Coverage of undocumented immigrants
Santa Clara University student Lucas Hill was a 2016 Honzel Fellow at the Markkula Center for Applied Ethics. Views are his own.
Introduction
In 2014, my family enrolled in health insurance through Covered California after the implementation of the Patient Protection and Affordable Care Act. Health care costs had been a consistent financial stressor for my self-employed parents, and the Affordable Care Act improved my family’s health care costs, quality, and access. I was relieved for my parents and felt more dignified and respected at medical appointments. I am very grateful for the benefit it had for my family and so many more families and individuals. The Affordable Care Act is the greatest improvement to United States health care policy since the creation of Medicare and Medicaid in the 1960s. After the ACA, the percentage of uninsured people in the United States decreased from 17 percent in 2013 to 11 percent in 2015[1] and the uninsured rate in California decreased from 16 percent in 2013 to 9 percent in 2015[2].
However, the Affordable Care Act also revealed to me the morally reprehensible exclusion of undocumented immigrants from affordable health care coverage for in the United States. The health insurance marketplace created under the Affordable Care Act as well as full-scope Medi-Cal specifically exclude patients based on immigration status. Unfortunately, approximately 2.5 million people living in California are excluded from access to the ACA’s health care coverage reforms because they are undocumented immigrants.
Excluding any Californians from affordable health care coverage is unethical public policy because the inherent dignity of every human makes all people equally deserving of basic opportunities in life, regardless of immigration status. Illegal immigration status does not deny an individual’s human dignity. Though California provides emergency service regardless of citizenship or ability to pay, emergency services are a basic moral duty of California’s community to all residents or visitors. To me, it is clear that all people living in California need affordable and quality health care to have an opportunity to live with basic physical and financial health.
Current Status of Health Care Access for Undocumented Immigrants in California
Though private companies do not directly exclude Californians from health insurance coverage based on immigration status, private health insurance is expensive and most undocumented immigrants have low incomes. As a result, about 60 percent to 70 percent of undocumented immigrants in California are estimated to lack health insurance, or about 1.4 million people[3]. California’s safety net health system has provided a patchwork of health care coverage across the state that leaves undocumented immigrants vulnerable to physical pain and financial hardship.
Generally speaking, undocumented immigrants in California receive health care at the emergency room of hospitals and at community health centers, typically federally qualified health centers (FQHC)[4]. California began providing guaranteed emergency services to undocumented immigrants at virtually all hospitals in 1985 when the United States Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA), requiring all hospitals that receive Medicare reimbursements to provide appropriate emergency examinations and treatment for all individuals regardless of citizenship, legal status, or ability to pay.[5] In California, Restricted Medi-Cal covers emergency care, pregnancy services, and end stage renal disease care. Though emergency care is essential, in my view, the basic human right to health care obligates the United States to provide health care services that are comprehensive and affordable, which is a much greater obligation than outlined in EMTALA.
In addition to emergency care, approximately 150 federally qualified health centers (FQHCs) throughout California provide comprehensive health services to uninsured patients at a discounted rate or through federal, state, county, or city government funded programs for low-income patients regardless of citizenship[6]. At FQHCs, undocumented immigrants without health insurance can receive non-emergent health care services either in exchange for fees that are reduced based on the patient’s income relative to the FPL.
At FQHCs, undocumented immigrants are sometimes eligible for episodic programs. The programs are designed for specific sub-populations of low-income uninsured patients, regardless of citizenship: children, young adults planning a family, and patients with breast cancer [7]. All low-income undocumented immigrants are eligible for family planning services through the Family Planning, Access, Care, and Treatment (Family PACT) program and long term care after a hospital admission through Medi-Cal.[8] Episodic programs for undocumented youth ages 0 to 21 include the Childhood Health and Disability Program (CHDP), a preventive program that provides periodic screenings and services, and California Children’s Services (CCS), a diagnostic and treatment program for youth with serious medical conditions such as cancer or heart disease.[9] Episodic programs for undocumented immigrant women include Access for Infants and Mothers (AIM) and Medi-Cal prenatal care, programs for expecting mothers with middle and low incomes, and the Breast and Cervical Cancer Treatment Program.[10]
Additional health coverage for non-emergency services for undocumented immigrants varies by county in California. Counties are required by state law to pay for the health care of their Medically Indigent Adults (MIA), the poorest residents of the county who are not covered through Medi-Cal or any other form of coverage[11]. Before 2015, eight counties in California, including Santa Clara County, provided some form of coverage options for non-emergency services to low-income patients regardless of immigration status.[12] In 2015, thirty-nine counties elected to remove the citizenship requirement for their MIA health care plan eligibility, including three counties, Sacramento, Yolo, and Contra Costa that had restricted undocumented immigrants from access to their health plans in 2009 amidst the economic recession.[13] However, as of 2015, ten counties continued to restrict undocumented immigrants from their county’s MIA health plan, excluding approximately 900,000 low-income undocumented immigrants.[14]
For the first time in state history starting May 1, 2016, children ages 0 to 19 living in California with a family income of 138 percent the Federal Poverty Line became eligible for full-scope Medi-Cal insurance regardless of citizenship or immigration status.[15] Previously, the only undocumented immigrants eligible for full-scope Medi-Cal were low-income undocumented immigrants with Deferred Action for Childhood Arrivals (DACA), and as of 2015, some 195,000 DACA recipients had enrolled in Medi-Cal. California’s decision to expand full-scope Medi-Cal is expected to serve around 170,000 children in 2016 and to cost $132 million annually.
