As Congress moves to plug the gaping hole in healthcare coverage for the nation's uninsured, a gap remains for the estimated 3.8 million to 5.1 million undocumented immigrants who rely on publicly funded services for urgent healthcare needs.
State and local governments and healthcare providers say they spend billions of dollars each year to care for illegal aliens. But pending healthcare reform proposals largely ignore the issue of how to pay for their care.
President Clinton's Health Security Act would guarantee the right to health insurance coverage for citizens and legal residents-an estimated 37 million uninsured and 22 million underinsured. The plan would provide $800 million for so-called vulnerable populations, such as the homeless, migrant workers and others who might not be able to get insurance coverage.
The reform plan introduced by Sen. Edward Kennedy (D-Mass.) allows $1.3 billion for such expenses.
But officials of states with the highest undocumented immigrant populations say those amounts fall far short of what's needed. In Los Angeles County alone, state and federal spending for Medi-Cal claims for illegal aliens topped $382 million in the 1993-94 fiscal year, up from just $21.1 million in fiscal 1988-89. Some $214 million of that was spent for services at 10 Los Angeles-area hospitals.
The National Association of Public Hospitals says at least $3 billion is needed annually by hospitals to care for people who slip through the cracks of a reformed healthcare system.
No consensus.With healthcare reform on the table and states stepping up pressure for assistance, the undocumented immigrant issue has gained increased visibility. But there's still no consensus about what to do.
American taxpayers are becoming increasingly intolerant of illegal aliens who don't have health insurance and rely on public hospitals and clinics.
The Center for Immigration Studies, a non-profit public education and research organization in Washington, estimates some 300,000 people enter the United States illegally each year. The estimate is based on data from the U.S. Census Bureau and the U.S. Immigration and Naturalization Service.
A new report by the Urban Institute in Washington says illegal immigrants,as opposed to legal immigrants, "are the ones likely to generate a negative fiscal impact" on the economy. Because they are "disproportionately poorly educated and low-skilled," undocumented immigrants "tend to have low incomes and place additional stress on local governments."
Many of those coming to the United States for jobs are young adults, who tend to be healthier. But that is changing, said Rosemary Jenks, senior analyst with the Center for Immigration Studies. Demographic data indicate a more diverse population is entering the country, including pregnant women and other people in need of intensive medical care. Ms. Jenks said there have been documented cases of people entering the country just to receive medical care and returning home without paying a cent (See story, p. 31).
At-risk population.Once here, illegal aliens are subject to the same health risks as legal immigrants, such as poverty, poor diet, unsafe working conditions and stress, the NAPH said. Living in cramped, unsanitary conditions, and fearful of being detected by immigration officials, many are at risk of contracting and spreading tuberculosis. Language and cultural barriers also discourage many from seeking healthcare services until diseases become serious enough to require emergency care.
State officials claim Uncle Sam's lax border-control efforts have left states carrying a weighty financial burden. And they're not going to take it anymore.
In recent months, California, Florida and Arizona each have sued the federal government for allowing illegal aliens to enter and remain in the country without providing adequate funding for public services. Texas is also preparing to sue, and the governors of Illinois and New Jersey, who have lobbied federal officials on the issue, may join the battle.
Florida Gov. Lawton Chiles filed suit April 11, seeking $1.5 billion in reimbursement for services to more than 345,000 illegal immigrants living in the state. The figure includes an estimated $9.3 million spent by the state's Department of Health and Rehabilitation Services and $4.1 million by the Agency for Health Care Administration.
California is seeking $370 million for healthcare service reimbursement and, in a separate suit, $2 billion for the cost of incarcerating felons who are illegal immigrants. Arizona sued to recover $121 million in such incarceration costs. Texas plans to file a $1 billion suit to recover state and local costs for incarceration, criminal justice, law enforcement, public education, public healthcare, and human and social services.
