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6. Insurance

© 2018 Marianne Jossen, CC BY 4.0 https://doi.org/10.11647/OBP.0139.06

In this, the final chapter that deals with empirical research, we will encounter patients who identify the acquisition of insurance as their most important moment of inclusion in healthcare. We have already seen that among the total number of patients who are looked after at the NGO, and similarly among the estimated total of undocumented migrants, patients with health insurance represent a minority of around 10–20%. Anna’s story will bring us back to the network of professionals that surround the NGO. It will also allow us to consider more deeply the process of obtaining insurance coverage and thus we will return to the interview with Patricia, the employee of the insurance company, and meet Brigitte, an employee of an NGO that provides care for undocumented migrants who are HIV positive. Fanny and Nicolas’ stories offer insights into the value of insurance to undocumented migrants. Nicolas’ case in turn will reveal more about emergency healthcare in case of accidents. His story is complemented by further contributions from Andrew, the hospital’s administrative employee.

Since insurance plays such an important role in this chapter, it is worth reminding ourselves of the reasons why such a tiny fraction of undocumented migrants are insured (see also Rüefli & Hügli 2011). Besides the important financial reasons and administrative difficulties, there is another, more fundamental reason, which leaves insurers reluctant to offer their services to undocumented migrants. As we have seen, Jonathan’s insurance cover was set up only at the moment there was an actual need. This is also the case for Anna, Fanny and Nicolas. Patricia says:

Of course, an insurance company is not interested in insuring people who cause a lot of write-offs because [their] costs are simply not covered by their premiums.

This argument is not compatible with the idea that an insurance provider balances costs versus income not at an individual but at a population level. However, only obtaining insurance at the moment of need is not quite in the spirit of things either. Companies react with different strategies, as the head of the NGO, Julia, explains:

Of course, now they bring forward all sorts of reasons as to why they won’t insure him, for example, they claim that ‘this was the wrong form you used’. Or, in the beginning, a lot of applications just went missing.

Julia contextualises this statement by saying that it is not always ‘bad will’ that causes lost applications, but also the fact that sometimes the more unusual circumstances of undocumented migrants do not fit what she calls the ‘insurance apparatus’. But Patricia confirms that there might be something more systematic behind the ‘loss’ of these applications:

And some insurers simply kick those applications into the long grass. As in, you’ve gone to the insurer’s office three times, and you say ‘I have your stamp here, you have received’ — ‘We have nothing’. That [application] ended in someone’s rubbish bin or similar.

Sometimes, the NGO obtains legal advice to push applications through. But as David, the general practitioner who volunteers at the NGO, puts it: ‘Some of them [insurers] make things so complicated, at some point you just give up’. For those insurers who cooperate, there is a delicate balance to strike between their willingness to insure and not wanting to become too attractive for NGOs taking out insurance. As the insurance employee, Patricia, explains, she sometimes initiates a conversation:

Well if there is a bit of a connection we sometimes just address them [NGOs] directly and ask if maybe one or the other case… if they’re in very bad health, well, we just have a frank conversation. We state that in general we are not interested. ‘We are obliged to insure them, you know that. But you have to also see our side […] wouldn’t it be possible to insure this client somewhere else [with a different insurer]?’ […] Of course they’re not happy about this either, but there are some who, as a result, switch insurers on an annual basis. […] For us, of course, this would be ideal, if we could all take turns a bit, that way all insurers are a bit involved.

Brigitte, an employee of an AIDS Advisory Charity bureau, who also obtains insurance coverage for HIV-positive undocumented migrants, confirms this practice. She was contacted by an insurance employee who ‘asked me whether we insure all of “them” with their insurance’. When asked directly whether the practice of complicating the registration process so that the patient or NGO desists, or negotiating a change of insurers, could be described as a kind of risk-selection, Patricia answers:

What you say is correct, there is a strong selection process. […] That’s the competition of course, everyone wants to grow, everyone wants to keep their losses as low as possible.

When it comes to asylum seekers, cantons distribute them amongst different insurers depending on the insurer’s size. However, as Patricia says:

with the undocumented migrants, you can’t do anything but talk. Because you can’t control [the insurer with whom they register].

