Uninsured and undocumented, it took Victoria Martinez's cousin six months to get around to seeing a doctor about the swelling in his left calf and foot.
At the hospital, it took a Spanish-speaking translator a matter of seconds to tell the twentysomething man that waiting so long to seek treatment for what were complications of diabetes had left no choice but to amputate part of the leg.
"When they told him the news, he put his head in his hands," Martinez said of her relative, whom she called only Manuel, "and he wept."
Manuel cried for the limb he would lose, she said, and for fear of what else the trip to the emergency room would cost him: his Goshen factory job, and in his mind, his secret status as an illegal immigrant.
But in the uneasy entry of Hispanic immigrants into Elkhart County institutions, some observers have sounded their own cry that poor, uninsured newcomers overwhelm the community's health providers and fuel higher medical costs for other residents.
Experts say immigrants and the health-care industry here both pay a toll, financially and socially.
Quantifying health care costs for immigrants -- illegal or otherwise -- is difficult because hospitals and clinics don't ask about citizenship status. Federal law requires them to treat anyone in need of emergency care, regardless of residency or ability to pay.
"When a patient presents to our facility, we do not inquire at all about their legal status," said Amy Floria, vice president of financial services for Goshen Health System. "We don't turn anybody away. We see everybody who's there."
Though ineligible for most public benefits, illegal immigrants can receive emergency care through Medicaid, the federal-state insurance program for low-income or disabled residents. They are largely left to pay out of pocket for non-emergency care.
Congress in 2004 approved spending $250 million annually for four years to help offset costs that health-care providers incur because they treat undocumented residents. Added together, providers in Indiana were slated to receive about $1 million in the first year of federal aid, according to the conservative Federation for American Immigration Reform.
Yet a 2005 study by Harvard and Columbia universities found that expensive care for immigrants might not be to blame for the nation's rising health costs. The study probed health-spending data collected by an independent research agency and determined that immigrants use health care far less than U.S.-born residents.
About a third of immigrants don't use health care at all in the course of a year, and uninsured immigrants use health care less than any other demographic, the study discovered.
"Health-care costs are up because of the number of uninsured people," said Vernita Todd, chief executive officer of Heart City Health Center, a federally funded clinic serving low-income people on Elkhart's east side. "It's not dependent on a racial group."
The surge of immigrants has increased the number of uninsured people in Elkhart County and elsewhere.
About 60 percent of undocumented immigrants in the United States don't have health insurance, according to the Pew Hispanic Center. The rate is more than twice as high as that for legal immigrants and four times higher than for U.S. citizens.
Closer to home, a conservatively estimated 18,000 -- or 10 percent -- of Elkhart County residents are uninsured.
It's a contributing factor in the amount of free care that the local health-care industry provides for the indigent.
In 2007, Goshen Health System wrote off $1.8 million in so-called charity care. Elkhart General Healthcare System racked up $13.8 million.
The figures don't break down in terms of ethnicity or citizenship status.
Goshen's Floria said that health system hasn't experienced any dramatic increases in charity care, even with the influx of immigrants into Elkhart County.
"We have pockets in our communities -- regardless of whether they are immigrants or the working poor -- who don't receive health care from their employers," Floria said.
Dr. David Van Ryn sees the trend in the Elkhart General Hospital emergency room, a place that for many uninsured immigrants is their only link to medical care.
"Their care results in more uncompensated care in the hospital, which is ultimately passed on in one way or another to people who pay their bills," Van Ryn said. "The reality is we're all seeing some effects of this in emergency departments. The emergency department is a safety net for the community."
It takes a lot of training and effort to keep the net in place.
Perhaps the most direct cost that immigration has imparted on the health-care system is the price of having to recruit and hire bilingual workers. Staffing hospitals and community health centers in Elkhart County means having Spanish speakers posted everywhere from the front desk to the exam room.
"Goshen has a very strong bilingual community," Floria said. "In our effort to meet those community needs, we look for key areas to hire bilingual staff."
At Heart City, the Elkhart clinic, about 40 percent of patients are Hispanic and many don't speak English, said Todd. So the clinic devotes money not only to hiring Spanish-speaking staff but also to printing appropriate signs and literature.
"You look around this place and you won't see anything in just English," Todd said.
In recent years, various organizations and health industry officials in Elkhart County have turned their attention to health education. The goal has been to make people better, smarter health-care consumers.
Todd and Van Ryn have concentrated on helping steer patients to family doctors and primary care physicians rather than to the ER.
But it can be tricky teaching people the difference between emergencies and less serious matters.
"To a lay person without any medical training, it's not always clear whether a high fever is a viral infection or something more serious," Van Ryn said as an example. "Is that chest pain indigestion or a heart attack?"
Among Hispanic patients at Heart City, many don't seek care until their ailments have worsened to dangerous points, Todd said. A growing number of them, like the Goshen factory worker whose leg was amputated, experience complications from diabetes, including kidney failure and high blood pressure.
"With adults, it's got to be serious before they will come in," Todd said. "We don't find them overusing care. I don't know if that's a cultural issue or maybe an economic issue."
Todd sees the nation's federally qualified 1,200 community health centers -- including hers -- as playing an important role in helping extend health care to the uninsured, both U.S.- and foreign-born. Unfortunately, she said, health centers have not factored into the solutions that Democratic presidential hopefuls Hillary Rodham Clinton and Barack Obama tout in their expansive health-care proposals.
Neither candidate's plan calls for covering undocumented immigrants.
"Our role is to provide access to health care and a medical home," Todd said. "Health care isn't a privilege. It shouldn't depend on how much money you have. It shouldn't depend on where you live. It shouldn't depend on your last name."