Silvia Ruiz remembers the sound of her father's labored breathing in the days before he died. Two years ago, he got sick with COVID-19 but delayed seeking the medical care she says he clearly needed because he was undocumented and afraid.
Many in health care fear other migrants in the country illegally may suffer the same fate due to recent changes to Florida's immigration law. The legislation (SB 1718), signed into law in May by Gov Ron DeSantis, requires Medicaid-accepting hospitals to ask admitted and emergency patients about their immigration status.
While that fear was present before in the migrant community, advocates worry the law could have pervasive effects on all of Florida.
Fear of health care. Death in the family
Ruiz lives in Florida under the Deferred Action for Childhood Arrival (DACA) program, which protects from deportation eligible young adults who were brought to this country as children. In 2005, Ruiz's family crossed the Rio Grande from Mexico with the help of coyotes, or smugglers. Her parents came to America hoping to make money and return to Mexico.
The latter would never happen for Valente Ruiz.
The Ruiz family settled in Apopka, where Valente, 43, worked as a welder and even helped create emergency staircases for well-known projects like Disney World's Animal Kingdom: Pandora, the World of Avatar, Silvia Ruiz said.
Her father was a big guy. He liked to drive motorcycles, listen to country music, wear "Patriotic USA" shirts and tease his daughter. She recalled her fifth birthday party, her first birthday in the U.S., when Valente caught her by surprise by pushing the birthday cake into her face.
"He was a jokester," she said and laughed.
In 2021, her father became sick.
"At first, we thought it was just allergies," Ruiz said. "I thought, he's probably going to be fine in the next couple of days."
Not long after, Valente couldn't breathe normally. He waited a week before finally admitting he needed serious medical attention. He was taken to a hospital and given an oxygen mask, but it wasn't enough. Medical staff put Valente on a ventilator and had him flown to Orlando Health for further treatment.
He struggled to breathe for a month before dying in May 2021 — his lungs were scarred from overworking, his daughter said. Valente left behind his wife, Silvia and three other young children who were born in Florida.
Silvia says her father's death left her with a lot to think about.
"My parents have suffered, sacrificed so much to even exist to be here," she said. "Now that he's gone, the moments that I've had to think about it, I've asked myself multiple times why didn't he get help sooner?"
Years later, Silvia can now answer that question.
"It's probably because he was afraid," she said. "If someone did ask him in a crisis what's your Social Security? Or can I have an ID? Already in a crisis, he had to put himself in a more vulnerable position and say, 'I don't have one because I'm undocumented.' "
Silvia said she is friends with other undocumented immigrants who have been living in Florida for a long time. She said her father was far from alone in avoiding health care to preserve secrecy.
"You're supposed to feel like you're going to the hospital to get help. You don't want to feel interrogated," Ruiz said. "You want to make sure that you feel 100% safe to share whatever you're feeling in order for you to get better."
Because her father lived in fear, Silvia is left wondering that if he could have approached a hospital without hesitation, would he have lived?
"I don't like to question and ask 'What if?' she said. "But I do think it's ... it's valid for me to think that maybe in a different situation, he'd be OK."
What does the immigration bill have to do with hospitals?
Since SB 1718 went into effect in July, Florida hospitals accepting Medicaid — acute care, critical care, and children's hospitals — are tasked with asking hospital admission and emergency department patients if they are U.S. citizens or lawfully present in the country.
Republican Sen. Blaise Ingoglia was the bill's sponsor. He didn’t respond to numerous WMFE requests for an interview. However, Republican Rep. Randy Fine, a co-sponsor, said the citizenship survey is to determine how many Medicaid dollars the state spends on migrants in the country illegally.
"Every illegal immigrant that gets health care at a hospital, every single one is being paid for 100% by taxpayers because they can't get insurance," Fine said. "They're illegal. So the idea here is to document to those who lie and say that, 'Oh, no,' this is a good thing to document just how expensive it is. That's the reasoning."
However, according to the Kaiser Family Foundation, more than half of undocumented immigrants are insured through the private market. The University of Southern California illustrated one way they may receive private insurance coverage as a dependent, albeit case-by-case basis, is through a spouse’s or parent’s employer program.
