Safety net systems step up care for immigrants barred from ACA coverage

While the Affordable Care Act cut the number of uninsured by about 32%, millions of immigrants don't qualify for the law's coverage expansions. They still have few options for primary care.

People living in the U.S. without authorization can't buy health insurance from the ACA's exchanges and aren't eligible for Medicare, Medicaid or the Children's Health Insurance Program. Even lawful residents who have lived in the U.S. for less than five years can't get Medicaid or CHIP. Local governments in areas with large numbers of new immigrants have stepped up to become their health safety net.

Local health officials see expanding preventive, coordinated primary-care services to undocumented immigrants as an effective means of achieving effective population health management by ensuring equitable health outcomes for the entire populace.

“The future is not about keeping individuals healthy, it's about keeping the population healthy,” said Dr. Ram Raju, president and CEO of NYC Health & Hospitals, the country's largest public healthcare system, which serves roughly half a million uninsured patients. “You cannot keep one part of the population healthy because they have access to healthcare because of their insurance, and then the other part of the population cannot get healthcare because they don't have insurance.”

In 2014 New York Mayor Bill De Blasio launched ActionHealthNYC, a program aimed at providing access to preventive care for the city's roughly 345,000 residents who are uninsured due to their immigration status.

And earlier this year NYC Health & Hospitals launched its own five-year initiative to develop a coordinated model to provide discounted or free care to uninsured patients that focuses on outpatient, preventive services in an effort to avoid hospitalizations and expensive treatments for otherwise manageable conditions.

“It's easier and cheaper for us to treat them as outpatients and keep them healthy rather than treat them in the emergency department or as an inpatient, which would cost us a lot more and for which we are not getting reimbursed,” Raju said.

Raju said it's too soon to put a number on the savings the program may reap, but its structure resembles the system's Medicare accountable care organization, which has generated savings for the past three years.

Other municipal public health systems are likewise betting that providing basic preventive health services now will help achieve long-term savings.

But such efforts raise questions about the ability of public health agencies to shoulder the cost of the services since federal dollars previously dedicated to subsidizing uncompensated care are expected to decline over the next several years.

The ACA calls for a 75% cut by fiscal 2019 to disproportionate-share hospital payments, which reimburse safety net hospitals for providing care to large numbers of low-income patients.

In California, the impending loss in DSH funds will be offset by a Medicaid waiver over the next five years. Under the waiver, DSH payments will be thrown into a “global payment” in a value-based payment model that encourages the use of preventive care to avoid high healthcare utilization.

“It sets up incentives for systems to provide care beyond just emergency services,” said Miranda Dietz, a researcher at the University of California at Berkeley's Center for Labor Research and Education. Dietz co-authored a recent report that profiles the work of county healthcare programs in San Francisco and Los Angeles that provide care to undocumented residents.

California Gov. Jerry Brown signed legislation this year to allow noncitizens, regardless of immigration status, to buy health insurance on the state's ACA exchange without subsidies. That, however, will require a federal waiver.

Providing healthcare to people who don't have permission to be in the country has been a contentious issue for years. Critics argue the services invite more illegal immigration and are an unfair use of public funds.

Unauthorized residents made up about 12% of the nation's 33 million uninsured in 2014, according to a statistical analysis published on website FiveThirtyEight.

Scrutiny of the costs of providing healthcare for them has increased in recent months amid anti-immigrant rhetoric from Republican presidential nominee Donald Trump. One of the arguments against illegal immigration is the economic burden on the healthcare system, but researchers have found that burden is often exaggerated. Health expenditures for noncitizens from 1999 to 2006 were 50% lower on average per capita than expenditures for U.S. citizens, according to a 2010 study in Health Affairs.

Advocates of providing care to this population contend it's a matter of common sense, particularly in the states where their numbers are concentrated. California, Illinois, New York and Texas are home to about 55% of all undocumented immigrants.

The leaders of public health systems see the services as part of their long-standing mission to deliver care to patients regardless of their ability to pay.

“We think it's the right thing to do,” said Dr. Jay Shannon, CEO of the Cook County Health & Hospitals System in Chicago. The system provides between $400 million and $500 million a year in uncompensated care to the county's uninsured, which includes an estimated 200,000 undocumented residents. In September, county officials approved a program to allow uninsured residents who do not qualify for Medicaid and earn up to 200% of the federal poverty level to get access to primary-care services.

The program is slated to launch by next year with initial costs expected to be about $2 million.

“These individuals are residents of our county,” Shannon said. “They pay taxes in our county, and because they are part of the population, they contribute in a meaningful way to the health status or lack of health status in our county.”