California’s Ethical Duty to All Californians
The inherent human dignity of all people is generally considered the fundamental reason for providing health care to any patient. From a secular point of view, human dignity is an individual or group’s sense of self-respect and self-worth, physical and psychological integrity, and empowerment. For many Californians of Protestant Christian or Catholic faith, human dignity originates from God, who created mankind in His image, and human dignity serves as the foundation of morality. From either view, human dignity is inherent to every human being and inalienable. According to Canada’s charter of rights and freedoms, human dignity is harmed by unfair treatment premised upon personal traits or circumstances which do not relate to individual needs, capacities, or merits. Thus, arguments for the exclusion of undocumented immigrants from equal access to affordable health insurance must either deny the existence or permanence of human dignity or insist that immigration status is a relevant factor to treat people differently for health insurance eligibility.
Furthermore, illegal immigration status is not a relevant factor for denying an individual affordable health insurance because, regardless of immigration status, undocumented immigrants are humans just like everyone else. Collectively in California, there are about 2.5 million undocumented immigrants. Immigrants, legal or otherwise, live in every county in California and are humans that are a part of California’s communities. Undocumented immigrants are about 6 percent of the total workforce of California and contributed $3.17 billion dollars to California’s tax revenue in 2015.[16] Throughout the country, undocumented immigrants contributed an $11.6 billion to the United States’ tax revenue.
Excluding undocumented immigrants from affordable health care ignores the reality that all Californians’ health and health care are interconnected. Contrary to the Affordable Care Act, I believe that an individual’s illegal immigration status does not nullify the shared responsibility of all Californians, as well as the state’s public and private sectors, to improve the state’s health care access, quality, and cost. Despite the common misconception that increasing access to affordable health insurance will increase the rates of illegal immigration to California, research has found that undocumented immigrants are usually motivated to immigrate to the United States for employment opportunities, education, and to unify their family[17].
Furthermore, undocumented immigrants have a right to affordable health care because all people should be equally entitled to the opportunity for a basic quality of life, and access to modern health care is essential to ensuring an opportunity for quality life to all Californians. The philosopher John Rawls aptly stated his argument that health care is a human right: “Everyone is entitled to an equal chance to obtain the basic goods of society, though there is no guarantee of an equal share of them. Health care preserves for us the range of opportunities we would have, were we not ill or disabled, given our talents and skills.” As Rawls concedes, health care coverage alone cannot bring about equal health outcomes among us, but people who are excluded from basic health care have an increased likelihood of living with disability or disease that was otherwise preventable.
The exclusion of undocumented immigrants and others from affordable health care substantially diminishes low income people’s opportunity to live with quality physical health and economic security. For example, consider the story of Sergio Ortega, a construction worker in Los Angeles who lived unaware of his diabetic condition for several years because he was uninsured and could not afford to see a doctor regularly[18]. As his diabetes progressed untreated, he physically could no longer work construction and eventually his left leg was amputated.
Without access to affordable health care, many Californians like Mr. Ortega will continue to face increased risk of developing an otherwise preventable diseases or disability and economic disenfranchisement.
Expanding Affordable Health Care for Undocumented Immigrants in California is Good, Ethically and Fiscally
California is providing greater access to affordable health insurance to undocumented immigrants because evidence suggests it may be more financially sustainable than the existing systems of “charity” care.[19] By permitting undocumented immigrants access to subsidized health insurance, California can reduce hospitals’ uncompensated care costs and improve patient outcomes. Current policies use taxpayer funds to subsidize charity care costs, which are health care services provided to patients at a rate below the cost of the service. Since patients who utilize charity care are uninsured, charity care expenses often occur when patients have become seriously ill and require more expensive health care than if they had full access to health insurance coverage throughout their lives [20]. DSH payments are provided to hospitals whose patient total includes 1 percent Medicaid patients or 25 percent low income patients.
