DES MOINES, Iowa — Days after they were badly hurt in a car accident, Jacinto Cruz and Jose Rodriguez-Saldana lay unconscious in an Iowa hospital while the American health care system weighed what to do with the two immigrants from Mexico.

The men had health insurance from jobs at one of the nation’s largest pork producers. But neither had legal permission to live in the U.S., nor was it clear whether their insurance would pay for the long-term rehabilitation they needed.

So Iowa Methodist Medical Center in Des Moines took matters into its own hands: After consulting with the patients’ families, it quietly loaded the two comatose men onto a private jet that flew them back to Mexico, effectively deporting them without consulting any court or federal agency.

When the men awoke, they were more than 1,800 miles away in a hospital in Veracruz, on the Mexican Gulf Coast.

Hundreds of immigrants who are in the U.S. illegally have taken similar journeys through a little-known removal system run not by the federal government trying to enforce laws but by hospitals seeking to curb high costs. A recent report compiled by immigrant advocacy groups made a rare attempt to determine how many people are sent home, concluding that at least 600 immigrants were removed over a five-year period, though there were likely many more.

Now advocates for immigrants are concerned that hospitals could soon begin expanding the practice after full implementation of federal health care reform, which will make deep cuts to the payments hospitals receive for taking care of the uninsured.

Health care executives say they are caught between a requirement to accept all patients and a political battle over immigration.

“It really is a Catch-22 for us,” said Dr. Mark Purtle, vice president of Medical Affairs for Iowa Health System, which includes Iowa Methodist Medical Center. “This is the area that the federal government, the state, everybody says we’re not paying for the undocumented.”

Hospitals are legally mandated to care for all patients who need emergency treatment, regardless of citizenship status or ability to pay. But once a patient is stabilized, that funding ceases, along with the requirement to provide care. Many immigrant workers without citizenship are ineligible for Medicaid, the government’s insurance program for the poor and elderly.

That’s why hospitals often try to send those patients to rehabilitation centers and nursing homes back in their home countries.

Civil rights groups say the practice violates U.S. and international laws and unfairly targets one of the nation’s most defenseless populations.

“They don’t have advocates, and they don’t have people who will speak on their behalf,” said Miami attorney John De Leon, who has been arguing such cases for a decade.

Nearly five years later, Cruz is paralyzed on his left side, the result of damage to his hip and spine. He has difficulty speaking and can’t work.

Rodriguez-Saldana said he has to pay for intensive therapy for his swollen feet and bad circulation. He also said he walks poorly and has difficulty working.