Illegal Immigration and Healthcare in the U.S.
David H. Cox
November 17, 2017
Illegal Immigration and Healthcare in the U.S.
Illegal immigration is a complex issue with various consequences, some of which are related to healthcare in U.S. hospitals. The Affordable Care Act (ACA) was not meant to provide health insurance to illegal immigrants. Despite this intention, illegal immigrants have managed to gain access to government health insurance in the U.S.
Description of the Policy
The ACA’s federal policy states that illegal immigrants are not eligible for government health insurance (Radnofsky, 2016). This shifts the burden to the state level, where states have flexibility with Medicaid, and 16 states have decided to extend health insurance to illegal immigrants (Radnofsky, 2016). These states have decided that providing healthcare to illegal immigrants will help to reduce the overall healthcare costs in this demographic. Los Angeles County in California, for example, treats an annual estimate of 135,000 out of the total illegal immigrant population of over 1,000,000 (Radnofsky, 2016). Their hope is that if preventative healthcare services are covered, then it will be cheaper in the long run because more expensive emergency room visits might be avoidable. However, states that provide large amounts of healthcare services to illegal immigrants are feeling the financial burden of such a decision, and it was estimated that by 2019 there would be 1.5 million illegal immigrants in California alone, requiring at least $400 million additional funding per year, or $720 million if all signed up for Medicaid coverage (Radnofsky, 2016).
Currently, state tax dollars help fund uncompensated healthcare costs incurred by hospitals through laws such as the Emergency Medical Treatment and Active Labor Act (EMTALA). In 2013 for example, states provided nearly $20 billion for such costs (Conover, 2016). Because the ACA increased overall health insurance coverage, the total amount of uncompensated care costs that the state had to fund decreased. In this way, Conover argues that the federal government essentially freed up $6.5 billion in state funds to be used for any purposes including providing care for illegal immigrants (Conover, 2016).
Despite the official policy of the ACA, illegal immigrants are still receiving healthcare benefits from the U.S. government. In addition to the ACA freeing up money that states can use for covering illegal immigrant primary healthcare costs, this population is also receiving government financed emergency medical care. EMTALA mandates that hospitals must treat anyone who enters the emergency room if the hospital wants to participate in government healthcare programs such as Medicare and Medicaid, and illegal immigrants are no exception (Andrews et al., 2016; “Eligibility for non-citizens in medicaid and CHIP,” 2014; Smith, 2010).
Illegal immigrants receiving healthcare are often unable to be billed, and a section of Medicaid (Emergency Medicaid) was created so that hospitals would not have to lose money caring for patients who would not be paying. This Emergency Medicaid program, as of 2013, was paying around $2 billion per year to hospitals, most of which was going directly to care for illegal immigrants, but also a small amount to homeless and other legal citizens (Galewitz & Kaiser Health News, 2013).
Unfortunately, many hospitals are struggling to recoup lost costs from programs such as EMTALA. Some hospitals are implementing medical repatriation for illegal immigrants as a means of decreasing costs that may not be reimbursed by Emergency Medicaid. From 2006-2012, there have been 800 cases of medical repatriation from various states (Donelson, 2015). Donelson argues that medical repatriation is due to a lack of emergency medical funds for hospitals caring for illegal immigrants, and states that it is a dangerous practice due to the lack of high-quality healthcare in the origin countries.
Pros and Cons
While the ACA does not explicitly provide coverage for illegal immigrants in the U.S., state tax dollars are still going towards their care. Some argue that the ACA is indirectly freeing up tax dollars to be spent on healthcare costs for illegal immigrants (Conover, 2016; Radnofsky, 2016). EMTALA requires treating anyone regardless of legal citizenship or ability to pay in emergent healthcare situations. Emergency Medicaid seems to inadequately cover these costs even at the current level of $2 billion per year. Some believe that this inadequacy in funding is causing medical repatriation and other “dangerous” practices (Donelson, 2015). EMTALA and Emergency Medicaid should be re-examined specifically regarding illegal immigrant patients. Even if deemed legal for this population, the costs are not being fully subsidized, the debt is rising in great part due to increasing Medicaid expenses, and therefore, this solution is not working (De Rugy, 2016).
Medical repatriation is not considered illegal, but some claim it is a dangerous practice simply skirting the law of patient dumping within the U.S., with the notable difference of doing this internationally instead of nationally (Donelson, 2015). Legislatures could examine this practice and come to a consensus on the legality and ensure that patient safety standards are being implemented.
There are many gray areas concerning the care and legality of illegal immigrant patients across various levels of U.S. healthcare, from clinics to hospitals and everywhere in between. Healthcare professionals could benefit from clear guidelines for this population. Partial coverage is provided for emergency healthcare through EMTALA. Primary care is not covered by federal law, but some states have allocated funds for this through Medicaid. In sum, existing legislation on the issue is murky, illegal immigrants have limited healthcare options in the U.S., and there is little consistency from state to state.
