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Everybody In, Nobody Out (That Means Immigrants Too!)
Annette B. Ramírez de Arellano, DrPH
Universal health care should mean that everyone is covered. With more than 46 million not insured in the U.S., extension of coverage is the major rationale for health reform.
Immigrants are over-represented among the uninsured; it is estimated that some 12 million immigrants currently lack coverage. Any health care scheme that seeks to extend coverage should make a dent in this number. Unfortunately, the proposed reforms will continue to leave many out because of their immigration status.
Coverage of undocumented immigrants has become a politically-sensitive issue, and President Obama has stated that any reform will explicitly exclude this population. This means that no subsidies will be given to undocumented immigrants. Moreover, the Senate version of the bill currently under discussion makes undocumented immigrants ineligible to buy coverage in the insurance exchanges that seek to provide a broader array of better-priced options. The President’s statement concerning eligibility prompted a “You lie!” from Rep. Joe Wilson, a comment that was strongly condemned as a breach of Congressional etiquette but that largely eclipsed the issue at hand.
Wilson’s eruption would have made more sense if he had said “Fie!” The fact is that exclusion of undocumented immigrants does not make good public health policy, nor does it make much economic sense. In addition, it places clinics and hospitals that treat this population at a distinct disadvantage.
The public health argument for covering undocumented immigrants is that a number of diseases do not stop at the border, or take citizenship or legal status into account. This is true not only of the H1N1 virus, but also other communicable diseases such as TB.
The economic argument is more complex, though equally compelling. Most immigrants are part of the risk pool that insurers seek to cover: they are young (35 percent are men between the ages of 18-39; only 1.2 percent of the total are 65 and older), and tend to be healthy and not in need of much care. This population is therefore more amenable to cost-effective preventive measures aimed at health maintenance rather than treatment. Covering them at younger ages would likely be protective of their health, thereby avoiding costlier care later.
Given their lack of coverage, many undocumented immigrants rely on community health centers and emergency rooms for care. The enactment of the Emergency Medical Treatment and Active Labor Act of 1986 ensures public access to emergency health services regardless of ability to pay. In many cases, this care is uncompensated, and providers must resort to other means to cover their costs. The federal government, through its Disproportional Share Hospital (DSH) program, covers part of the costs incurred by hospitals that treat uninsured patients, including the undocumented. But these funds are not sufficient to cover the entire costs of uncompensated care; hospitals therefore raise the fees they charge other patients to increase their revenues. This cost-shifting means that everyone pays, whether they are aware of it or not.
The health reform bills now being considered reduce DSH payments on the assumption that the uninsured would be reduced, and there would therefore be fewer uninsured patients. This may be true overall, but not for certain hospitals. Facilities treating many undocumented patients rely on DSH payments to make ends meet, and are therefore facing an increasingly precarious situation. This is particularly the case with border institutions, which are the health care safety net for many immigrants.
We favor the inclusion of all persons residing in the U.S., regardless of their citizenship status. We therefore oppose any nativist arguments that exclude non-citizens. We consider health to be a public good, whose benefits accrue not only to the immediate recipient but also to society as a whole. Our stance is based on both public health and social justice reasons. But there are also economic and practical reasons for our position, as we have summarized above.