ALLENTOWN, PA. (AP) — Junior Clase’s cluttered kitchen table paints a picture of his life in the United States. Scattered across it are bottles of deodorant and conditioner that he sends back to the Dominican Republic, a Spanish-language Bible and a plastic medical brace for his wife, Solibel Olaverria.

Olaverria began having intense headaches and vomiting five months after she joined her husband in the U.S. In the emergency room, she was diagnosed with a brain aneurysm; during surgery to stop it from rupturing, she suffered a stroke and was induced into a coma.

She left the couple’s Allentown row house in December 2022 and has yet to return. Clase worries she never will.

In February 2023, Clase said, hospital administrators suggested transporting his still-comatose wife to a facility back in the Dominican Republic – an option he refused.

“They told me that they could send her back to my country,” he said – even without his consent. “At that moment, she was missing a piece of her skull. … If they put her in an airplane or a helicopter, it was possible that she would die.”

Though the federal government is the only entity with the jurisdiction to remove people from the U.S., hospitals across the nation sometimes return uninsured noncitizen patients in need of long-term care to their countries of origin.

Advocates call this “medical deportation.” Hospitals and medical transport companies refer to it as “medical repatriation.” By either name, the practice exists in ethical and legal gray areas – without specific federal regulations, widespread public knowledge or a national tracking system.

Facing limited options for care, some immigrant patients and family members may voluntarily decide to continue treatment outside of the U.S. Other times, experts say, the process occurs without full consent.

Lori Nessel, a professor at Seton Hall University who supervised a 2012 report about medical repatriation, said the practice amounts to “private deportation.”

“They were essentially being deported,” she said, “but outside of the legal process for deportation, because there was no immigration court involved.”

While some foreign governments track these repatriations, data is inconsistent and doesn’t reflect whether patients wanted to return, felt they had no other option or were forced to leave.

Over the past two decades, academics, advocates and reporters have struggled to put a number on the phenomenon, which involves a tangled network of hospitals, air transport companies and consulates that work in different states and countries.

Since 2020, the Philadelphia-based Free Migration Project has tracked 19 cases of patients facing medical deportation, through referrals and a telephone hotline it runs. Six of those came in the first six months of 2025, from cities in Pennsylvania but also Florida, New Jersey and New York, according to Adrianna Torres-García, deputy director of the organization.

“We’ve had a higher volume of cases in the same span of time than any other given year,” Torres-García said. “It’s also more complex cases.”

Experts believe medical deportation happens more than tracking efforts account for, and some worry cases could now increase, given that the practice sits at the intersection of health care and immigration – two systems undergoing drastic change in the second Trump administration.

Early on, Olaverria was able to get treatment under a federal law that requires Medicare-participating hospitals to provide stabilizing care to anyone with an emergency condition, regardless of insurance, ability to pay or immigration status. Hospitals can then file for reimbursement through Emergency Medicaid.

But the tax and spending cut bill President Donald Trump signed in July significantly reduces how much the government will pay into Emergency Medicaid. The law also makes some immigrants, including refugees and asylees, ineligible for traditional Medicaid and Medicare.

Immigrants without legal status have long been ineligible for these programs, and even green card holders have to wait five years before they are eligible for Medicaid.

In effect, experts said, the changes will leave even more immigrants uninsured and provide less funding for emergency care if they need it.

“If immigrants are unable to get as much coverage, then they’re not going to be able to get as much care,” said Andrew Cohen, an attorney with Health Law Advocates, a public interest law firm in Boston. “That’s where medical deportations could really grow.”

The legal requirement to treat anyone with an emergency condition won’t go away, said Benjamin Sommers, a health policy researcher at Harvard University. But with the federal government paying less toward Emergency Medicaid, states could also decide to reduce how much funding goes to emergency care, shifting the burden to hospitals – or individuals.

Patients “get sent bills that they often can’t pay, that often are going to go to collections,” Sommers said, adding that some may even go bankrupt. “Sometimes we see hospitals diverting patients. … I think there’ll be more of that.”

Raymond Lahoud, a Pennsylvania lawyer who represents hospitals and health networks in cases related to immigration, said hospitals fulfill their obligations to treat all patients but often need to consider further options once those patients are stabilized.

“There comes a point where the hospital has done everything it medically could do, and now that person has to move on to their next step in rehabilitation or certain kinds of end-of-life care,” he said.

U.S. citizens might be discharged to other hospitals, long-term care facilities or their families. Noncitizens, with limited access to health insurance, might instead get sent to a facility in their country of origin.

Hospitals sometimes pay private medical transport companies to conduct repatriations and provide in-air care. These services routinely cost tens of thousands of dollars but may still be cheaper than long-term or indefinite care; in the U.S., inpatient hospital care cost an average of $3,132 per day in 2023, according to health policy research firm KFF.

“Unfortunately, it becomes a financial burden to the hospital,” said Craig Poliner, president of MedEscort, an Allentown-based medical air transport company that works with hospitals to facilitate medical repatriations.

Poliner insisted that MedEscort would never repatriate a patient without consent and said company officials work with hospitals to follow the American Medical Association’s discharge guidelines.

“The patients really do better in their own countries, in their own culture,” he said. “We’re not forcing anybody back. We convince them why we think it’s better. If we have the right approach, it usually resolves itself.”

However, advocates noted that immigration status, a lack of insurance, the injury or illness itself, unfamiliarity with the health care system and language barriers can hinder someone’s ability to give informed consent.