Anna: ‘Sometimes, I have a friend’

Anna is a woman in her forties. She entered Switzerland in 2011 and contacted a relative who told her that there was no way to get any healthcare without papers in Switzerland. However, when she began to earn her livelihood as a sex worker, she was informed about the NGO by a social worker. When she went to register, the general practitioner ascertained that there was a large lump in her breast. Anna, who is a mother of six, said that she had had this lump since breastfeeding her fourth child.

However, soon after, the lump started to hurt and the breast oozed liquid. Anna returned to the NGO. Echoing Béatrice, she describes having been given a hospital appointment immediately. The exams showed that she had breast cancer. She explains here that what would become her most important opportunity for inclusion was immediately put in jeopardy:

He said you have breast cancer. So then I started to cry because […] you know in [my home country] almost everyone who has this illness, their only end is death. So, from then on they started to treat me. And then I made the mistake. Because they [the social worker’s NGO] had been paying for my health insurance, I was told I should file for asylum.

Anna did not file an asylum request, because her relative told her there would be no chance. She regrets this today, as the NGO subsequently stopped paying her insurance and she still has to ‘live in the shadows’, as she puts it. The realization of how important the insurance was and is for her health and healthcare thus came to Anna retrospectively. From this moment on, she decided to pay for her insurance herself as an aging sex worker.

Still, and importantly, the insurance made it possible for her to receive cancer treatment. She had surgery and chemotherapy during 2012–2013. Anna describes the treatment as good most of the time, with medical staff acting in a caring and professional way towards her. She has a general practitioner who has been attending her since 2014, but she tries as best she can to take care of her own health. Asked what good healthcare means to her, she says:

It’s my health. So I have to take care of it. Yes, it’s my health. It’s my life after all.

When she feels bad, she tries to use preventative measures at home before attending a healthcare facility. She goes for walks as her general practitioner recommends, having recently been diagnosed with diabetes. As David says, a general practitioner can be an important professional for an undocumented migrant. The NGO helps its patients to contact them:

Well we have some general practitioners where we can place them so to speak. Yes, it is rather important that they [the general practitioners] have some experience with undocumented migrants and are a bit aware as to what kind of problems that entails.

Interestingly enough he again mentions professionals who are a part of the NGO’s network.

Generally, as soon as patients are insured ‘we are no longer responsible [for them]’, David explains. Still, as we have already seen with Peter and Jonathan, David says that patients tend to return

because they have found they trust us, they still return [to us] with one problem or another, or to ask us to explain something.

That is also the case for Anna. She says, echoing statements made by Peter:

I didn’t hide anything from [Julia]. When I have a little problem I come and I explain to her. Sometimes, she even tells me when someone has dropped by with some clothes, […] and I come and sort them and […] I send them to the children.

For Anna, it is also important that she is accompanied by either the social worker or the head of the NGO whenever she has chemotherapy, or when being looked after by doctors who do not speak the Swiss national language that she speaks. All these elements contribute to her inclusion in healthcare.

On the other hand, Anna recalls an episode in which, after a session of chemotherapy, she returned to hospital because she had started to feel very ill. A mistake had been made with her medication. She says:

I don’t even know anymore how I got out of the house to […] take the tram and go to the hospital, but still, I arrived there. […] All these parts [points at her arms] were already numb; I couldn’t feel my feet anymore. They kept me there for eight days.

What is striking, in parallel with Jonathan’s and Béatrice’s accounts, is that Anna does not mention the option of calling an ambulance either.

Still, Anna’s main problem is paying the insurance premiums. The NGO has found a way to reduce the premiums for its patients (see Chapter Two for more detail about premium reductions). Nevertheless, administrative difficulties prevent them from having access to the cheapest insurance packages. Anna’s serious illness likely makes it very difficult for her to continue working, which she has to do to earn enough to pay her insurance premiums. Asked about how she manages, she says: ‘Sometimes, when I have a friend, I explain to him. Yes, he gives me something’. As Julia explains,

The high premiums that they have to pay for with their [low] or even non-existent wages, well, […] especially women enter into highly dependent relationships. […] Even so, a good third to a half of our people are in some way or another involved in sex work. With the corresponding illnesses.

This statement, taken together with Anna’s account about how she manages to pay her premiums, provides more evidence that undocumented migrants are sometimes forced to engage in practices that may compromise their health, in order to be included in healthcare.

