Health Care Overhaul Ignores Illegal Immigrants
Protesters hold Spanish and English signs at a rally for universal health care reform - Signs in Spanish and English are seen at a May rally of immigrant and labor communities demanding universal health care reform. (Stan Honda / Getty Images)
As Congress wrangles with overhauling the health care system, there is one population not being discussed. No proposal for a national health plan would cover the nation's estimated 11 million illegal immigrants.
This would seem like a big problem, one that could seriously undermine the cost-savings benefit of a program that aims to be universal, but analysts say the notion that illegal immigrants drain the health system is overblown.
Simply figuring out how many undocumented immigrants lack insurance is not easy. Foreign-born noncitizens are the fastest growing segment of those without insurance about 20 percent of the nation's estimated 46 million uninsured but surveys don't ask legal status. John Sheils of the Lewin Group, a nonpartisan health care consulting firm owned by UnitedHealth Group, has looked at numerous studies to extrapolate a best guess.
(Stan Honda / Getty Images)
"We've estimated about 6.1 million of the uninsured are actually undocumented," Sheils says.
That's only about half the total population of undocumented immigrants. Sheils says many illegal immigrants use false documents to work on the books, with regular tax deductions and benefits.
"A lot of those people are getting employer health benefits as part of their compensation," Sheils says.
(Stan Honda / Getty Images)
A spokesman with America's Health Insurance Plans says it's possible that individual insurance companies could check for legal status, but employer-provided coverage is vetted at the workplace. If a fake ID can get you a job, it can also get your family health insurance.
In fact, Sheils says, this is something lawmakers might want to consider as they craft legislation aiming for near-universal coverage. "If you design a plan improperly, you actually would wind up taking away their insurance, creating new uninsured people," he says.
But what about those illegal immigrants who, today, do not have health insurance? Six million people — others estimate 8 million — is still a sizeable chunk. So how much health care do they use each year?
"The economics aren't as great as they've been made out to be," says Paul Fronstin of the Employee Benefit Research Institute.
Fronstin says illegal immigrants are younger, and so generally healthier, than the overall population, and studies show they go to the doctor far less than the native born. He estimates their total share of the health care system at about 1 or 2 percent, with only a small slice of that paid for in public money.
About $1 billion a year is paid by Emergency Medicaid, a federal program that covers emergency care for patients who would otherwise be eligible for Medicaid but can't prove their legal status. Sheils estimates that an additional $5 billion is uncompensated in any way. He says that's a blip on the national health care system — some two-tenths of 1 percent — but it can hurt when it falls disproportionately on hospitals, say, along the southern U.S. border.
"Some hospitals have had to cut back services to their community at large because they have to absorb the added costs," says Carla Luggiero of the American Hospital Association.
Luggiero has seen more and more hospitals face the burden of caring for illegal immigrants in the past decade. Some have had to raise fees. Others qualify for extra federal subsidies if they have an especially large number of Medicare or Medicaid patients. Luggiero says this can be a way to indirectly cover part of the cost of caring for the undocumented.
"So although those programs do not reimburse for the care of undocumented and uninsured individuals," she says, "collectively we as society do end up bearing that cost."
Luggiero says if Congress does not include illegal immigrants in any health plan, hospitals will look for those federal payments to continue. They would also like lawmakers to revive a separate subsidy that reimbursed hospitals several hundred million dollars for care of the undocumented in recent years but has expired.
Peter Harbage of the Center for American Progress says health care for the undocumented is as much a political question as an economic one. No one wants to subsidize primary care for those with no right to be in the country, says Harbage, yet it is accepted that no one is turned away for emergency care.
"So there's this very interesting tension," he says. "If some of those dollars were used up front, you could have, maybe, a more efficient system. But that's not the conversation that's being had on Capitol Hill."
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RENEE MONTAGNE, host:
Those confirmation hearings come in the same summer as Congress works to overhaul the health care system, although one segment of the population is not being discussed in Congress. There's no proposal to cover the nation's estimated 11 million illegal immigrants. NPR's Jennifer Ludden reports on the political and economic questions involved.
