Im­mi­gra­tion re­form pro­pos­als will leave mil­lions with­out health cov­er­age

Modern Healthcare - - FRONT PAGE - Paul Barr

They live here, many work here and an un­known num­ber of them get in­jured or sick here. But for now, at least, it ap­pears that the es­ti­mated 11 mil­lion il­le­gal im­mi­grants liv­ing in the U.S. will not get fed­er­ally sub­si­dized ac­cess to health in­surance cov­er­age as a re­sult of planned leg­is­la­tion that would al­low many il­le­gal im­mi­grants to live in the coun­try legally.

That news came as a dis­ap­point­ment to those who pro­vide med­i­cal care to il­le­gal im­mi­grants, and do so largely with­out be­ing paid. Im­mi­grant ad­vo­cates also were let down by the re­lease last week of two pro­pos­als for leg­is­la­tion to re­form the U.S. im­mi­gra­tion process, nei­ther of which would give health in­surance as­sis­tance to the il­le­gal im­mi­grants that would gain pro­vi­sional le­gal sta­tus un­der the plans.

Pro­po­nents of giv­ing lim­ited health­care ben­e­fits to cur­rently il­le­gal im­mi­grants ar­gue that do­ing so would al­le­vi­ate some prob­lems that af­fect ev­ery­one and could re­duce costs. The num­ber of unin­sured res­i­dents would fall much closer to zero; re­im­burse­ment for hos­pi­tals and health cen­ters would im­prove; and in­surance costs could fall as the younger and health­ier im­mi­grants join the in­surance pool.

But pro­pos­als coming from both the Se­nate and Pres­i­dent Barack Obama would not ex­tend any health­care ben­e­fits to cur­rently il­le­gal im­mi­grants who qual­ify as pro­vi­sion­ally le­gal res­i­dents un­der the plans. “We had at least hoped to see some progress in the af­ford­abil­ity and ac­ces­si­bil­ity of cov­er­age,” said Dan Hawkins, pol­icy di­rec­tor for the Na­tional As­so­ci­a­tion of Com­mu­nity Health Cen­ters. Health cen­ters are big providers of pri­mary care to il­le­gal im­mi­grants.

“The coun­try seems ready to solve the prob­lem of im­mi­gra­tion and ac­cep­tance of im­mi­grants into this coun­try, (but) it seems on this level they’re go­ing to be left out,” Hawkins said. “By mak­ing it dif­fi­cult if not im­pos­si­ble to gain ac­cess to af­ford­able cov­er­age ... I don’t want to call it sec­ond-class cit­i­zen­ship, but it’s like that,” he said.

One ma­jor ob­jec­tion to giv­ing fed­eral health in­surance as­sis­tance to il­le­gal im­mi­grants would be the ex­tra costs. And while a broad con­sen­sus has emerged in Washington to cre­ate a path to cit­i­zen­ship for th­ese im­mi­grants, im­mi­gra­tion re­mains a hot-but­ton is­sue for many Amer­i­cans. A sur­vey con­ducted last April by the Pew Re­search Cen­ter found that 46% of Amer­i­cans say the grow­ing num­ber of new­com­ers from other coun­tries threat­ens tra­di­tional Amer­i­can cus­toms and val­ues. So it was per­haps a big enough po­lit­i­cal risk for four GOP sen­a­tors to join four Democrats in of­fer­ing an im­mi­gra­tion re­form pro­posal and not sur­pris­ing that they de­cided to not in­clude health­care ac­cess in their plan (See story, p. 7).

But it was a sur­prise to some that Obama de­clared in a fact sheet that he would not seek to give cur­rently il­le­gal im­mi­grants ac­cess to sub­si­dies and tax cred­its to buy health in­surance through the pro­vi­sions of health­care re­form should they qual­ify as pro­vi­sional le­gal im­mi­grants. Obama’s plan, like the sen­a­tors’, would cre­ate a new class of res­i­dent for those im­mi­grants. Some had hoped he would leave the door open to giv­ing the newly le­gal im­mi­grants as­sis­tance with paying for health in­surance.

