Monday, April 05, 2010

Forward on Health Reform: Undocumented immigrants and healthcare

The United States has chosen, for better or worse, to organize access to health services on an insurance model. In contrast, in countries like the United Kingdom and Canada, you just show up with minimal documentation at a clinic or hospital, which gets reimbursed directly by the government.

In health reform, the issue of undocumented immigrants was so contentious that the Democrats left undocumented immigrants completely out of the bill. They are forbidden to participate on the exchanges at all. The original House bill would allow them to buy insurance on the exchanges if they used their own money.

Undocumented immigrants will continue to access community health centers, which will charge sliding scale fees. They will be eligible for emergency treatment, and hospitals will still receive compensation for treating them under Disproportionate Share Hospital funds (DSH, pronounced "dish", funds).

Access to care for this population will continue to be a problem. The U.S. will have to keep investing in community health centers, which will also serve Medicaid patients and many minority communities.

What is clear is that as the ranks of the uninsured diminish, immigrants like Medrano will continue to patch together health care as they can — at health centers such as Fresno's Clinica Sierra Vista, at hospital emergency rooms, or through programs like Healthy San Francisco, which offers universal health care to all who live in the city.

"We have to be very creative — not asking for labs unless it's really essential, working with generics, working with drug companies, giving them samples," said Juan Carlos Ruvalcaba, the doctor seeing Medrano at Clinica, which charges on a sliding scale of $40 to $70, depending on the patient's ability to pay.

Once an undocumented immigrant himself, Ruvalcaba was able to become a citizen and attend medical school because of an amnesty program in 1986. He remains committed to serving all patients, no matter their insurance or immigration status, but there is only so much he can do, he said.

He was able to give Medrano the drugs she needed, but he asked, "What happens when they need a specialist? What if they end up in the emergency room, and end up with a big bill?"

Some who work with this population are afraid that with the focus shifting onto providing care for the newly insured, those shut out of the system will be forgotten, left to fend for themselves with even fewer resources.

"It may make things worse — if you say 32 million are covered, there may be less done for these large groups who are here, who are working, who are such a large part of our agriculture industry," said Norma Forbes, executive director of Fresno Healthy Communities Access Partners, a nonprofit network of eleven health care organizations in California's rural Central Valley.

One anti-immigration commenter interviewed for the article said there is no foolproof way of verifying documentation to keep undocumented immigrants from participating on the exchanges. That's a fatuous comment, because there is no foolproof way of doing anything. That said, she does have a point in that someone with a false Social Security number belonging to a citizen could potentially get into the exchanges and receive subsidies. I don't expect that this will happen very much, though.

All permanent residents and refugees would be eligible for subsidies, and in the latter case, for Medicaid. If undocumented immigrants had participated in the exchanges, they would be easily identifiable because they weren't receiving subsidies. If the government wanted to round them up, the information on the exchanges could be subpoenaed. I'm not sure that many of undocumented immigrants would participate in health reform if they could, but I still think they should be given the chance. Furthermore, in the long run, we do not want a market outside of the exchanges for technical reasons. In any case, this is one of the things we will have to fix, along with the immigration system.

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