JENNIFER LUDDEN: Of the estimated 46 million uninsured, a good 20 percent are foreign-born, non-citizens. In fact, this has been the fastest growing segment of those without insurance. But figuring out how many in this group are illegal immigrants and what's spent on them is tough.
Mr. JOHN SHEILS (Lewin Group): This is something you have to estimate. Nobody sat down and just tallied this up.
LUDDEN: John Sheils is with the Lewin Group, a nonpartisan healthcare consulting firm. He says surveys about insurance don't ask legal status, but an array of analysts has extrapolated a best guess.
Mr. SHEILS: Well, we've estimated about 6.1 million of the uninsured are actually undocumented.
LUDDEN: That's only about half the total population of undocumented. Sheils says many illegal immigrants use false documents to work on the books, with regular tax deductions and benefits.
Mr. SHEILS: And a lot of those people are getting employer health benefits as part of their compensation.
LUDDEN: A spokesman with America's Health Insurance Plans says it's possible that individual insurance companies could check for legal status, but employer-provided coverage is vetted at the workplace. If a fake ID can get you a job, it can also get your family health insurance.
In fact, Sheils says this is something lawmakers might want to consider as they craft legislation aiming for near-universal coverage.
Mr. SHEILS: If you design a plan improperly, you actually would wind up taking away their insurance, creating new uninsured people.
LUDDEN: But what about those illegal immigrants who today don't have health insurance? Some estimated six million people, others about eight million. That is still a sizeable chunk. How much health care do they use each year?
Mr. PAUL FRONSTIN (Employee Benefit Research Institute): The economics aren't as great as they've been made out to be.
LUDDEN: Paul Fronstin is with the Employee Benefit Research Institute. He says illegal immigrants are younger, and so generally healthier than the overall population. And studies show they go to the doctor far less than the native born. Their share of the healthcare system is miniscule.
Mr. FRONSTIN: We're talking about 1 or 2 percent of what we spend on health care, which, keep in mind, is over $2 trillion now.
LUDDEN: That 1 or 2 percent includes those who are insured, or those who pay out of pocket. A small slice - but still about $1 billion - is paid for by Emergency Medicaid. That's a federal program that covers emergency care for patients who can't prove their legal status.
Analyst John Sheils of the Lewin Group estimates that about $5 billion in care for the undocumented is uncompensated in any way. He says that's a blip on the national healthcare system, some 2/10ths of 1 percent. But it can hurt when it falls disproportionately, say, on hospitals along the southern border.
Ms. CARLA LUGGIERO (American Hospital Association): Some hospitals have had to cut back services to their community at large because they have to absorb the added costs.
LUDDEN: Carla Luggiero is with the American Hospital Association, and she's seen more and more hospitals face the burden of caring for illegal immigrants in the past decade. Some have had to raise fees. Others qualify for extra federal subsidies if they have an especially large number of Medicare or Medicaid patients. Luggiero says this can be a way to indirectly cover part of the cost of caring for the undocumented.
Ms. LUGGIERO: So although those programs do not reimburse for the care of undocumented and uninsured individuals, collectively, we as society do end up bearing that cost.
LUDDEN: Luggiero says if Congress does not include illegal immigrants in any health plan, hospitals will look for those federal payments to continue.
Peter Harbage of the Center for American Progress says health care for the undocumented is as much a political question as an economic one. No one wants to subsidize primary care for those with no right to be in the country, yet it's accepted that emergency care will be provided.
Mr. PETER HARBAGE (Center for American Progress): And so if some of those dollars maybe were used up front, you could have a more efficient system.
LUDDEN: But Harbage says that's not a conversation Congress wants to have right now.
Jennifer Ludden, NPR News, Washington.
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MONTAGNE: This is NPR News. Transcript provided by NPR, Copyright National Public Radio.
