Will Aspiring U.S. Citizens Be Caught in Healthcare Limbo

Will Aspiring U.S. Citizens Be Caught in Healthcare Limbo

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PHOENIX, Ariz.--Teresa Ramirez learned to live with the pain of ovarian cysts after she was diagnosed a year ago. As an undocumented immigrant, she doesn’t qualify for Medicaid, which would cover an operation, and she can’t afford private insurance.

“I’m waiting for immigration reform so I can go to Mexico to have an operation,” said
Ramirez, who is 45.

Undocumented immigrants like Ramirez make up one in seven medically uninsured people in the United States. And they are excluded from the Affordable Care Act (ACA) that will take effect in 2014, expanding Medicaid and offering tax credits to help people buy insurance.

Although comprehensive immigration reform could create a path to citizenship for 11 million undocumented immigrants, the current framework would keep Ramirez from ACA for 10 to 15 years, until she becomes a legal permanent resident. They would form a new category of residents--authorized to be in the U.S., but denied treatment coverage unless they could pay out of pocket.

Denying Care Could Be Costlier

The political argument to exclude this new category of aspiring citizens from ACA is framed in economic terms, but health care advocates argue that the long-term impact of leaving a segment of the population in health care limbo would be costlier.

A recent report from the Migration Policy Institute (MPI) says that by keeping this new category of immigrants –in many instances low-income- from accessing affordable healthcare, would shift the costs of their care to localities and states.

States with the largest unauthorized population will face the bigger challenges, once these immigrants gain legal status but are excluded from ACA. MPI’s report, just published in the prestigious journal, Health Affairs, identifies California, Texas, Florida, Arizona and Georgia.

“The states and localities will continue to pay a high share of the uninsured cost,” said Randy Capps, senior policy analyst at MPI and one of the authors of the study.

He explained that in this case, a new group of U.S.-approved immigrants would join the ranks of the uninsured in states that already have mandates to provide services to authorized immigrants.

“It will be particularly harder for those states, which in the past have been extending health benefits to immigrants, to look the other way,” Capps said.

Another challenge for localities, Capps said, would be that federal reimbursement for hospitals caring for the uninsured is expected to decrease after ACA is implemented, although health care reforms will increase funds for community health centers and clinics that provide primary health care.

Those changes would not answer the needs of Ramirez and her mixed-status family.
Her husband, for example, has checkups for his diabetes at a local charity clinic that provides free services. But he recently had to be hospitalized for two days, and the family is struggling to pay over $5,000 in bills.

The challenges Ramirez and her family face are no different than what uninsured, low-income U.S. citizens experience, but they are compounded by fear of seeking help.

The state provides Medicaid coverage to two of Ramirez’s grandchildren because they were born in the U.S., but Arizona won’t cover the other children because their father, an undocumented immigrant, makes slightly more than the earnings limit to qualify.

“He makes $40 more than you’re supposed to,” said Leticia Ramirez, whose husband brings home $500 a week. The threshold for a family that size is $1,963. (Amounts differ by state.)

National Advocates for Health Access

“The largest question is why are we keeping people from participating in a system that is fundamental to the American infrastructure in which we ultimately want them to be participating,” said Jen Ng’andu, director of health and civil rights policy for the National Council of La Raza (NCLR).

NCLR and other groups are pushing for any immigration reform package to include a way for the aspiring citizens to obtain affordable insurance by at least being able to receive tax credits for purchasing it in the market place, such as the subsidy under ACA.

Currently, not all immigrants-- even permanent legal residents -- have immediate access to all the components of ACA. Green card holders or legal permanent residents get some benefits but have to wait five years to participate of Medicaid.

Creating roadblocks to health care for a segment of the population has an overall impact on everyone’s access, said Sonal Ambegaokar, a health policy attorney at the National Immigration Law Center (NILC).

“If you don’t give them any options for affordable insurance then they have to wait until they get very sick. We’re not saving any money by excluding them now,” Ambegaokar said. “The question is what is the most efficient way to make sure people don’t get sick and we don’t pay unnecessary expenses.”

Whether the status quo changes or not, some local groups in Arizona are preparing to ramp up their primary health care services to fill the current void for undocumented immigrants, who are often fearful about seek affordable treatment.

Phoenix Allies for Community Health (PACH) has been functioning for two years as a mobile service with volunteer doctors and nurses taking house calls for undocumented families and organizing health fairs.

The group’s vice president, Jason Odhner, who is cofounding a health clinic in the heart of an immigrant neighborhood in Phoenix, has seen the value of offering people preventive care. He has also seen the worse case scenario.

Odhner remembered an undocumented man who couldn’t afford the care for his diabetes and eventually had a leg amputated.

“Regardless of what happens with immigration reform, we need to provide basic care,” said Odhner, who is also a registered nurse.

An advantage to having more immigrants become authorized U.S. residents is that more would be considered for jobs offering health insurance or enabling them to afford coverage. “If we had a better-paying job, you’ll pay for your own insurance,” said Ramirez.

On the other hand, undocumented immigrants who now have insurance may loose it, said Capps. That is because under ACA small employers won’t be mandated to provide health insurance so they might decide to drop it or give people a stipend to help them buy it privately.

Politics vs. Public Opinion

The frameworks of both President Obama’s and Congress’ so-called Gang of Eight (the bipartisan group negotiating a reform plan) exclude this new category of immigrants from ACA. That is consistent with the administration’s directive to exclude deferred action recipients from it as well, although if reform passes this group of young people may get on a fast track towards citizenship.

Although debate in Washington is apt to be contentious in the coming months, the issue might not be as polarized among the public. Opinion polls have shown support from Americans towards including a new category of provisional immigrants into ACA.

In a poll released this February by the Kaiser Family Foundation, 63 percent of respondents said they would support ACA coverage for provisional immigrants whose income is low enough to qualify for Medicaid.

If things don’t change, for immigrants like Ramirez, the choice maybe to continue to rely on the safety net of free clinics, emergency rooms and charities in Arizona, with the advantage of accessing less expensive care on the other side of the border.

“I think that if they’re going to do a legalization they should legalize healthcare too,” Ramirez said.