While California non-profit hospitals receive tremendous subsidies and tax exemptions for providing charity care, hospitals are not required provide any particular level of charity care to the community by the IRS. By limiting about 50 percent of the 2.5 million undocumented immigrants to charity care from California’s safety net health system, the taxpayers’ money will continue to be used for allotments to non-profits for charity care, through county governments’ medically indigent programs, restricted Medi-Cal, and Disproportionate Share Hospital payments. Thus, taxpayers’ funds may be used more efficiently by expanding access to affordable health insurance and preventing serious and costly health consequences in the future rather than excluding undocumented immigrants from health insurance.
Research suggests that increasing health insurance rates is generally more financially sustainable and better for public health than excluding patients from health insurance. Hospitals as Insurers of Last Resort, a 2015 study of American Health Association hospital financial data from 1984 through 2011, found that hospitals pay $900 more in uncompensated care for each additional person without health insurance.[21] Another study, the Oregon Medicaid Experiment, found that from 2008 to 2010, compared to patients who did not receive Medicaid coverage, patients who received Medicaid coverage were significantly less depressed and catastrophic financial hardships were nearly eliminated,[22]. In addition to preventing death and raising quality of life, Medicaid makes measurable financial sense as an investment in children in California. According to a study entitled Medicaid as an Investment in Children, the government can expect to recoup $0.56 of every $1 spent on childhood Medicaid by the time the beneficiaries are 60 years old.
Altogether, the research suggests that providing affordable health insurance to all Californians, regardless of citizenship status, could provide better health at lower costs. Providing all Californians with affordable health insurance would reduce uncompensated care costs for hospitals, while also improving patients’ physical health and protecting more people from financial catastrophe. Jane Garcia, CEO of community health centers, La Clinica de la Raza, suggested that restrictive health insurance policies are less cost-effective than policies that include undocumented immigrants. Regarding Contra Costa County’s decision in 2015 to include undocumented immigrants in its health plan for the medically indigent, Contra Costa Cares, Garcia argued that “Providing health care coverage to all is not only about the human morality issue that we should address, but also from a cost effective point of view … this is absolutely the right thing.”[23]
Although California’s investment in full-scope Medi-Cal for undocumented immigrant children may be modest, it is an important step towards aligning morality and fiscal responsibility in California. The collective community of California must acknowledge that for-profit, shareholder driven business practice is inappropriate in basic health care. All Californians have a right to affordable health care, so California has a duty to provide affordable health care coverage to all through a publically financed health care insurance program. If California’s people, businesses, and government have the fortitude to invest in the health and quality of life for all residents of California, it could set a global precedent that government policies that are inclusive towards immigrants and refugees are both ethically and financially superior to policies that are exclusionary.
[1] “Key Facts About the Uninsured Population.” Kaiser Family Foundation. http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/
2 “California’s Uninsured.” California Health Care Foundation http://www.chcf.org/publications/2016/12/californias-uninsured
[3] Gallup. February 2015. http://www.gallup.com/poll/181664/arkansas-kentucky-improvement-uninsured-rates.aspx?utm_source=tagrss&utm_medium=rss&utm_campaign=syndication
[4] Human Resources and Services Administration
[5] Warthaite et al. 2015
[6] Health Resources and Services Administration
[7] Ibid.
[8] “Major Benefit Programs Available to Immigrants in California.” National Immigration Immigration Law Center. November 2014.
[9] Ibid.
[10] Ibid
[11] Ibid.
[12] Ibid.
[13] Ibid.
[14] Ibid.
[15] “Governor’s Budget Summary 2015-2016.” California Health and Human Services.
[16] “Undocumented Immigrants’ State and Local Tax Contributions.” Lisa Christensen Gee, Matthew Gardner, and Meg Wiehe. Institute for Taxation and Economic Policy (ITEP). February 2016.
[17] Berk, Schur, Chavez, and Frankel. “Health Care Use Among Latino Undocumented Immigrants.” Health Affairs. Vol 19.4. July/August 2000.
[18] “Immigrants, the Poor and Minorities Gain Sharply Under the Affordable Care Act.” Sabrina Tavernise, Robert Gebelhoff. April 17, 2016. http://www.nytimes.com/2016/04/18/health/immigrants-the-poor-and-minorities-gain-sharply-under-health-act.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=second-column-region®ion=top-news&WT.nav=top-news
[19] “Hospitals as the Insurers of Last Resort.” Garthwaite et al. 2015.
[20] http://www.nytimes.com/2016/04/18/health/immigrants-the-poor-and-minorities-gain-sharply-under-health-act.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=second-column-region®ion=top-news&WT.nav=top-news
[21] “Hospitals as Insurers of Last Resort.” Garthwaite et al. 2015.
[22] Oregon Medicaid Experiment 2010
[23] Romero Farida Jhabvala.“Contra Costa Restores Health Care for Undocumented Adults.” KQED News. September, 2015.