– Sarai Carranza Iraheta spent days lying in bed in a church basement here, paraplegic and suffering from a kidney infection. Her body ached; she had a fever. She vomited a lot.

Fearful of high medical bills, her mother waited to see if she got better. Sarai got worse. Finally, an ambulance rushed her 130 miles east to HCMC in Minneapolis.

The family, originally from El Salvador, crossed the U.S. border in May along with a caravan of others seeking asylum. But as their case winds through the overloaded immigration courts, Sarai’s predicament highlights the difficulties that impoverished asylum-seekers face in caring for ill family members without access to health insurance or authorization to work. It also reveals the challenges of a health care system that is legally required to care for anyone who comes to the emergency room regardless of their immigration status.

“If [critics] think that we’re here to receive medical resources then they’re wrong,” Maria Iraheta Martinez, 47, said in Spanish, as she stood by her daughter’s hospital bed. “They are very wrong. We are here to flee violence.”

In a week at HCMC, a team stabilized 21-year-old Sarai, placed a catheter and provided other specialized treatment. It cost $40,000.

While Sarai’s undocumented status makes her ineligible for nearly all types of public assistance, taxpayers will cover her medical bill through Medicaid’s Emergency Medical Assistance program that covers health care emergencies for noncitizens. The state spent $35 million on such aid last year, including $9.6 million for nearly 900 undocumented immigrants.

The state and federal government split most emergency Medicaid costs, which are a fraction of the $11 billion spent on Medicaid for Minnesotans each year. But the state pays for more expansive services such as kidney transplants and cancer treatment for noncitizens.

“I wouldn’t characterize it as a coverage option for the individuals,” said Samantha Artiga, an analyst for the Kaiser Family Foundation. “It’s more of a financing source for the safety-net providers that helps offset uncompensated care costs and the financial burden on [them].”

She added that there’s a lot of confusion and fear among immigrants about access to health care, and they don’t always understand their eligibility for medical programs. Some worry about being asked about their immigration status.

But as Sarai’s condition worsened, the family had no choice but to seek help.

Escape from gang

Gang members tried to recruit Iraheta’s son Rafael, threatening the family and holding them hostage in El Salvador. They escaped and spent several years in Mexico before arriving at California’s San Ysidro Port of Entry last spring with the record number of Central American migrants who applied for asylum at the southern border in 2018.

The Trump administration is trying to discourage people in their circumstances, cracking down on asylum-seekers at San Ysidro last month and saying gang violence is not a qualifying form of persecution. A spokesman for the U.S. Citizenship and Immigration Services said the low bar for establishing “credible fear” — the initial step toward having an asylum claim considered — is ripe for fraud and abuse, with most people released on a promise to appear for a court date far into the future.

“In other words, a credible fear referral doesn’t equal asylum status, but it does earn a free ticket into the U.S., allowing individuals to disappear into the interior to live and work illegally,” spokesman Michael Bars said in an e-mail.

Iraheta and Sarai were quickly released from detention — Iraheta thinks because of her daughter’s medical condition — while others in the family were let out later with ankle monitors. Iraheta had a family connection in Montevideo and settled in the western Minnesota town. She liked the rural setting because it reminded her of the farms they made a living on back home.

Pastors at a Pentecostal church with several dozen Central American congregants opened the basement to the family and helped with food and transportation to doctor’s appointments. The family members must regularly check in with the authorities as they wait for their asylum cases to be processed.

Sarai was born with a spinal defect, has had a shunt in her brain since she was a baby and relies on a wheelchair. She was rushed to a hospital to have several kidney stones removed last fall. Thousands of dollars in medical bills for the ambulance began arriving — bills the family couldn’t afford.

“They’re afraid to go [to the hospital] because they don’t want to get more bills,” said Cristina Aldana, a pastor in Montevideo who took the family to several medical appointments.

As the state’s largest safety net hospital, HCMC sometimes cares for emergency Medicaid patients with huge bills: The largest last year was for $540,300. The state approves an extra $1.3 million a year in annual grants to a handful of safety-net hospitals, including HCMC, to offset the expenses.

In a recent grant application, HCMC wrote about a 73-year-old with renal failure. After providing some initial treatment, HCMC had to find a facility to give him further care, though it was difficult due to his immigration status and participation in emergency Medicaid. The man’s treatment cost $325,910.

So Sarai’s was far from an extreme case. It was, nevertheless, serious.

Her neurogenic bladder “predisposes her to infections,” said Dr. Brian Yablon, who treated her. “If left untreated long enough and if pressure backs up to the kidney, it could cause eventual kidney failure.”

Her kidneys are fine for now, but without insurance, it will be harder for Sarai to manage her condition. The emergency Medicaid program doesn’t cover routine care when she is not in the hospital. And while emergency Medicaid will cover childbirth costs for Rafael’s wife, who is pregnant, the program doesn’t cover prenatal care.

“That is something that we do worry about and we think about as we’re getting ready to discharge people and to plan their follow-up care,” said Yablon. While doctors reach out to other specialists and HCMC’s social worker, financial counselors and others to come up with a plan, “those plans are not always foolproof, and there are certainly cracks in our health care safety net.”

Iraheta slept in a bed next to her daughter every night for a week at HCMC, worrying about the future. They regularly spoke by phone with Cesar Rafael Carranza, Iraheta’s husband and Sarai’s father; he arrived after the rest of the family and is still in detention in California.

“My biggest dream,” said Sarai, “is to see my dad and be able to hug him and tell him how much I love him.”

Iraheta acknowledges that asylum requests for people like her family are denied most of the time. But she feels she has no choice but to be here.

“We will work to get ahead,” Iraheta said at her daughter’s hospital bedside.

As they prepared to leave the hospital for a brief stay with a family in Golden Valley, a nurse stepped into their room and said that the insurance covered a ride home.

“I’m very thankful,” Iraheta told her, “for everything you’ve done.”