According to the American Immigration Council, Florida is home to about 775,000 undocumented immigrants. Currently, no database of how much money goes toward the Florida population exists. Fine believes that tracking the spending is necessary.
"An illegal immigrant by definition doesn't have insurance. So they get hurt in their job, which again, the radical left says, 'Oh, this is so great. they're working illegally without insurance and without paying taxes. That's fantastic.' And then they happen to get hurt, and they show up in the emergency room, the taxpayers of the state of Florida are eating that," Fine said.
DeSantis released a statement May 10, when he signed the bill, that expressed a desire to alleviate Floridians of the burden of supporting the health of immigrants in the country illegally.
"The legislation I signed today gives Florida the most ambitious anti-illegal immigration laws in the country, fighting back against reckless federal government policies and ensuring the Florida taxpayers are not footing the bill for illegal immigration,” he said.
Orlando Health and AdventHealth did not respond to WMFE regarding how they planned to address patients in terms of citizenship. HCA Healthcare vowed to "provide exceptional and compassionate care to all of our patients," said Trip Farmer, spokesman for HCA. "Any time the legal, legislative or regulatory landscape changes, our responsibility is to be in compliance with applicable state and federal laws and regulations.”
The law states that patients’ answers to the citizenship question will not influence the quality of care nor will it result in a report of a patient's immigration status to immigration authorities. Additionally, patients aren’t required to even answer the question.
Hospitals must turn over findings at the end of January to the Florida Agency for Health Care Administration. Then on March 1, AHCA must send its own report to DeSantis andthe Legislature.
More harm than good
The argument of data collection has left some in health care questioning what conclusions might be drawn from asking about citizenship when people can opt out of answering.
"In their database amongst all the people who did not answer that question, how do you tell the difference between citizens and noncitizens if they're all hodgepodge and mixed in," said Erick Suarez, a nurse practitioner at Pineapple Healthcare, a clinic focused on treating immigrants and the LBGTQ+ community in Central Florida.
Pineapple Healthcare was founded during the COVID-19 pandemic as a means of addressing health disparities in the community, Suarez said. The pineapple is a symbol of hospitality. Iterations of the spikey fruit can be found around its office adjacent to Interstate 4, near Orlando's Holden Heights community, and south of Rio Grande Park.
"I am not an immigration officer. I treat bacteria and viruses and medical conditions. I don't come to find out what their immigration status is or is not," Suarez said.
However, he is aware that immigrants in the country illegally come to Pineapple.
"A telltale clue for me will oftentimes be that they're checking out ID, maybe a passport from a different country," he said.
Suarez is concerned the new law will have effects on the migrant community in ways that are similar to Valente Ruiz.
"I think we’re going to see delays in care," Suarez said. "Someone who should have gone to an ER or an urgent care, or someone who probably should have seen medical attention for something that is easily treatable, they're going to wait until it's too late."
Additionally, not receiving treatment for an illness risks exposing others to it. In the case of Valente Ruiz, his wife was also sick, Silvia said.
Suarez said COVID is a good example of how a patient's fear of health care can potentially affect an entire community, risking more exposure and transmission.
In terms of recognizing how much money the state is spending on migrants here illegally, some medical workers believe creating fear around health care will cost Floridians more money.
"Being sick costs more money," said Ethan Suarez, a Pineapple Healthcare case manager. "Because you have to take time off of work, you have to take time for health care needs. And you're not being productive members of the economy."
Reducing fear of health care and getting people to routinely seek out preventative care can ultimately be more cost-efficient, Ethan said.
According to the National Library of Medicine, preventative care is not a magic pill for saving money in the hospital system but has strong potential for improving health spending by as much as $45 billion a year in terms of treating patients with key long-term conditions: like diabetes, chronic lung disease or long COVID.
Prior to Valente's COVID infection, Silvia believes her father suffered from sleep apnea but refused to seek medical attention for it. Research in the National Library of Medicine shows those with sleep apnea face a greater risk of detrimental COVID outcomes.
