The debate swirling around immigration policy has been heating up for the 2016 presidential candidates. Despite a wide disparity of solutions from both Republican and Democratic parties, there’s no doubt it needs to be addressed, especially with an estimated 11.3 million unauthorized immigrants currently living in the U.S. Although that number has remained somewhat stable over the past five years, according to the Pew Research Center, the daunting question about how to provide healthcare for this population remains unanswered. A UCLA study estimates by 2016, 5.1 million unauthorized immigrants will be uninsured. While a few states have recently addressed this situation with legislation and new programs, historically hospitals have been bearing the brunt of costs.
Attempts to limit assistance
Federal limitations on immigrant welfare date back to 1882, when Congress banned entry for anyone unable to take care of themself without becoming a public charge. Former President Bill Clinton’s Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 was enacted to reduce immigrant use of public assistance and had two main provisions. Those who arrived in the country before August 22, 1996, were to be taken off Supplemental Security Income and food stamps within a year and immigrants who arrived after that date were prohibited from receiving most public assistance. This restriction was lifted when the immigrant would became a U.S. citizen. However, several pieces of the provisions were repealed. Congress granted individual states the option to supplement federal benefits and extend state-funded safety nets to immigrant households, according to the Center for Immigration Studies (CIS).
In fact, the Center’s research from 2009 estimated the costs for treating uninsured undocumented immigrants at $4.3 billion overall per year, mostly at safety-net emergency departments and community health clinics. Furthermore, CIS concludes that current restrictions have not prevented unauthorized immigrants from using welfare and that, “In the end, it is probably easier and cheaper to address the problem raised by the immigration of public charges not by “ending welfare as we know it” but by reforming immigration policy instead.”
Emergency care for all, emergency Medicaid for some
The Emergency Medical Treatment and Active Labor Act (1986) provided treatment for anyone at an emergency department in a hospital that participates in Medicare to be given an initial screening and emergency treatment, if needed, until stable. A legal dispute arose around whether the stabilization requirement continues to apply if a patient is admitted to the hospital. Three circuit courts decided hospitals have no stabilization duties once patients are admitted, but the Sixth Circuit Court held the opposite opinion.
Although federal law restricts unauthorized immigrants from receiving Medicaid and from purchasing health insurance through state exchanges, there is a state-federal health insurance program called Emergency Medicaid, which pays close to $2 billion a year for emergency treatment. Covered services vary somewhat from state to state (e.g., New York covers chemotherapy and radiation treatment to undocumented patients with cancer) but births are covered nationwide.
This has led to some debate from groups seeking to limit immigration. The Federation of American Immigration Reform told Kaiser Health News the funding increases the number of women having children in the U.S., knowing they would be American citizens. However, the group doesn’t dispute hospitals should be reimbursed for costs. “Our focus should be that you could save this money if you prevent the illegal immigration from happening in the first place. You can’t do it after the fact,” Jack Martin, special projects director of the organization, told Kaiser Health News. Data collected from seven states with the highest number of unauthorized immigrants estimate Emergency Medicaid covers costs for emergency services for more than 100,000 people each year.
The federal government doesn’t require states to report how many people receive services via Emergency Medicaid payments to hospitals. Spending varies depending on immigration patterns, according to state officials. For example, Florida changed its policy in 2012 to pay emergency services for unauthorized immigrants only until their condition “stabilized” instead of the previous policy, which included care “medically necessary to relieve or eliminate the emergency medical condition.” An administration law judge ruled the state made the change improperly because it didn’t include a public hearing process and the state appealed. Hospitals in the Miami and Tampa area, with large numbers of unauthorized immigrants, raised concerns their funding would be cut. However, Judge John D.C. Newton later agreed with the state and rejected the hospitals’ claims the Agency for Health Care Administration had overstepped its authority. However, the stabilization standard was discontinued and the state changed the process for evaluating claims.
California takes big steps
California, the state with the highest number of unauthorized immigrants at 2.45 million, is working to expand health coverage for unauthorized immigrants. An estimated 60% to 70% of those immigrants lack health insurance.
