Healthcare Propsal: Are Immigrants Left

Healthcare Propsal: Are Immigrants Left Behind?

The Healthcare Proposal: History and Background

One of the platforms upon which Illinois Democratic Senator Barak Obama campaigned for election in the 2008 presidential race was healthcare reform. Obama promised Americans that if he were elected president, all Americans would have access to affordable healthcare. After he was successfully elected president by an overwhelming voter turnout and margin, Obama reiterated his promise in numerous town-hall meetings around the country to provide all Americans health coverage. Contrary to his campaign trail speeches and promises about healthcare, Obama and his supporters of a national healthcare plan were assailed with questions, and they came face-to-face with angry Americans who were suspicious of Obama's plan and who held that, like the financial bailouts, the Cash for Clunkers program, a national healthcare plan would be poorly managed by the government and quickly become a well intended albatross for future generations of Americans to contend with.

One of the issues with which opponents fanned the flames of public mistrust over the plan was the extent to which the proposal would cover immigrants. The mistrust, especially over the question of coverage for immigrants, only demonstrated how little Americans understand healthcare coverage and the administration of benefit plans by third party payers (TPAs), group coverage, under which most insured Americans are covered for healthcare, as well as their lack of understanding of Medicaid, and Medicare benefits. This is especially true as it pertains to illegal immigrants.

This brief essay is an exploration of the healthcare proposal as it appears in the Senate Finance Committee proposal titled America's Healthy Future Act of 2009; the Senate HELP Committee Affordable Health Choices Act (S.1679); and the House Tri-Committee America's Affordable Health Choices Act of 2009 (H.R. 32). The focus of this essay is narrow, examining only those parts of the proposal that address legal and illegal immigrants, because that focus is one of the prevalent issues concerning Americans about the legislation, and is one that has divided Americans on a plan that is very much in the best interest of all Americans.

Uninsured Americans, Legal and Illegal Immigrants

Figures representing the population of Americans who do not have health insurance coverage as ranging from thirty to forty to fifty million lives. The Centers for Disease Control (CDC) estimated that in 2006, 14.8% of Americans, or 46.3 million people did not have healthcare coverage that would ensure them access to medical care that would help them to pursue the highest quality of life as could be afforded them in our present high tech medical and pharmaceutical care industries (CDC, 2009, online). "Almost a third (32.1%) of Hispanic people were uninsured when interviewed in 2006 (CDC, online)." This segment of the population is one of great importance to opponents of Obama's proposed healthcare plan, because many Americans think of illegal immigrants as being comprised largely of Hispanic people who cross the southern borders of the United States without documentation or valid passports or visas. Yet each of the three version of healthcare plans arising out of the previously cited three House and Senate committees, and as emphasized by President Obama while campaigning and in post presidential election town hall meetings, has emphasized with clear language that the coverage will be limited to U.S. citizens and to legal immigrants (persons possessing legal documents of stay in the United States). The Senate Finance Committee proposal titled America's Healthy Future Act of 2009 language reads:

"Limit the availability of premium credits through the Gateway to U.S. citizens and lawfully residing immigrants who meet income limits and are not eligible for employer-based coverage that meets minimum qualifying requirements criteria and affordability standards, Medicare, Medicaid, Tricare, or the Federal Employee Benefits Program. Individuals with access to employer-based coverage are eligible for premium credits if the cost of the employee premium exceeds 12.5% of the individual's income (Focus on Health Reform, 2009, found online)."

The House Tri-Committee America's Affordable Health Choices Act of 2009 (H.R. 32) language concerning reads exactly the same as does the above cited Senate Finance Committee proposal titled America's Healthy Future Act of 2009, and the House Tri-Committee America's Affordable Health Choices Act of 2009 (H.R. 32) differs in language, and meaning, reading:

"Limit availability of premium and cost-sharing credits to U.S. citizens and lawfully residing immigrants who meet the income limits and are not enrolled in qualified or grandfathered employer or individual coverage, Medicare, Medicaid (except those eligible to enroll in the Exchange), Tricare, or VA (with some exceptions). Individuals with access to employer-based are eligible for the premium and cost-sharing credits if the cost of the employee premium exceeds 11% the individual's income (E&C Committee amendment: To be eligible for the premium and cost-sharing credits, the cost of the employee premium must be exceed 12% of the individual's income) (Focus on Health Reform, 2009, found online)."

