Obama's 2009 healthcare proposal and coverage for immigrants

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.

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.

In his book, Wounded Profession: American Medicine Enters the Age of Managed Care (2002), Arnold Birenbaum says:

"The popular fear of the early Clinton years, that governmental-led reform would restrict the freedom of doctors to make medical decisions and patients to choose their providers, is past. Today, change is driven by the market place. It is most obvious in the widespread indifference among buyers of care to the plight of the uninsured and the embarrassment of providers who can no longer afford to cross-subsidize care for the uninsured. Managers of delivery systems are expected to practice cost-containment, not give away services. Investor ownership of managed care plans has created an environment in which providers are more scrutinized than dimpled ballots in Florida (pp. 37-38)."

What Birenbaum is saying, in short, is that in order for a publicly traded entity to demonstrate growth, it must demonstrate increased profits. In healthcare, the only way to increase profits is to decrease the entity's cost to the medical provider of care under private and employer-based plans. In our system, the only way that can be done is by withholding care, delaying care, thus delaying payments, denying care in those cases where the outcome is inevitable terminal demise of the patient, and by increasing patient shares and deductibles such that, as we now see, they become unaffordable to the members of the plan, and those members drop off, becoming uninsured, or electing not to take coverage at all.

Obama's plan satisfies the communitarianism and the utilitarianism theorists, because it addresses both ideologies. This does not mean that Obama's plan is perfect, but it does mean that it is feasible, and that the arguments targeting undocumented persons is a frail one in lieu of the evidence to suggest that it is not, after all, the undocumented person who is responsible for the increasing cost of healthcare. What has been shown here, too, is that the much touted argument that the market will take care of itself is an argument that no longer is one of substance, because it was the market that brought about the current crisis in healthcare that Obama has pledged to change.

Reference List

Birenbaum, A. (1997). Managed Care: Made in America, Praeger Publishers, Westport,

CT.

Birenbaum, A. (2002). Wounded Profession: American Medicine Enters the Age of Managed Care, Praeger Publishers, Westport, CT.

Centers for Disease Control and Prevention (2009). Uninsured Americans: Newly

Released Health Statistics, CDC Features, found online at http://www.cdc.gov/Features/Uninsured/, retrieved November 15, 2009.

Centers for Medicare and Medicaid (2009). Department of Health and Human Services

Fiscal Year 2010 Budget in Brief, May 7, 2009, found online at http://www.hhs.gov/asrt/ob/docbudget/2010budgetinbrief.pdf, retrieved November 17, 2009.

Focus on Health Reform (2009). Care Reform Proposals, found online at http://www.kff.org/healthreform/upload/healthreform_tri_full.pdf, retrieved November 16, 2009.

Goyle, R. And Jaeger, D. (2005). Deporting the Undocumented: A Cost Assessment,

Center for American Progress, found online at http://www.americanprogress.org/kf/deporting_the_undocumented.pdf, retrieved November 16, 2009.