“We were cer­tainly dis­ap­pointed in that part of the state­ment,” said Tom Nick­els, se­nior vice pres­i­dent of fed­eral re­la­tions at the Amer­i­can Hospi­tal As­so­ci­a­tion. “We would like for them to have the op­por­tu­nity to qual­ify for cov­er­age,” and the as­so­ci­a­tion will be work­ing on Capi­tol Hill and with the Obama ad­min­is­tra­tion to try to get it added to any im­mi­gra­tion re­form leg­is­la­tion, he said.

Oth­ers in the hospi­tal in­dus­try were less di­rect about the need to get il­le­gal im­mi­grants cov­ered by health in­surance, but ac­knowl­edged that re­duc­ing the num­ber of unin­sured would be a good thing and even­tual cit­i­zen­ship would pro­vide that. “We are en­cour­aged that both plans of­fer a path­way to cit­i­zen­ship,” said Gabriela Sanz, sys­tem di­rec­tor-ad­vo­cacy and pub­lic pol­icy for Christus Health, a 17-hospi­tal sys­tem based in Irv­ing, Texas, with op­er­a­tions in large seg­ments of the state. Texas has roughly 1.7 mil­lion il­le­gal im­mi­grants, which repre-

sent 6.7% of its pop­u­la­tion, ac­cord­ing to the Pew Re­search His­panic Cen­ter.

And of­fi­cials for Christus and oth­ers in the hospi­tal in­dus­try would like to see the fed­eral government re­in­state spe­cial pay­ments to hos­pi­tals specif­i­cally for il­le­gal im­mi­grant care pro­vided in emer­gency rooms. The fed­eral government had funded such pay­ments through a pro­gram known as Sec­tion 1011, with a $250 mil­lion con­tri­bu­tion for four years through 2008, and those funds have been ex­hausted for many states that qual­i­fied for the funds.

Hospi­tal in­dus­try rep­re­sen­ta­tives, in­clud­ing the AHA and the Cal­i­for­nia Hospi­tal As­so­ci­a­tion, ar­gue that most of the care pro­vided to il­le­gal im­mi­grants re­sults from the fed­eral re­quire­ments of the Emer­gency Med­i­cal Treat­ment and La­bor Act. AHA Pres­i­dent and CEO Richard Umb­den­stock wrote Obama in June in an un­suc­cess­ful bid to get the Sec­tion 1011 fund­ing in­cluded in his im­mi­gra­tion re­form plan, and Nick­els said the as­so­ci­a­tion is still pur­su­ing the is­sue on the Hill.

Cal­i­for­nia has the big­gest stake in get­ting the Sec­tion 1011 funds re­stored. It has the most il­le­gal im­mi­grants, roughly 2.5 mil­lion, which make up 6.8% of its pop­u­la­tion, ac­cord­ing to Pew. “His­tor­i­cally, the CHA has ad­vo­cated that the fed­eral government has a re­spon­si­bil­ity to pay hos­pi­tals for care pro­vided to un­doc­u­mented pa­tients,” said Jan Emer­son-Shea, spokes­woman for the as­so­ci­a­tion.

The CHA es­ti­mates that 10% of its un­com­pen­sated care goes for il­le­gal im­mi­grants, which trans­lated to a cost of $1.37 bil­lion in 2011, Emer­son-Shea said. Mean­while, Cal­i­for­nia’s share of the Sec­tion 1011 fund, $250 mil­lion to­tal, ran out in March and did lit­tle for the state’s hos­pi­tals. “It was a drop in the bucket,” she said.

Data is sparse on how much care is pro­vided to il­le­gal im­mi­grants be­cause un­der fed­eral law, hos­pi­tals are not al­lowed to ask about ER pa­tients’ abil­ity to pay. The Sec­tion 1011 pro­gram re­lied on a pre­sump­tion that a pa­tient was in the coun­try il­le­gally based on a se­ries of cir­cum­stan­tial ques­tions.

But some hospi­tal in­dus­try rep­re­sen­ta­tives in Ari­zona and Cal­i­for­nia say that the prob­lem of treat­ing il­le­gal im­mi­grants has less­ened in re­cent years as a re­sult of the weak­ened econ­omy and tighter re­stric­tions on the bor­der. Pew’s es­ti­mate of their pop­u­la­tion na­tion­ally has de­clined slightly from a peak of 12 mil­lion in 2007.