We can see right away, of course, that there is a loophole in the House Tri-Committee America's Affordable Health Choices Act of 2009 (H.R. 32), because the language reading "with some exceptions," leaves open to those not previously mentioned as "U.S. citizens and lawfully residing immigrants who meet the income limits," to mean not U.S. citizens and not lawfully residing immigrants, or those who are residing in the United States illegally. This loophole, so-to-speak, is what is fueling the controversy and is creating the hostility amongst opponents of the legislation who equate the illegal immigrant population with that of the one third uninsured Hispanic population cited by the CDC.

While the opponents of the legislation are correct in identifying a loophole in the legislation, they are perhaps short-sighted in that they do not understand the nature of the relationship between the United States and those countries south of its border, especially Mexico from a healthcare perspective. The opponents hold a utilitarianism view of healthcare, focusing on the greatest good principle and cost-benefit ratio. While proponents of the plan perceive it from a communitarianism perspective, holding that common good principle and the re-emergence of virtue principle outweigh the cost-benefit ratio that could ostensibly increase the taxpayer debt for decades to come, and could essentially bankrupt the American economy.

The Truth is In Between

What we have here are two different ideologies, neither of which is well informed on healthcare administration and delivery in America. While both groups focus on population segments, neither takes into consideration the business component of the American healthcare delivery system that is called managed care. While Obama has said that under his plan -- call it a national plan or public option -- no American shall be deprived of access to care and services because of financial considerations or because of pre-existing conditions, he has been consistent in his referencing of managed care components as an element of his proposed legislation.

Arnold Birenbaum (1997) explains managed care as a purely economic approach to healthcare based on cost and savings. Birenbaum says:

"Managed care defies our common-sense understanding of value in the world of work and in the area of health care . . . Managed care is driven by a cost and oversupply of physicians, making it possible to persuade some, at least, to work within a cost-conscious environment. In addition, an oversupply of hospital beds encouraged HMO (health maintenance organizations) to contract with hospitals and thereby avoid investment in hospital construction, making it less expensive to get off and running as a service provider since there was no wait for to be built or for loans to be acquired (p. 13, p. 31)."

All of this, however, caught up with the healthcare delivery as managed care organizations and preferred provider organizations (PPOs) contracted and eliminated competition among healthcare service providers. As the providers contracted for guaranteed numbers of insured lives, the incentive to compete by delivering new and innovative healthcare technology services and by providing quality care in clean and safe environments eroded. Additionally, the contracted services had limits on reimbursements, and while payments for services to providers increased minimally, the co-insurance (patient shares) and deductibles (patient shares) increased rapidly. Also, the rules governing access to care through the managed care entity as the gatekeeper reviewing need and authorizing care, has continued to erode access to care and quality of care. People began finding it more difficult to access services and care, while at the same time if access to care was not granted, and the providers of care had no reimbursement even for the contracted lives. This, in brief, has caused the healthcare system to deteriorate, as the costs of healthcare by way of patient shares have skyrocketed, causing the current chaos and crisis in healthcare that is the basis for the Obama proposal for reform.

Obama, however, certainly understands the managed care component in healthcare delivery, because while he assures Americans that they will have access to care and services without regard for pre-existing conditions, there remains the managed care component in his plan which will oversee and regulate access to the care and services, denying care, as it has done since its inception, based on opposing medical views and interpretation of data between the managed care provider and the physicians ordering the care and services. Unless the physicians can succinctly argue their case for care and services, the managed care entity will, for reasons of medical necessity, deny access to care and services.

What Cost-Added Ratio Based on Illegal Immigrant Population?