As things stand, the immigration law will probably deter migrants from hospitals more so than ever before, Ethan said.
"I think people will become more afraid of the government, and they're going to live in fear and live in shadows," Ethan said. "We just want to care for people."
Alternative medicine options
Dr. Armen Henderson practices medicine in Miami. For him, the questionnaire goes against his beliefs.
"I think that is a direct insult to the oath that we take to do no harm to individuals. By collecting information like that," he said, "I just don't see it as a necessity. And it actually will deter individuals from seeking care at the hospital."
Every Saturday, Henderson runs a free mobile clinic in Miami for the homeless population as well as immigrants. The clinic receives hundreds of patients, Henderson said, but with more people becoming aware of the hospital-mandated citizenship question, he thinks the clinic may become overrun with patients.
"We know that we're going to see more people as a direct result of these new laws," Henderson said. "It's going to limit the amount of resources we're able to offer individuals who are going to seek care with us as a last resort."
Elsewhere in Miami, a unit of medical workers hits the road every Saturday searching for homeless or migrants who may not want to seek a hospital or even the mobile clinic for fear of being spotted by an U.S. Immigration and Customs Enforcement agent. The Miami Street Medicine team offers simple procedures like physical exams and wound dressing, but also more complex offerings of portable diagnostics like ultrasound, EKG and glucose test kits — free of charge.
Hana Abdullah, a medical social worker, has led the team through city streets for nearly a year. It's a job she loves.
"I get to show up as myself and be the best version of myself and do the work that I know how to do without politics and policies that essentially have nothing to do with the work itself," she said.
However, the new law has raised concerns for her.
"I've never been one to be nervous about political impacts," Abdullah said. "I am very nervous."
Abdullah is afraid for her patients. She doesn't trust the wording of the law. Specifically, the part that would guarantee safety from immigration authorities. Additionally, Abdullah has concerns about the racial profiling she says the bill potentially licenses.
"If it's not about (profiling), then why are we not providing sources and resources for classes or doubling down on our cultural competence?" she asked.
Abdullah's fear is over the fact that there appears to be no penalty written in the law for a hospital worker — on or off duty — to call an ICE agent and report an undocumented immigrant in the facility.
"The lack of accountability, and the lack of tools or any type of acknowledgment or conversation around what it looks like for cops, for doctors, for nurses, for firemen (to be accountable)?" she said. "Where are we implementing anything beyond just allowing changes that are definitely going to put racial profiling on steroids."
"I love this place"
Prior to her father's death, Ruiz was attending school in Miami studying to be a social worker. These days, school is on pause. She's working to help her mom and her three siblings in Apopka, but she plans to return to school and study public relations.
She's scared of the current political landscape. Not just for her fellow immigrants, but also for her mother — who, like her father, won't go to the hospital if she's feeling sick.
Silvia's mother, who asked not to be named, questions whether she and her husband made the right choice coming to America. Was it worth the struggle and the daily fear of getting caught?
Silvia reminds her mother that, yes, it was worth it.
"Of course, it is," Silvia said. "Aside from me, you have three other kids that are growing up, and they're having amazing lives, and they're getting to do so many things that they probably would have never experienced back in Mexico."
In Florida, Silvia and her siblings have access to education. They live a short driving distance from a natural spring, two beachline coasts and theme parks. The family considers them all to be gems they've come to associate with home.
When Silvia thinks back on her sacrifice and struggles to give herself and her siblings a good life, she has a hard time reconciling with why anyone could make life harder for undocumented workers.
"You're threatening my mom's existence. You're threatening my neighbor's existence. If that doesn't make you frustrated, I don't know what would," she said.
Despite the struggle and the state's stance, Ruiz is hopeful for the future. She thinks this is a temporary tunnel her family is passing through and that the not-so-far future could be much brighter.
"Hopefully, in 10 years, (my mom) has a primary care physician and she has all the checkups that she needs," Ruiz said. "I hope to be living in Florida. Florida has been my home for the past 18 years and counting. I want to live here forever. I love this place."
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