JAMA Forum: Is Affording Undocumented Immigrants Health Coverage a Radical Proposal?

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During the Democratic presidential debate on July 31, all 10 candidates raised their hands when asked if they would provide health insurance to undocumented immigrants. Among all Democratic ideas for health reform, this is least popular. A recent poll found that only 38% of respondents approve. The idea drew extensive criticism, which is understandable: Why should the United States provide health coverage for people who don’t have a legal right to be here? Extending coverage could be seen as rewarding individuals who have violated the law.

There are, however, strong reasons to afford health coverage for this population: modest economic costs, safeguarding the public’s health by curbing the spread of infectious diseases, and complying with international law that requires health coverage for migrants. Many countries fail to afford migrants equitable access to health coverage, so adopting a policy of providing undocumented immigrants on par with other residents—integrated into existing federal health insurance programs—would help the United States regain moral leadership, in line with World Health Organization (WHO) and United Nations (UN) guidelines, and potentially save money (discussed below).

Current Health Care for Undocumented Immigrants
The more than 10 million undocumented immigrants in the United States are systematically excluded from federal health insurance programs: Medicaid, Medicare, the Affordable Care Act (ACA) marketplaces, and the Children’s Health Insurance Program (CHIP). Lawful immigrants can participate in these programs, with limitations, which vary by program. For example, many immigrants who arrived after August 1996 must wait 5 years before qualifying for Medicaid. If courts do not block the Trump administration’s new regulation on US immigration law’s long-standing provision requiring most immigrants to demonstrate that they will not be a “public charge,” more than very limited participation in Medicaid (excluding immigrants younger than 21 years old and pregnant women) and several other safety net programs will count against immigrants seeking to obtain permanent residency status. This will likely deter huge numbers from obtaining benefits to which they are legally entitled.

Refugees are generally eligible for Medicaid but only for the first 7 years of residence. Asylum seekers qualify for ACA exchanges starting 180 days after applying for asylum. Several states extend Medicaid and CHIP to lawfully present children and pregnant women without the 5-year wait. Currently, Medicaid payments for emergency services are the only federal funds allowed for undocumented immigrants; federal law requires hospitals to stabilize patients with life-threatening conditions, irrespective of immigration status.

Consequently, almost half of undocumented nonelderly adults and one-third of undocumented children are uninsured. For basic medical care, immigrants often turn to 1400 federally funded health care centers providing services on a sliding-scale based on ability to pay, irrespective of residency status.

Several states and localities have tried to fill the coverage gap. Sixteen states provide prenatal care to women through CHIP, regardless of immigration status. Six states and Washington, DC,  use state funds to expand Medicaid to cover children up to age 18 years. This year, New York City offered undocumented immigrants access to health care through a new $100 million program. Among all states, California stands out. Since 2015, California counties like Los Angeles have expanded coverage at local clinics, and the state expanded Medicaid eligibility to individuals protected by the Deferred Action for Childhood Arrivals (DACA) program and their families. Recently, California expanded coverage to 90 000 undocumented income-eligible young adults through the age of 25 years.

Many countries mirror the United States in its sporadic coverage of undocumented immigrants. For example, despite its universal health system, Norway ensures care for undocumented immigrants only for emergencies, pregnant women, and children. Some European countries are more progressive, offering near-equal coverage for undocumented persons and citizens. Thailand has among the best coverage, affording undocumented immigrants comprehensive coverage.

Equitable Coverage Has Modest Costs
Equitable coverage for undocumented immigrants makes financial sense. The federal government already covers urgent care, which is very expensive. The Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to stabilize all low-income individuals with life-threatening conditions, and Emergency Medicaid covers emergency services for immigrants who would otherwise qualify for Medicaid but for their immigration status. Thus, undocumented patients often receive care much later in the course of diseases, as documented in a study of New York City public hospitals. Often, individuals return repeatedly to emergency departments for the same condition. By delaying needed care, undocumented persons face serious, more costly, health conditions in the long term. Shifting toward prevention and early diagnosis and treatment would avoid or reduce costs over time.

Consider, too, children born to undocumented mothers. They are US citizens, entitled to equal coverage. Yet that care will be far more costly if their mothers don’t receive prenatal care. One study found the cost of postnatal and long-term pediatric care can be twice as high if the mother has not received prenatal care. Intensive neonatal services for low-weight or premature neonates are 4 times higher.

Moreover, self-reported and Emergency Medicaid data in California suggest that costs for undocumented immigrants are lower than those of citizens. The California data also suggest that these populations have a relatively lower need for health care because they are younger and healthier than the general population.

Thus, expanding coverage for undocumented immigrants could save costs over all. Also consider that undocumented immigrants pay tens of billions of dollars in taxes, including income and sales taxes, as well as Social Security, Medicare, and workers’ compensation payroll taxes.

Beyond cost, critics of the extending coverage argue that it would incentivize waves of migrants seeking free health care. Yet experience strongly refutes that idea. EMTALA has not led to an influx. California’s inclusion of undocumented children in its Medicaid coverage since 2016 has not increased migration. European countries extending coverage to irregular migrants have not experienced “medical tourism.”

Safeguarding the Public’s Health
Increased access to insurance coverage by the undocumented community has public health benefits, including the potential to curb the spread of infectious diseases like tuberculosis (TB). Rates of TB rates are reportedly 15 times higher among foreign-born versus US-born persons. States with large undocumented populations, such as California, Texas, New York, and Florida, often have the highest TB case counts. With vaccine-preventable diseases like measles rising, it is in everyone’s interests to ensure high vaccination rates among migrants. Driving migrant populations underground also impedes surveillance of key diseases such as TB and sexually transmitted infections, including HIV.

Beyond disease spread, failing to extend coverage may exacerbate antimicrobial resistance if migrants receive only sporadic treatment. Patients with drug-resistant pathogens are harder to treat, often requiring far more expensive antibiotics. Extending affordable access to health care and enabling rapid detection and response of communicable diseases makes everyone safer.

International Legal Obligations
The UN Committee on Economic, Social and Cultural Rights states unequivocally that the right to health guaranteed in the International Covenant on Economic, Social and Cultural Rights requires nondiscrimination against nonnationals, regardless of legal status. The UN High Commissioner affirmed that the right “applies to migrants in an irregular situation.”

Last year’s UN Global Compact for Safe, Orderly and Regular Migration reaffirms the human rights of all migrants, regardless of status, promoting nondiscriminatory access to health services; it was endorsed by all 193 UN members except the United States, the sole holdout. And this past May, the WHO’s Global Action Plan also commits to equitable access of migrants to health coverage. In September 2019, the UN will adopt a political declaration on universal health coverage—something the world will never achieve without equitable inclusion of ever-growing migrant populations.

The United States could reassert global moral leadership by extending health coverage to undocumented immigrants. This would not create special entitlements, only equitable access to existing health insurance programs. It takes courage for political leaders to adopt highly unpopular programs. However, affording equitable access health care would not simply be the most humane course of action. It could save public funds, safeguard the public’s health, and demonstrate respect for international law.

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About the author: Lawrence O. Gostin, JD, is University Professor and Faculty Director, O’Neill Institute for National and Global Health Law, Georgetown University Law Center, and Director of the World Health Organization Collaborating Center on Public Health Law and Human Rights. His most recent book is Global Health Law (Harvard University Press).  (Image: Georgetown University Law Center)

 

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Categories: ACA, Caring for the Uninsured and Underinsured, Health Policy, Medicaid, Public Health, The JAMA Forum

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