The argument by opponents that loopholes exist that would allow illegal immigrants to access Obama's proposed legislation on healthcare services is rendered moot in lieu of the fact that those illegal immigrants are currently receiving healthcare services Medicaid and through Immigration and Naturalization Services (INS). The Federal Reimbursement of Emergency Health Services Furnished to Undocumented Aliens states:

"Section 1011 of the (Medicare Prescription Drug, Improvement, and Modernization Act (MMA) (P.L. 108-173)) MMA appropriated $250 million dollars in FY 2005 through 2008 for payments to eligible providers for emergency health services provided to undocumented aliens and other non-specified citizens who are not eligible for Medicaid (Centers for Medicare and Medicaid Services, 2009, found online, p. 68)."

The Federal Government has long reimbursed providers for emergency services to undocumented (illegal) aliens. Opponents are not looking to the past costs of providing that care, but to the future cost of it, and it is not the cost of services to undocumented workers that would increase the cost to taxpayers, because they have been paying that cost for decades; but is the cost of U.S. citizens and legal immigrants whose incomes, in conjunction with the rising costs of managed care business practices resulting in increased patient shares, have made access to affordable healthcare premiums privately or through employer-based plans unaffordable to them. Here, we have demonstrated that the segment of the population that would benefit from this plan is not the undocumented illegal alien in the Hispanic segment of the CDC uninsured segment previously cited, but the legal U.S. citizen and immigrant or resident.

Why We Should Provide Healthcare to Undocumented Persons

When we consider the proximity of Mexico to the United States, indeed, Mexico and Latin America; we should have a strong and proactive interest in maintaining the health of those individuals in the southern continent, and especially those who cross the border into the United States illegally. The recent Swine Flu outbreak should serve to help reinforce that rationale. Infectious diseases are contagious, and if we do not take steps to treat to cure illegal aliens entering the country, and deport them with contagious diseases like tuberculosis and HIV / AIDS, then the risk of transferring those infectious diseases, and a plethora of other infectious diseases, to Americans increases with each case we deport to Mexico and Latin America without treating. This is especially true in the case of tuberculosis, a disease which can alter itself to immunity to known cures. To withhold or deny treatment and medical care to illegal aliens is putting at risk each and every person that comes into contact with that person. Also, sending them back to their country of origin without follow-up care means that likelihood that they will seek or receive proper care to resolve the disease once returned is increased, and the disease will mitigate any treatment medications used to combat it without follow-up to cure, potentially creating a new and untreatable virus or disease.

The estimated cost, according to a Center for American Progress report by Rajeev Goyle and David A. Jaeger, PhD (2005) estimated the cost to deport back to their country of origin all illegal aliens, some 10,000,000 people, to be approximately 206 billion dollars over five years (p. 3). This solution is not feasible for numerous reasons. First, the nature of immigration law would prevent the immediate deportation of the illegals, and the estimated 206 billion dollars would probably increase exponentially with the cost of immigration court, legal, and other costs. Add to this cost, too, the cost of Border Patrol, which Goyle and Jaeger estimate would be 14.95 billion over a five-year period to find and arrest the 10,000,000 illegal aliens (p. 11). Consider, too, that many deportees have been found to reenter the United States after having been deported, and we then can see the vicious cycle this idea presents. Providing healthcare services to the undocumented persons, especially those who work and would be in the income levels where they would contribute to the cost of the premiums for coverage, could ostensibly decrease the cost of healthcare the United States is currently paying for undocumented persons. The cost over a five-year period would certainly be less to provide healthcare coverage to those undocumented people than would be the cost associated with searching them out, arresting, putting them through the legal systems, and subsequently deporting them.

Is Obama's Plan Ready for Implementation?

The answer to whether or not Obama's plan is ready for implementation, or whether or not it requires additional work, is yes to both questions. The solution, however, is not to delay, but to implement the plan so that the real and working components of the plan can be identified through utilization, and then addressed legislatively. Especially as it concerns the uninsured, including undocumented illegals, the plan should be implemented as soon as possible. The plan would reduce the cost of healthcare delivery, because the uninsured would have access to physicians as primary care sources, instead of emergency rooms, where the cost for non-emergency conditions is dramatically higher than the cost of a physician's office visit.