The New York Times by Jennifer Medina –
June 21, 2013:
When Congress passed President Obama’s health care overhaul, a critical compromise provision was that immigrants living in the United States illegally would not be allowed access to publicly subsidized health insurance. Even now, as lawmakers in Washington are debating an overhaul of immigration laws, leaders from both parties are arguing that no federal money should be spent on health care for immigrants on their way to obtaining citizenship.
But not in California, where there are an estimated 2.6 million illegal immigrants. Here, public health officials, elected representatives and advocacy groups are going in the opposite direction, trying to cobble together ways to provide preventive care for such immigrants, who are expected to make up the largest share of the remaining uninsured once the state’s expanded Medicaid program takes full effect.
By many measures, California, with roughly seven million people currently uninsured, more than any other state, is taking the lead in aggressively rolling out changes before January, when most Americans will be required by law to have medical coverage or pay a penalty, the so-called universal mandate. While other states are resisting efforts to expand Medicaid, California has already begun public campaigns to encourage more residents to enroll in subsidized health plans.
But in counties with large immigrant populations like Los Angeles, officials say that not including immigrants in coverage, regardless of their legal status, will only cost local government more in the long run. So they are lobbying state and federal officials to find ways to pay for preventive health care, rather than rely on emergency rooms to care for them.
The push shows how dramatically the debate around immigration has shifted in California, which approved a state ballot initiative 20 years ago that prohibited illegal immigrants from receiving any kind of public benefit, including health care. Now, public opinion polls show that the vast majority of the state’s residents approve granting illegal immigrants a path to citizenship, though they are opposed to offering them the same benefits for public services as legal residents.
Granting any kind of access to health care for immigrants is becoming a focal point in the current Congressional debate, as many Republicans have said they would refuse to support change if it included providing care for immigrants who have been living in the country illegally. Representative Raúl R. Labrador of Idaho, for instance, walked out of bipartisan negotiations in the House, arguing that illegal immigrants should be denied emergency room care and that unpaid medical bills should become a deportable offense.
In the current system, illegal immigrants in California rely on a patchwork of community clinics, whose services and availability vary across the state. Few offer comprehensive coverage, and those that do often struggle to find government money to pay for the services they offer. Some advocates worry that as more people get insurance or enroll in Medicaid, the clinics will be inundated with new patients and forced to squeeze out anyone — including illegal immigrants — who cannot pay for care.
Nowhere is this issue more pressing than in California, which has more illegal immigrants than any other state.
“California has really acknowledged that all immigrants who are here are part of our present and our future, so we need them to be healthy and included in any effort we make to expand health care,” said Daniel Zingale, a senior vice president with California Endowment, a health care foundation leading the charge to persuade the state to pay for comprehensive care for all immigrants. County leaders, immigrant advocates and labor unions have formed an unlikely alliance to press for change.
“It doesn’t take much to figure out these people will be driving our economy in the decades to come, so it’s in our interest to keep them healthy,” he said.
While the state budget does not explicitly earmark any money to pay for health care for illegal immigrants, it also does not forbid counties from using state money to do so, something Mr. Zingale and others count as a victory.
This year, the California Endowment began running television advertisements showing young illegal immigrants pleading for health care. To Mr. Zingale’s surprise, the foundation faced almost no public outcry.
“A few years ago, this would have been unimaginable, even having this conversation,” he said. “But we’ve seen a total sea change in the way we think about health care for all and immigration. I think in the end, it’s inevitable that we’re going to come down on the side of inclusion broadly.”
According to estimates from the University of California, Los Angeles, the state will have about two million to three million people left uninsured after the changes in health care law are fully put in place. While that number includes others who are ineligible for Medicaid and are unlikely to enroll in the state’s health care insurance marketplace, most of the uninsured are expected to be illegal immigrants.
By federal law, emergency rooms are expected to treat anyone who walks in, regardless of legal status, insurance or ability to pay. For decades, that has often meant that immigrants living in the country illegally seek medical attention only in emergencies, which many say ends up costing more.
When the federal government began offering subsidies for the early expansion of Medicaid, Los Angeles and other counties began to seek out more residents to enroll in low-income health programs, using money from the state to pay for it.
Now, many here believe that some kind of change in federal immigration law is inevitable, but they say the current plan to prohibit immigrants on a path to citizenship from receiving any federal subsidy for care would simply force local governments to take up the cost.
“I’m worried that if the federal government isn’t willing to pay, the question will become, Why should the counties pay?” said Dr. Mitchell H. Katz, the director of the Los Angeles County Department of Health Services.
Don Knabe, a Los Angeles County supervisor, said the debate over immigration and health care in Washington had often ignored the realities on the ground.
“We’re the ones who have to deal with the people who show up,” said Mr. Knabe, a Republican. “We can’t just shut our doors, which sometimes you might like to do. You don’t want millions of sick people walking around.”
A Harvard Medical School study released last month showed that immigrants helped pay for the growing costs of Medicare because they put in more money than they cost the system. And a study released this month by researchers at the University of Nebraska found that immigrants living in the country illegally accounted for less health care spending than both legal immigrants and citizens.
“We know that recent immigrants and undocumented tend to be cheaper and healthier than the general population,” said Jim P. Stimpson, the lead author of the study. “There’s a selection effect because people really have to have a lot of gumption and motivation to come here without authorization, and they’re often coming here for manual labor jobs.”
California is likely to be the first to grapple with a problem other states may face in the coming years. Diana Dooley, California’s secretary of health and human services, said that while the administration was not philosophically opposed to offering preventive care for illegal immigrants, Gov. Jerry Brown and other state leaders were reluctant to pay for more services.
“We just can’t do everything everyone wants us to do,” Ms. Dooley said. “We’re already in the middle of a very ambitious undertaking, so it’s strictly a question of how much we can do and how fast.”