Friday, June 29, 2007

Health care and immigration

Do undocumented - illegal - aliens have a right to health care? I view health care as a human right. However, the fact is that it is not free under the best of times, that the American health care system is inefficient and very expensive, and that many Americans lack health insurance. Many move in and out of insurance when they change jobs (and although their employers are required to keep offering insurance after employees leave, they aren't required to subsidize it any more, so many ex-employees can't afford the bills). Under these circumstances, access to health care is seen as a limited good. Many Americans will, understandably, not be particularly eager to extend coverage to undocumented immigrants.

This Marketwatch article discusses some of the efforts to secure care for undocumenteds.

Despite widespread belief to the contrary, documented and undocumented immigrants don't overburden taxpayer-funded health insurance programs, according to a report released earlier this month by the Center for American Progress, a nonprofit, nonpartisan think tank in Washington.

Noncitizens don't consume many health-care resources, nor do they drive up the costs of care, said Meredith King, the report's author and a health policy analyst at the center. That's partly because many illegal immigrants are reluctant to seek care for fear they will be deported or it will hurt their chances of becoming citizens.

Under federal law, undocumented immigrants aren't eligible for Medicaid or the State Children's Health Insurance Program. Legal immigrants have to wait five years after entering the country before they become eligible for those programs.

States can opt to change those regulations, but it means they have to fund the programs without federal matching dollars, King said, noting that 22 states cover children and pregnant women who have legal status.

About 44% of documented immigrants were uninsured in 2005, more than three times the rate among the native-born, the study found. Although federally funded community and migrant health centers served more than 675,000 migrant and seasonal farm workers in 2004, many noncitizens lack preventive-care services.

Federal law requires emergency rooms to accept and stabilize anyone who seeks emergency medical care. But areas such as Cleveland and Little Rock, Ark., that have smaller immigrant populations see higher ER use than do Miami, Phoenix and Orange County, Calif., which have much larger numbers of noncitizens, according to the study.

"Especially along the Mexico-U.S. border you can see [immigrants are] actually not going to emergency rooms as much as the public commonly thinks," King said. "But when they do go they're sicker, and that's the issue. That does increase the costs, but it's not because they're going more often. They're putting off health services until it's absolutely necessary."

Hospitals' uncompensated care costs that result from people unable or unwilling to pay their medical bills amounted to $26.9 billion in 2004, or 5.6% of total expenses, according to an AHA survey of nearly 5,000 hospitals.

There are some undocumented immigrant families with, say, one child born in the US, and one born abroad. The child born here is a US citizen and eligible for SCHIP (the state children's health insurance plan, administered separately by each state with federal matching funds). I have heard that some families, out of fairness, will choose not to cover both children in this case. (And by the way, the parents and family members of a child born in the US can apply for permanent residency and later naturalization based on the child's citizenship, but they have to wait until the child turns 21. And staying illegally in the country can pose a severe barrier to achieving legal status.)

In Massachusetts, which is rolling out a landmark universal coverage initiative that forces government, employers and individuals to share the costs of health insurance, low-income, legal immigrants now have access to coverage, said Brian Rosman, research director of Health Care for All, a Boston nonprofit advocating for universal care.
"They're eligible for the new subsidized coverage program even if they're ineligible for Medicaid. That was a real positive aspect of the law," Rosman said. "It's letting some low-income legal immigrants get coverage, and they pay on a sliding scale."
Undocumented immigrants can get emergency care that's paid for out of an uncompensated-care pool, he said. "There needs to be some place, to protect the public health, where undocumented people know they can get care."

Several competing bills in California are looking to emulate the compromise that Massachusetts has forged, though the Golden State has 6.5 million uninsured to consider. All but one of the bills, which calls for a single-payer system, falls short of reaching everyone, said Anthony Wright, executive director of Health Access California, a nonprofit consumer advocacy coalition in Sacramento.

"One of the areas of consensus among the governor and legislators is expanding coverage to all children, and by all children we mean up to 300% of the federal poverty level and without regard to immigration status," Wright said. "There's a desire for us not to weed out the children who are undocumented."


If immigrants fail to get coverage that may affect U.S. citizens' way of life as well, King said. Those who don't have preventive care are likely to forego doctor visits and vaccinations, which may increase public health risks.

That's cause for concern, said Rosemary Jenks, director of government relations for NumbersUSA, a Washington nonprofit that advocates for immigration reduction.
"With illegal immigrants, we don't screen them at all, and they're coming from countries where health-care systems are very bad, generally," Jenks said. "There are significantly large numbers of people with [infectious] diseases," especially tuberculosis.

Other challenges include mixed-status households, where low-income, foreign-born parents don't have access to health care but their American-born children qualify for public programs.

"Obviously there's a lively policy discussion and a question of values and priorities about whether that's appropriate or not," said Marian Mulkey, senior program officer at the California Healthcare Foundation in Oakland.

Reshma Shamasunder, director of the California Immigrant Policy Center, an advocacy group in Los Angeles, said Americans want both immigration and health-care reform.
"Everyone needs some form of usual, preventive care," she said. "That's just common sense and good fiscal sense."

"There's lots of forms of thinking about this issue, but the bottom line is there should be affordable, comprehensive care for all residents of our country," said Shamasunder.

The California debate is volatile and could change at any minute, Mulkey said. "These are really complicated issues....I think a lot of people are waiting and seeing at this point."

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