Increasing access to healthcare is a noble goal, but it seems improbable to create a viable solution for this population considering the illegality of their citizenship. The logical solution would be to either grant amnesty to current and or future illegal immigrants or to enforce immigration law. With amnesty, current illegal immigrants could gain legitimate and unfettered access to U.S. health insurance programs. On the other hand, securing the border and enforcing immigration law could significantly decrease the illegal immigrant population in the U.S. creating less strain on hospitals and the budget. Numbers USA states that the cost of amnesty could be up to 70 times more expensive than attrition through enforcement at the cheapest level (“Amnesty costs 70 times more than enforcement,” n.d.).
Providing access to government health insurance for illegal immigrants is a hot topic in the U.S. Some argue that it makes financial sense to provide preventative care outside of the expensive environment of the emergency room as you must under EMTALA. Furthermore, those in favor of providing coverage argue that regardless of citizenship or finances, people deserve to be treated with respect and dignity as human beings and therefore deserve healthcare.
On the other hand, an argument can be made that the government providing services of any kind to non-citizens is unfair for those who are legal residents of this country, many of whom are struggling themselves. Their argument is that any funds currently going towards groups of non-citizens could be spent on legal citizens first and that the government has a responsibility to take care of its people above all others.
As far as finances are concerned, EMTALA is being used to provide healthcare to many individuals, including illegal immigrants. This emergent care is extremely expensive. If the overall healthcare costs in the illegal immigrant population could be reduced by providing preventative treatment to patients outside of the hospital environment, it would make sense from a fiscal standpoint. However, such government provided services to non-citizens would likely encourage more illegal immigration, further compounding the problem. By drawing more illegal immigrants to the U.S., you might see a once cost-effective program become even more expensive than the one it had replaced.
One proposed solution is enforcing current immigration laws, which should decrease the illegal immigrant population in the U.S. and lead to a reduction EMTALA and Emergency Medicaid costs. If welfare was no longer extended to non-citizens, then overall illegal immigration rates might subside. Even if it did not, the cost savings by withholding all existing benefits (including healthcare) to illegal immigrants could prove fiscally beneficial to U.S. taxpayers.
It seems the best solution would be to start by choosing a concrete stance on the status of illegal immigrants living in the U.S. Either the U.S. should grant amnesty and allow proper legal access to the U.S. health systems, or immigration law should be enforced. The inevitable limbo state derived from living in a country without legal authority is not a sustainable long-term solution. It is difficult if not impossible to create legitimate legislation for those who are non-citizens. It is my belief that until the U.S. can reach a consensus on this, that the issue of providing healthcare for illegal immigrants in the U.S. will be riddled with perpetual conflict.
Amnesty costs 70 times more than enforcement. (n.d.). Retrieved June 22, 2017, from https://www.numbersusa.org/pages/amnesty-costs-70-times-more-enforcement
Andrews, S., Brown, D., Dee, L. A., Carter, C., Hayes, B., Leonard, J., … Bockius, L. &. (2016). Emergency medicaid for non-qualified immigrants – Medical coverage and services for immigrants emergency medicaid for non-qualified immigrants introduction and general guidelines. National Immigrant Women’s Advocacy Project (NIWAP). Retrieved from http://library.niwap.org/wp-content/uploads/2015/pdf/PB-Man-Ch17.1-EmergencyMedicaid.pdf
Conover, C. (2016). Because Of Obamacare, illegal immigrants get taxpayer-financed care. Retrieved June 11, 2017, from https://www.forbes.com/sites/theapothecary/2016/03/25/because-of-federal-health-law-illegal-immigrants-get-care/#18b584992139
De Rugy, V. (2016). Tax reform alone won’t solve the coming entitlement crisis: Just look at the numbers. Retrieved June 25, 2017, from http://www.nationalreview.com/corner/441205/deficit-growth-medicaid-medicare-social-security-spending-are-cause
Donelson, K. (2015). Medical repatriation: The dangerous intersection of health care law and immigration. Journal of Health Care Law and Policy, 18(347). Retrieved from http://digitalcommons.law.umaryland.edu/jhclp
Eligibility for non-citizens in medicaid and CHIP. (2014). Centers for Medicare & Medicaid Services. Retrieved from https://www.medicaid.gov/medicaid/outreach-and-enrollment/downloads/overview-of-eligibility-for-non-citizens-in-medicaid-and-chip.pdf
Galewitz, P., & Kaiser Health News. (2013). How undocumented immigrants sometimes receive medicaid treatment. Retrieved May 13, 2017, from http://www.pbs.org/newshour/rundown/how-undocumented-immigrants-sometimes-receive-medicaid-treatment/
Radnofsky, L. (2016). Illegal immigrants get public health care, despite federal policy. The Wallstreet Journal, 1–5. Retrieved from http://www.wsj.com/articles/illegal-immigrants-get-public-health-care-despite-federal-policy-1458850082
Smith, J. M. (2010). Screen, stabilize, and ship: EMTALA, U.S. hospitals, and undocumented immigrants (international patient dumping). Houston Journal of Health Law & Policy, 309–358. Retrieved from https://www.law.uh.edu/hjhlp/volumes/Vol_10_2/Smith.pdf