When a patient requires such expensive treatment, it is very important to have insurance that covers costs from the very beginning. Inclusion has to occur at the right time. Even if it might seem obvious that insurance should cover the necessary costs right from the start, it does not always work this way in the case of undocumented migrants. Usually, as the administrative employee of the hospital explains, people who arrive in Switzerland are obliged to organise insurance during the first three months of their stay. If they receive care during this time, while their insurance is not yet in place, costs are covered retrospectively as soon as the contract is signed. The insurance in turn will fix the start of the contract at the moment the person has registered at a municipality.

But in the case of undocumented migrants, it is not possible to know whether the individual really intends to stay. As a result, the insurance provider has to bear the risk of signing contracts with clients who might have only entered the country in order to get treatment. In such a case the insurance company can refuse to sign the contract, or rescind the contract when the individual leaves the country. Because of this, Patricia states, the company is ‘very sensitive to the fact, if there’s a recent hospital admission’ just after a contract has been taken out. On the other hand, it also might be that the insured undocumented migrant has already been in the country for years. In this case, as Patricia explains:

there’s an article [in law] that states — this applies specifically to people who are in Switzerland, who are in a bit of a, let’s call it a grey area — that, in those cases, we can rely on [the fact] that the date that counts is the date on which we receive the insurance document. […] So, nothing is done retroactively.

Indeed, the Verordnung über die Krankenversicherung (KVV) states that if a person registers later than three months after their arrival, the insurance starts only at the moment of the registration (Art. 7 al. 1). Also, the insurer can demand a supplementary premium (Art. 8). Julia relates a case in which an insurance company made a patient pay a month’s premium as a supplement, but without covering expenses that had arisen during this time. As she put it: ‘You pay an empty premium’. In this case, the NGO ended up paying the uncovered care costs of CHF 400; 4/5 of the annual budget for one patient.

Brigitte, the employee of the NGO caring for HIV-positive undocumented migrants, says that this practice is rather recent. In order not to generate costs that would not be covered by insurance, she asks doctors not to start HIV treatment as soon as the diagnosis is made, even if there is some urgency, especially when the HIV is already in a progressive state. Rather, doctors should wait until the insurance is certain to be valid:

We informed [the doctors] that their medical standards and the actual possibilities do not always coincide.

The most salient aspects of Anna’s story are the difficulties that her inclusion in healthcare cause her. Once more, an undocumented migrant is included in healthcare at the cost of harm to her health, as well as being heavily dependent upon other people. And while such difficulties might also affect Swiss citizens, being undocumented exacerbates these problems, due to the absence of any legal, social and working security entitlements. Taking financial responsibility for her inclusion in healthcare is, first and foremost, a huge burden for Anna. Her situation is such that even if she still tries to actively care for her health, her opportunities to do so have become very restricted. The spectres of despair and hopelessness pervade the whole interview.

The debate about the exact point at which insurance coverage begins shows once again the extent to which undocumented migrants are dependent on the NGO to ensure that all the administrative procedures are carried out correctly. These are also closely tied to financial aspects of inclusion in healthcare-related communications and the healthcare system itself, governed by interactions with medical personnel. This close entanglement between the financial, administrative and care aspects of inclusion might result in important treatments being postponed.

While Anna’s treatment for her breast cancer is certainly very important to her health, there are still problematic gaps in her inclusion when it comes to her ability to access help in emergency situations. Anna also depends on the help of NGOs. Just like Peter, Maria and Jonathan, Anna stresses the importance of the NGO in maintaining her healthcare in a wider sense, despite having a family doctor who sees her.

Fanny: ‘I can just make an appointment’

Fanny, a woman in her late twenties, has now been living in Switzerland for about twelve years. At the time of her arrival, like Jonathan and Maria, though in better health and still a minor, she enrolled in an asylum process. During this time, she learned one of the national languages, which she now speaks fluently. At that time, she also had a family doctor at her side who regularly examined her one remaining kidney. As she explains, she lost the other one in her home country, while undergoing surgery because of a kidney stone:

And then they said, now there’s nothing we can do. This kidney […], the right one, so this side, they removed everything.