“When Ari­zona’s econ­omy was peak­ing be­fore the Great Re­ces­sion ... there was a height­ened aware­ness about il­le­gal im­mi­gra­tion,” said Pete Wertheim, a spokesman for the Ari­zona Hospi­tal and Health­care As­so­ci­a­tion. But a lot of that at­ten­tion di­min­ished quite a bit dur­ing the re­ces­sion, he said.

In San Diego County, Calif., stricter con­trol of the bor­der helped ease the prob­lem of treat­ing il­le­gal im­mi­grants, said Steven Es­coboza, pres­i­dent and CEO of the Hospi­tal As­so­cia-

tion of San Diego and Im­pe­rial Coun­ties. “Our emer­gency room direc­tors, I would think they would say there’s not as many im­mi­grants crowd­ing the EDs as some peo­ple think,” he said. Nev­er­the­less, treat­ing them is still a prob­lem, with the two coun­ties pro­vid­ing about $125 mil­lion worth of care to il­le­gal im­mi­grants in 2011, he said.

And de­mand for hospi­tal care in the ER could in­crease if im­mi­gra­tion re­form is passed, even with­out the in­clu­sion of health in­surance as­sis­tance, some say. The new le­gal sta­tus could make some im­mi­grants less fear­ful of be­ing de­ported as a re­sult of go­ing to the hospi­tal, said Dy­lan Roby, an as­sis­tant pro­fes­sor of health pol­icy and man­age­ment at UCLA and re­searcher at the UCLA Cen­ter for Health Pol­icy Re­search.

“We have seen sup­pressed lev­els of care among the un­doc­u­mented. You could see an in­crease in the like­li­hood of us­ing those ser­vices,” Roby said. “They’re no longer il­le­gal,” he said.

Some of that sup­pressed use of health­care ser­vices also may be tied to the be­lief that the il­le­gal im­mi­grant pop­u­la­tion is younger, and for that rea­son, health­ier than the gen­eral pop­u­la­tion. If true, then in­surance com­pa­nies would have an in­cen­tive to get them cov­ered.

Im­mi­grant ad­vo­cates say that keep­ing the sta­tus quo re­gard­ing il­le­gal im­mi­grant health­care would be a mis­take. “The cur­rent sys­tem leads to a lot of prob­lem­atic care on the ground,” said Michael Gusmano, re­search scholar at the Hast­ings Cen­ter, a not-for-profit re­search group fo­cused on bioethics. “It leads to strange de­ci­sions about the man­age­ment of disease.”

Pa­tients with chronic or se­vere con­di­tions who could be treated by a spe­cial­ist go with­out care un­til they have to go to an emer­gency room. They can then be sta­bi­lized, but will likely be back in the ER at some point, Gusmano said.

And im­mi­grant ad­vo­cates also point to what they would see as un­fair­ness in hav­ing im­mi­grants live and of­ten work legally, per­form­ing jobs for low wages, yet be­ing de­nied the abil­ity to get af­ford­able in­surance cov­er­age. “If we’re talk­ing about bring­ing im­mi­grants out of the shad­ows, and want­ing them to fully in­te­grate, that in­cludes giv­ing them ac­cess to health­care,” said Sonal Am­be­gaokar, health pol­icy at­tor­ney for the Na­tional Im­mi­gra­tion Law Cen­ter.

But the pres­i­dent and Congress ap­pear ready to keep health­care out of im­mi­gra­tion re­form. “I think that gives im­mi­grants a mixed mes­sage about how wel­come they will be,” Am­be­gaokar said.

Hun­dreds line up at a Los An­ge­les im­mi­gra­tion rights cen­ter in Au­gust af­ter Pres­i­dent Obama an­nounced a pol­icy of “de­ferred ac­tion” for il­le­gal im­mi­grants who ar­rived in the U.S. as chil­dren.


Un­doc­u­mented im­mi­grants, here ap­ply­ing in Chicago in Au­gust for de­ferred im­mi­gra­tion sta­tus an­nounced un­der an Obama ad­min­is­tra­tion pol­icy, would not qual­ify for ben­e­fits un­der tem­po­rary le­gal sta­tus en­vi­sioned in new pro­pos­als for a path to­ward cit­i­zen­ship.

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