New York Gov. Mario Cuomo, who weighed a possible lawsuit, has decided to work with administration officials and Congress members because it's cheaper and faster.
New York spends $950 million to $1 billion a year on all government services for undocumented aliens, and a large part of that is healthcare, said David Egner, a spokesman for the governor. "That doesn't mean we won't file a lawsuit sometime in the future (if the federal government doesn't come up with more funding)," he said.
Slim chance.State public policy experts said the lawsuits will at least draw attention to the problem.
"Personally, I think the lawsuits are more of a symbolic political statement than a real attempt to solve the problems of undocumented immigrants," said the Center for Immigration Studies' Ms. Jenks. Although states are right to pursue funding for costs that should be the federal government's responsibility, the likelihood of success is slim, she said.
In fact, experts believe the suits will be dismissed. Even if they stand up in court, the expense of substantiating the estimated costs of illegal immigration could exceed any awards given.
Lucas Guttentag, an attorney and director of the American Civil Liberties Union's national immigrants' rights project, said the suits ignore the tax benefits of immigration to states' economies. He cited a recent Urban Institute study that shows the taxes paid by legal and illegal immigrants exceed the cost of providing social services by $25 billion.
States are inappropriately targeting the immigrant issue to solve the "federal government's abandonment of urban areas and problems," such as the need for more primary-care services, he said. "Germs don't question a person's immigration status," Mr. Guttentag said. "The need is what should drive where the money goes."
In states such as California and Florida, the suits are a ploy to draw attention away from fiscal mismanagement and boost the governors' re-election chances, charged Jeanne Butterfield, a senior policy analyst at the American Immigration Lawyers Association in Washington.
As part of the Immigration Reform and Control Act of 1986, Congress established a grant program to reimburse states for costs of providing services to immigrants seeking legal status. But the program, intended to provide $4 billion over seven years, has ended, and states are still owed more than $800 million, according to the Immigration Policy Project of the State and Local Coalition on Immigration, a collaborative effort of five national organizations representing state and local governments.
Providers feel the pinch.States aren't the only ones carrying the burden. Except for limited emergency care and labor and deliveries, which Medicaid covers-along with disproportionate-share reimbursements-most healthcare services for undocumented immigrants are uncompensated, the NAPH said.
Hospitals that treat large numbers of poor people do qualify for disproportionate-share funding to support the costs of treating vulnerable populations. But if healthcare reform is enacted, those payments-some $18 billion this year-will stop.
It's often difficult for undocumented immigrants to obtain medical care because of insurance, language and cultural barriers. But, in emergencies, they turn to public hospitals and clinics.
The NAPH's recent briefing paper on the needs of "vulnerable populations" quoted one researcher's finding that, of six groups of undocumented workers apprehended by immigration authorities between 1976 and 1978, one-quarter to one-half used hospital or clinic services while in the United States.
The NAPH estimates its 100 public hospital members spent roughly $1.4 billion caring for undocumented immigrants last year. It's not clear how that compares with past years, only that the burden seems to be growing.
No exact figures.Some public hospitals don't want their exact expenditures publicized. "If they admit how big the problem is, they could have a local taxpayer revolt," said NAPH Executive Vice President Christine Burch.
Since healthcare providers and states can't control immigration policy, they think the federal government has a responsibility to pick up the tab.
"Our policy says that (states) should provide for coverage for everybody, regardless of their status," said Joy Wilson, senior committee director for health at the National Conference of State Legislatures in Washington.
Healthcare providers echo that position. In a statement adopted last October, the American Public Health Association rejected calls for constitutional limits on access to healthcare services for undocumented immigrants, saying that national reform must provide coverage "comparable" to what U.S. citizens and permanent residents receive.
The APHA went as far as saying healthcare reform should create and fund public health outreach and treatment programs targeted to undocumented immigrants. Such programs already exist in many corners of America, where immigrant populations reside. But without funding, Ms. Burch said, "they're going to be in some jeopardy."