Fanny’s asylum request was turned down in 2007, but she decided to stay in Switzerland. She was in the company of compatriots during her migration and from the very beginning of her stay. Via this diaspora community, she found a cleaning job that enabled her to afford housing and food. When it came to her health, Fanny medicated herself with some paracetamol when she experienced pain. She expresses concerns about this kind of self-medication:

I also have stomach pain, many [times], and I have always taken medicine, but that’s not good either, no? I don’t know if I can just take this medicine, or, I don’t know. And then I still have such strong pain.

Then, in 2012, she fell pregnant. Having had no examinations during her pregnancy, she decided, towards the ninth month of her term, to undergo the asylum process for a second time, as she explains:

Because, it’s difficult. When you are illegal in Switzerland to have a baby you have to pay [so] much, and you have to work [so] much […]. That’s why I made a second request.

Fanny explains that she only felt safe to begin the asylum process again because she was so heavily pregnant that she was sure she would not be deported. At the end of this second asylum attempt, she went into hiding once more, this time with her newborn child.

It was during her second pregnancy in 2015 that Fanny was finally introduced to the NGO by a friend. All pregnant patients attending the NGO are urged to take out insurance, and Julia stresses that she does not want a ‘parallel universe’ of healthcare for undocumented migrants and deplores any situation in which a patient remains without insurance. Fanny did not even know she was entitled to take out insurance, but once this was established she was very pleased to have it. She is in a less financially precarious situation than Anna, and so she focuses most of all on its organizational and administrative advantages. She can go ‘to the women’s clinic, just normal’. She continues:

Now that I pay the insurance every month and when I have pain somewhere, then I go, then [there] is no problem. […] Then I have no worries, right. When I have pain or something, I don’t have to think, ah, what should I do or something. I can just make an appointment. [It] is easier and much better.

Fanny stresses the value of the insurance again in the following statement, comparing her current situation to that in her home country:

When I go to hospital or the like [in my home country], I always heard them talking, they wanted money. We have to give something, right. And then they do it. But if we don’t give anything or so, then they didn’t want to. No, that is different, right, here in Switzerland they don’t do this, right. When I go to hospital, I give money to nobody.

We see similarities here to Béatrice’s experience, when she talked about the relief of not having to incentivise every medical interaction with some sort of payment. Paying for and receiving care are social relations enacted at different points in time and with different organizations. The insurance means that Fanny’s inclusion in healthcare is independent from any individual’s goodwill or corruptibility. It allows her to take part in a process in which personal negotiation and bargaining are not necessary.

Asked about how she finances the insurance, Fanny just says that she has to ‘work a lot’ in order to pay the premiums. Her two children are not insured, but get some basic care at the NGO. Even Fanny, who is at this point able to handle most of her interactions with healthcare organizations herself, states that the NGO gives the hospital a call before she visits, ‘so then they don’t ask too many questions’.

With Fanny’s story we have encountered a case that, although more turbulent than Anna’s in some respects, shows clearly how migrants can create a significant amount of space for autonomous inclusion and how much they value this autonomy. For Fanny, it seems, the insurance gives her a sense of having a certain right to exist and to be recognized in Switzerland, if not as citizen, then at least as a patient. Again, contact with the diaspora and inclusion in a labour market, however precarious, allow Fanny to obtain healthcare relatively independently.

On the other hand, Fanny’s case shows once more what kind of inclusion undocumented migrants can obtain while remaining excluded from charitable organizations and insurance. To file an asylum request is a marginalizing and risky strategy for inclusion in healthcare.

Nicolas: ‘I know I have to pay because I know why’

Nicolas came to Switzerland in 2003 after abandoning his studies in Germany for financial reasons. He always thought that maybe he could earn enough money to finish his studies, but he was never able to save anything on the side. Still, of all the patients discussed in this book, he is financially probably the most secure. He works in agriculture and on building sites, as he explains:

I know maybe a good ten or fifteen people; sometimes I work with people like that. Sometimes he says no, this time there’s no work, but I’ll call you. So sometimes they call.

Nicolas’ first experience with health issues in Switzerland is directly related to one of his jobs. Working on a building site, while not yet having taken out insurance, he has an accident and hurts his knee:

There was a lady […] she says ‘mister mister hello what’s up’, and I say ‘listen, I fell, I don’t know what’s up’. She said ‘my husband is ambulance driver’ […] and she called and he came with the ambulance and he put a thing like this, like ice.

