Dozens of patients file through Sutter Solano Medical Center's emergency room every day in this recession-wracked Northern California city, often without insurance, cash or legal immigration status. They all get health care, no questions asked.
Medical providers in Vallejo teamed up to establish the program, generating community opposition because illegal immigrants were among those who benefited from services funded in part with county money. This led to a civil grand jury investigation, and a Board of Supervisors vote.
The partnership survived, but the skirmish was a reminder of how touchy the issue of health care for illegal immigrants remains for many Americans, whether in towns like Vallejo or in Washington, D.C., where legislators are skirting the matter as they work to overhaul the nation's health system.
The program also serves as an example of how a community has found a way to confront the reality that undocumented immigrants will not be covered by health care reforms.
Illegal immigrants make up about one-third of the approximately 24 million people under age 65 who would remain uninsured even under the health reform bills being debated in Congress. With limited exceptions, they do not qualify for federal health programs, and the bills being debated would not change that.
The program in Vallejo, a city of 120,000 northeast of San Francisco, was born from the need to alleviate pressure on overcrowded emergency rooms _ and balance hospital budgets.
Vallejo was hit hard by the foreclosure crisis, filing for bankruptcy in May 2008. Rising unemployment deprived many residents of job-based health insurance.
The number of people showing up at Sutter Solano's emergency room was going up year after year, along with the percentage of those not facing true emergencies. Like other hospitals, it is legally bound to help anyone who shows up, regardless of ability to pay.
The economic downturn made it worse. Over the last two years, the percentage of non-emergency patients in Sutter Solano's emergency department went up 51 percent. Caring for uninsured, non-emergency patients has cost the hospital $1.8 million this year.
Under the partnership, true emergencies are seen at the hospital. Other patients are sent to a clinic where they get long-term care and follow-up visits, all on a sliding fee scale.
Providers say the partnership is saving money, largely because it's better for the hospital to have people get preventive care at the clinic than constantly showing up at the emergency room. Patients say it works.
Sergio Santana recently lost his job as a unionized painter, and the health insurance that went with it. When a cut on his foot got infected, he turned to Sutter Solano's emergency department three times _ a total cost of $1,600.
Then he realized that he could get a follow-up visit at the clinic under the program. That cost him $21.40.
"When I went to the hospital, I wasn't thinking about cost, I was just worried about my foot," said Santana, who is a citizen. "Here, though, they're doing a good job, and I'm paying what I paid when I had insurance."
The bill being debated in the Senate would bar illegal immigrants from getting government subsidies, and from using their own money to buy coverage offered by private companies in an insurance exchange.
The House-approved bill would forbid them from getting government subsidies, but would allow them to use their own money to buy coverage. It would also require them to carry insurance, but many illegal immigrants will likely not be able to afford it, said Shana Alex Lavarreda, a senior researcher at the University of California, Los Angeles' Center for Health Policy Research.
"It's just a given. They're going to remain out of this reform," said Judy Solomon, a senior fellow with the Center on Budget and Policy Priorities.
That usually means going to the emergency room for care.
Nationally, emergency room visits jumped 32 percent from 1996 to 2006 _ the latest numbers from the Centers for Disease Control and Prevention. Of the 119.2 million patients who showed up in 2006, more than 85 percent were not classified as urgent or as an emergency.
Proponents of reducing immigration believe providing health care to illegal immigrants, whether at the federal or local level, creates an incentive for them to come. It's also unfair to ask Americans to subsidize their care, said Yeh Ling-Ling, executive director of the Oakland-based group Alliance for a Sustainable USA.
"Many American citizens have filed for bankruptcy because of their medical bills, and others are struggling to pay their tax bills," said Yeh. "How can we ask them to pay for health care for illegal immigrants?"
To Vallejo hospital officials, investing in a program that helped them reduce unnecessary visits to the emergency room made sense.
Sutter Solano and Kaiser Permanente Medical Center committed $300,000 each over three years to jump-start the clinic, called La Clinica de la Raza, North Vallejo. The county contributed $250,000 up front, and promised $256,500 more over three years.
One year after its inauguration, La Clinica is seeing about 800 patients a month. One-third are referrals from hospital emergency rooms.
Even with the clinic nearby, Sutter Solano saw 6,000 more emergency room visits this year than projected.
"It frightens me to think what would have happened had La Clinica not been there," said CEO Terry Glubka.
County officials said that regardless of what happens in Washington, they're keeping the program.
"For the health of the community, you can't exclude some populations," said Patrick Duterte, the county's director of Health and Social Services. "You're going to pay for it in the long run."
Like the hospitals, the clinic doesn't ask about immigration status. It's not their business, said Monique Sims, the clinic's director.
"As far as their health is concerned, immigration status is not a factor," she said. "We're just trying to meet a need here _ an unmet need."