Immigrant health on hold

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.

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 represent 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 Association 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.

TAKEAWAY: Immigration reform won't offer the healthcare help that some providers and immigrant advocates were hoping for.