Despite receiving this first aid, Nicolas does not let the driver take him to hospital. He instead says he wants to go home, as it is already late. He also repeats twice that he ‘doesn’t know anybody’ in the hospital. The fear of going to an emergency unit because he does not know anybody echoes the dependency on personal connections that has already been stated by other patients. Again, it seems that undocumented migrants have to rely so heavily on personal and informal relationships that they do not dare to interact with organizations where no such connections exist. Only the next day, when the knee has swollen even more, is Nicolas willing to go to the hospital. His boss picks him up in a car, drives him to the unit and pays for the care given.

For Nicolas, things are uneventful after this incident until his sight starts to trouble him. Still not insured, he is examined by an ophthalmologist. When describing this incident, Nicolas says ‘I paid him for nothing’. The doctor tells him that there’s nothing wrong and that he just should get new glasses. Nicolas continues:

I said ‘listen, I tell you the truth. I trust you. I don’t have papers here in Switzerland. How much does this cost?’ He said ‘500 francs’. I said […] ‘can you, can you wait a little moment, for example, some days, a week?’ He said ‘listen, you have to pay now’. […] Maybe he is stressed, maybe he thinks I won’t pay.

Nicolas therefore has to pay CHF 500 for a diagnosis he suspects to be wrong and, as the doctor wants the money at once, he bargains with an employer in order to get an advance on his salary.

Nicolas then turns to another professional, who tells him that he does indeed need surgery on his eyes and should take out insurance. We will come back to the details about how Nicolas obtains and affords this insurance. For now, suffice it to say that with the contract taken out in 2010, he can get the surgery he needs. He says he was afraid during the first surgery, which is reminiscent of Peter’s experience. Both men know that surgeries in their countries of origin can be very risky procedures, potentially accompanied by dangerous complications. Nicolas describes how the hospital personnel calmed him and informed him about every step taken. He is very happy with the results and with the operation on the second eye, as he says, ‘I go there easy and hop hop, no problem’. Like Fanny, he values the insurance a great deal:

The insurance, that works very well here, that helps a lot. […] And I know I have to pay because I know why.

He does his best to pay the premiums on time. When things get tight with money, he can sometimes get an advance from one of his employers and ‘sometimes I don’t eat’. We encounter here another example of inclusion in healthcare creating a need for behaviour that threatens the patient’s health. On one occasion, Nicolas ends up calling the insurance company:

Once I called them, they sent me a letter: if you don’t pay — police. I said, ‘Listen, I’m not like you. You have a salary, I don’t. I work a bit here and there and then I don’t work for two or three months, it depends’. Ah, he understood. ‘Listen, when I have [a] delay […] I pay it anyway’.

Nicolas again stresses the importance of insurance in his next statement, though adding at the same time a bleaker comment:

The insurance is obligatory because sometimes I do dangerous work. So it has to be done. […] The problem, when I have no work, how do I pay? I have to take any kind of work I can get.

Nicolas’s statements reinforce the pattern seen in Anna’s story, in which friends helped to pay for her insurance and she therefore developed dependent relationships common amongst undocumented migrants in order to pay premiums. Again, we see how healthcare has to tackle problems that, to a great extent, have been caused by the financial difficulties encountered during the process of gaining inclusion in healthcare. To ‘know why you have to pay’ in Nicolas’s case therefore means knowing you have to pay because you know you are at the risk of injuries. These injuries are caused by the hard and risky physical work you have to carry out in order to be able to pay for the insurance in the first place.

To acquire and maintain health insurance also involves a lot of administrative work for Nicolas. As soon as the doctor tells him that he needs insurance, he turns to a social worker he happens to know. The social worker does some research and finally tells him that he needs a ‘legal’ person whom he trusts and who trusts him, so that financial transactions and correspondence can take place. After he finds this person, whom Nicolas describes as a good friend, the three of them meet up and organize an appointment at an insurance company:

Because she [his friend] made the bank account and all, and then every time I call or I send an SMS like this, I say, ‘Listen, are there any bills?’ […] She says yes. Ok, I’ll come at once. And then, sometimes, I don’t find her at home, so I put the money in an envelope for her. And then she organizes everything.

To ‘organize everything’ means, for example, to try to get a premium reduction and to try to ensure the provision of the canton’s contribution in case of hospital stays. As Patricia explains, hospitals who cannot assign patients to a certain canton, because they are not registered, tend to send the whole bill to the insurance company, while usually the canton has to pay 55% of a hospital stay. Patricia adds: ‘Usually, it’s the institution [e.g. an NGO] that checks whom one can turn to’.