In 2013, John Sullivan, a social worker based in Tempe, Arizona, traveled to Mexico to study medical repatriation as part of a Fulbright scholarship. He interviewed patients who had been sent back, along with family members, health workers and Mexican officials.

Sullivan said the circumstances surrounding consent in some of those cases were “unclear.” “It was almost like migrants would describe feeling like they had no other choice,” he said.

Olaverria entered the U.S. on a temporary tourist visa, and when she sought treatment, she was uninsured. In the first days of March 2023, Clase said, hospital administrators gave him an ultimatum: Find care for his wife elsewhere, or they would follow through with her transfer to the Dominican Republic.

Clase said the only option he felt he had was to keep his wife where she was. He didn’t believe she would survive the flight to the Dominican Republic, and if she did, he didn’t trust that she’d receive the care she needed there. He couldn’t properly care for her at home, and she didn’t have insurance to cover the cost of another facility in the U.S.

Local advocates connected Clase with the Free Migration Project, which organized protests against Olaverria’s transfer. Outside the hospital, protesters carried homemade signs on neon-colored posters calling for an end to medical deportation.

After local media coverageClase said, hospital administrators agreed to hold off on the transfer if they could work together to find another long-term care option. The hospital did not respond to requests for comment.

Media coverage of Olaverria’s case helped bolster interest in a bill before the Philadelphia City Council to stop nonconsensual medical repatriations, and in December 2023, it became the nation’s first and only law banning the practice, according to experts.

The policy requires hospitals in the city to obtain patients’ written consent and provide information about their rights and options for care before transferring them out of the U.S. It also requires hospitals to determine whether patients are eligible for programs that could pay for their care – and, if so, help them enroll.

Philadelphia hospitals also must now report medical repatriations to the city’s Department of Public Health. Agency spokesman James Garrow said hospitals submitted five repatriation reports in 2024, the first full calendar year for which data was collected.

Claudia Martínez participated in the campaign to pass the law after her uncle faced medical repatriation. The personal photos, wedding memorabilia and Bible quotes that decorate her living room walls hang alongside a “Community Power Award” from the Pennsylvania Immigration Coalition.

“I don’t want anyone to go through what I went through,” Martínez said.

In May 2020, a motorcycle struck Martínez’s uncle, an immigrant from Guatemala. When Martínez arrived at the hospital, she found him comatose and intubated, with injuries that rendered him almost unrecognizable.

Weeks later, Martínez said, a hospital social worker asked for her uncle’s immigration status. She later learned the hospital and MedEscort planned to transfer him to a facility in Guatemala.

“I was in shock,” Martínez said. “He was intubated. … He was not in a condition to travel.”

She said she rejected the transfer in conversations with hospital officials and MedEscort, but Poliner said MedEscort got authorization for the repatriation from family members in Guatemala. Martínez disputes that.

Eventually, Martínez connected with the Free Migration Project, which organized a protest outside the hospital on the day of her uncle’s scheduled trans fer.

In the end, the medical deportation was scrapped. Ultimately, with the help of community advocates, Martinez’s uncle was able to access a form of state-sponsored insurance. He moved into a rehabilitation center and stayed for three years, until his insurance ran out.

In May 2024, his family decided it would be best for him to return to Guatemala to be at home with his wife. He can walk again but has significant memory impairments.

“He is someone who loves to joke,” Martínez said. “This, I think he didn’t lose.”

Consulates are often involved in the medical transport of their citizens, helping to secure travel documents and occasionally paying for airfare on less expensive commercial flights.

Between 2014 and 2024, the Mexican General Directorate of Consular Protection and Strategic Planning reported 8,227 medical repatriations; 328 of those took place in 2024. The data does not distinguish between patients who wanted to return and those who felt pressured or coerced.

“Sometimes the level of care that they are going to receive in their hometowns … is not going to compare to the one they receive here, and they know that – so it’s very rare that a patient says, ‘I want to leave,’” said one Mexican consular official, who did not want to be named to avoid repercussions in their ongoing work with hospitals.

If patients want to stay in the U.S., they may not know what options are available to them. Hospitals, too, may be unaware of alternatives, said Cohen, who runs a program that helps eligible immigrant patients access insurance.

In some states, immigrants who don’t qualify for federal insurance programs may be able to access certain state-funded programs instead.

“(Hospitals are) preemptively doing something that they wouldn’t even need to do if they knew about these pathways into better coverage,” Cohen said.

In May 2023, Olaverria was transferred into a long-term care facility in Allentown. Two months later, she woke up from the coma. She still cannot walk or use the bathroom on her own, and she can speak only a few words.

Later that year, Clase and his wife obtained medical deferred action, which allowed them to temporarily remain in the country. It also allowed Clase to get a work permit and Olaverria to access emergency medical assistance from the state.

Between working two jobs and attending church services three times a week, Clase keeps his ritual of visiting his wife every day. Flower bouquets rest on the bookshelf in her room.

He wipes her mouth, adjusts her neck and massages her curled-in hands. And he still tells her stories that can make her laugh.

For him, life outside this routine is virtually nonexistent. When he gets home each night, he sleeps and occasionally cries.

“This country consumes you,” he said.

Clase and Olaverria are working to apply for a visa that would allow them to stay longer. But her ability to continue in long-term care is uncertain.

Despite this, Clase carries forward, focused on the familiar paths of his daily routine, all of which lead to Olaverria.

“The majority of my time,” he said, “I dedicate it to my wife.”

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This report is part of “Upheaval Across America,” an examination of immigration enforcement under the second Trump administration produced by Carnegie-Knight News21. For more stories, visit https://upheaval.news21.com/