. If that approach failed or was ruled illegal, the group recommended that Border Patrol agents be stationed at all hospitals on a 24-hour basis, and that the state pay for them.

`They are not thinking of this'

Despite the concern in California, several visits to poor Tijuana neighborhoods found little evidence that pregnant women there are being drawn north by Medi-Cal benefits.

In the sprawling hilltop slum of Flores Magon, one of the city's oldest and largest poor neighborhoods, Maria Gregio Quiroz has helped run a community clinic for 15 years. She said most women from the neighborhood use government hospitals, which provide free services for private and government workers, or private local clinics, where the cost of prenatal care and delivery can be as low as $300.

"I have never known anyone to cross," said Gregio. "They are not thinking of this. Even if they knew about this (Medi-Cal program), I don't think they would go."

In the Zona Norte, a bawdy district of smugglers, prostitutes and drug dealers where border-crossing is routine, mention of the Medi-Cal program drew only a vague recognition from residents. "I think there's a woman around here who crossed over (to give birth)," said one bar owner. He sent a barhand out to the street to find her, and the barhand came back with a wisecracking prostitute called La China.

At 19, already the mother of one, La China was pregnant again. She said she had her first baby in Long Beach, on the Medi-Cal program. She'd gone north with her boyfriend, a professional smuggler. His relatives handled the arrangements. It was easy, she said.

But this time, with no boyfriend and no U.S. connections, La China was resigned to delivering at the city's General Hospital, where about 4,000 of the city's poor and unemployed give birth each year. The charge is about $150 for prenatal care and delivery -- but those who can't afford it don't have to pay, said hospital director Rosalinda Guerra Moya.

"There is no reason for these women to go north, and it would be very risky to cross," said Guerra, who, like other professional women, said she knew only of upper-class women crossing the border to give birth.

"I just can't imagine a poor woman crossing the border like that -- pregnant -- and then being in a strange place, and going through the bureaucracy of the welfare system," said Blanca Lomeli, director in Mexico for Project Concern, a nonprofit health-care agency with clinics in 10 poor Tijuana communities. "It's not like all the world is waiting for the chance to cross and have a baby there."

The practice isn't new

Drawn by better medical care and U.S. citizenship for their children, Mexican residents have given birth in San Diego for generations -- but most were from the upper classes and paid for the services. Some of Tijuana's top business leaders, as well as the governor of Baja California, were born in San Diego hospitals -- legally.

A rare academic study of the phenomenon, which focused on 184 Tijuana residents who gave birth in the mid-1980s, found that about 10 percent delivered across the border.

Researcher Sylvia Guendelman, a public health specialist at the University of California Berkeley, said nearly all the border crossers paid for their care, though some took advantage of discount rates at community clinics.

Guendelman found few border crossers among Tijuana's poor mothers, but noted in her report that the new Medi-Cal program for undocumented women could alter that picture. She recommended further research.

Several South County doctors and nurses said they thought the Medi-Cal program had attracted women who might have paid cash before. "Some women are honest. Some actually need it, but there are those who abuse the system," said John Shockley Jr., an obstetrician who delivers at Scripps Memorial and Sharp hospitals in Chula Vista.

"Once the laws changed, anyone who's pregnant could get Medi-Cal. It's just so easy to do. The hospitals help them. The hospitals want to get their money."

Jim Lott, president of the Hospital Council of San Diego and Imperial Counties, said the Medi-Cal program has helped beleaguered emergency rooms -- which can't legally turn away women in labor -- to remain open. "It has meant millions of dollars in revenue reimbursement to San Diego providers," he said.

Fernandez, the Medi-Cal investigator, compared the situation here to a similar phenomenon on the U.S.-Canada border, where U.S. residents have been accused of cheating Canada's health-care system.

"It's just a cultural thing about the border," he said. "When there is something on the other side of the fence and there is no penalty or very little penalty for crossing over where the grass is greener, anybody will do it."