As we saw in the introduction to this study, Nicolas did not receive an insurance card:

I don’t have an insurance card, but with the [insurance] number they find it. Now, this works at [one particular hospital], but the other hospitals I don’t know.

The interesting part of this statement is that Nicolas mentions a specific hospital, at which he had his eye surgery. Other hospitals, such as the one I accompanied him to, do not have him registered as a patient and therefore, being unable to verify his insurance without a card, are reluctant to register him.

Finally, the biggest remaining problem for Nicolas is his lack of papers. This is a particular difficulty. Given his country of origin, he has very little chance of legalizing his status in Switzerland. At the same time, he cannot return. Because there is no repatriation agreement between Switzerland and the country in question, the government there simply refuses to take back any undocumented migrants. As Julia puts it:

It’s like they belong nowhere. Switzerland doesn’t want them and [Nicolas’ country of origin] doesn’t want them anymore either.

For undocumented migrants in this situation, encounters with the police end up being pointless, but can still have serious repercussions, as Julia explains:

Sometimes they end up in administrative detention because they were stopped by police. And because they can’t be deported, they can just keep them there for a few months and then they put them back on the street.

Being in prison for months can easily result in loss of work, housing and contacts. Having lived under these threats for fifteen years now, Nicolas, like Maria, says that he does not tell people about his problems. He states that he is otherwise in good health, he does a lot of exercise to stay healthy and to avoid thinking too much about his problems. He can always rely on the NGO when he needs to talk. But he adds:

I don’t sleep when I think, I don’t sleep how I should, really. Even when I spend the whole day outside, I do sport, but there’s always a nightmare because of [lacking papers]. Believe me, sometimes I cry.

Nicolas’s story also returns us to the issues surrounding emergency care, this time in the context of a work accident. Regardless of the issue of cost, the fear of being exposed due to a lack of personal connections often holds undocumented migrants back from attending emergency care, as we have already seen. In the case of a work accident in a black market setting, for instance, this fear is not completely unfounded. As Andrew, the hospital’s administrative employee, confirms:

Well it does happen that they are ‘visiting’ someone on the construction site. And then they have an accident. And then we see what we can do with the police.

Julia relates this as a situation of conflicting loyalties:

In some way, they [the hospital’s employees] have a conflicting task. On the one hand, to protect the client, and on the other hand, to collaborate with the authorities.

From Andrew’s perspective, these different loyalties can clash in a paradoxical way. Sometimes, Andrew, himself a Swiss citizen, thinks it might be better for the patient to force their employer to live up to their legal responsibilities and provide healthcare, even if this results in the patient losing their permit to stay in the country.1 As Andrew puts it:

There’s the question as to what’s more important. In this particular situation, it’s probably a matter of weighing things up. And depending on the severity of [the accident] it’s certainly better for the patient to accept the consequences.

Nicolas’ case effectively demonstrates how undocumented migrants try to deal with incidents of ill health when they are broadly excluded from healthcare. There are options, such as simply to ignore a problem, or to depend on an employer to provide transport to and payment for treatment, but this carries the risk of arousing the suspicion of healthcare professionals about one’s legal status and/or financial precarity. We see again that the fear of being exposed and/or being burdened with very high costs of care excludes migrants like Nicolas from emergency departments.

Nicolas’s story also demonstrates, once more, the benefits that insurance can bring for undocumented migrants, in contrast to the difficulty of their attempts to be included in healthcare without it. It must be understood, however, that this value also carries a high price — a substantial financial burden, but also the cost to one’s health that is often inflicted by attempts to afford insurance.

We also see the lengths to which undocumented migrants can go to continue their participation in an insurance scheme, and how, despite this effort, they usually remain dependent upon someone else, who functions as an addressee and bank account holder. Being able to receive treatment from medical personnel is not assured even then, because exclusion at the hospital is a potential issue if the patient is not backed by an organization like the NGO.


1 As soon as a patient who has had an accident declares himself to be employed — whether legally or on the black market — his employer’s insurance has to bear the cost of his healthcare. But by declaring themselves to be illegally employed, undocumented migrants expose themselves and are deported after treatment.