Non-citizen residents can currently only be eligible for the state’s Medicaid program, Medi-Cal, if they are in “satisfactory immigration status.” Changes to federal immigration policy have created opportunities for some unauthorized immigrants to register for protected status, which could make them eligible for Medicaid if they receive low incomes. The Deferred Action for Childhood Arrivals (DACA), implemented in 2012, allowed unauthorized immigrants who came to the U.S. as children and continue their education to register for protected status. Close to 195,000 Californians to date have registered for DACA, according to the Public Policy Institute of California.
President Obama’s second executive order, the yet-to-be implemented Deferred Action for Parents of Americans and Lawful Permanent Residents (DAPA), expanded those eligible for DACA by including adults over age 35 who came to the U.S. as children and separately, all parents whose children are legal residents or citizens. This could provide deportation relief for up to 1.2 million unauthorized immigrants in California alone.
However, a lawsuit was filed by 26 states to block the implementation of these immigration policies last November. The U.S. Court of Appeals for the Fifth Circuit denied the Obama administration’s request to lift the hold on these policies. The ruling stated the administration failed to show it would be harmed if the programs were further delayed and also denied the administration’s request to limit the hold to states involved in the lawsuit. A total of 14 states plus the District of Columbia have requested a federal appeals court to allow the immigration programs referred to above to begin.
Expanding California Medicaid
Governor Jerry Brown (D) recently signed a bill to expand Medi-Cal coverage to unauthorized immigrant children aged 19 and younger, set to go into effect May 2016, as previously reported in Healthcare Dive. Led by Senator Ricardo Lara (D-Bell Gardens), the program allocated $40 million in state funds for the initial year of health coverage for 170,000 children, but it’s estimated to cost $132 million each following year. Senator Lara told the Los Angeles Times, “We can demonstrate that not only is there a need, but we can implement this successfully. It’s a precursor for us to getting healthcare for all in the next year or so.” However, a USC Dornsife/LA Times poll found Californians split over providing healthcare to unauthorized immigrants: Forty-eight percent support providing healthcare and 47% oppose it.
A recent report by the Public Policy Institute of California says close to 1.4 million undocumented immigrants could obtain health insurance via Medi-Cal if coverage is extended. Healthcare Dive reported the state dropped a plan to insure otherwise eligible undocumented immigrants because of costs exceeding $1 billion. The Public Policy’s report, according to the Contra Costa Times, examines a proposal to authorize the state to seek a federal waiver to allow those with higher incomes to pay full price for health plans through the state’s health insurance exchange, Covered California.
New York’s Direct Access
New York has an estimated 750,000 unauthorized immigrants. Mayor Bill de Blasio recently announced a pilot program, called Direct Access, that will expand low-cost healthcare to uninsured immigrants regardless of their legal status. The $6 million program, slated to start next spring, will initially apply to 1,000 immigrants, some of whom may be here legally but unable to qualify for ObamaCare. A network of primary and preventative healthcare providers will be established specifically for the program. A task force appointment by the Mayor said New York City immigrants have been discouraged from seeking primary and preventive care because of high costs and language barriers. The new provider network will conduct public outreach and education efforts about the program to immigrants.
Although unauthorized immigrants are not eligible for Medicaid in New York unless pregnant nor eligible through the state’s healthcare exchange, immigrants with a work visa under President Obama’s immigration policies are eligible for Medicaid or another public health insurance, depending on their income level.
Alvaro Huerta, a staff attorney at the National Immigration Law Center, told the International Business Times, it’s “shortsighted” not to provide undocumented immigrants access to primary care since it is cost-effective. “Every principal of health reform, [for the] documented or undocumented, says put your money into preventative care, because you’re going to be spending 100 times the investment in preventative care when people wind up sick in emergency rooms or hospitals.”
Marguerite Telford, director of communications at the Center for Immigration Studies, told Healthcare Dive if the next president secures the border and heightens the level of interior enforcement “then those leaving through natural attrition will not be replaced. This would definitely decrease the cost to hospitals and could then possibly decrease the cost of insurance for legal immigrants and citizens.” She added 45% of unauthorized immigrants are "visa overstayers, not border crossers."
No one has a crystal ball, so we’ll see what happens next November.