Posted on 03/15/2004 12:43:32 PM PST by Marine Inspector
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The Sinking Lifeboat: Uncontrolled Immigration and the U.S. Healthcare System
America's health care system is in crisis: Costs and insurance premiums are skyrocketing, the number of the uninsured is rising rapidly, providers are reducing staffing and services and increasing rates, and hospitals are closing or facing bankruptcy.
As states cut their health care budgets to try to make ends meet, high rates of immigration are straining the health care system to the breaking point.
Federal laws requiring hospitals to treat anyone who enters an emergency room regardless of ability to pay have created an unfunded mandate for states and localities to fund health care for non-U.S. citizens and illegal aliens. Yet at the same time, lack of enforcement of federal laws against illegal immigration has led to a pool of nine to eleven million illegal aliens in the U.S.—and state and local taxpayers are being forced to foot the bill. Although immigration law enforcement is a federal responsibility, most hospitals receive little or no reimbursement for the care to immigrants that the federal government mandates that they provide.
The escalating burden incurred by hospitals and other health facilities for the uncompensated treatment of aliens is driven by both rampant illegal immigration and a legal immigration system that allows large numbers of people to gain permanent residence despite the fact that they are unlikely to be working in jobs with health care coverage or have personal resources sufficient to pay for health services.
At the same time that Washington is neglecting to pick up the tab for aliens whom it has failed to prevent from settling here illegally, the problem is exacerbated by state and local policies that grant costly benefits to people who violate immigration law.
Reversing the escalating burden of uncompensated health care for immigrants and illegal aliens will necessitate enforcing laws against illegal immigration; reimbursing states and localities for the costs of failures in federal immigration policy but denying reimbursement to communities that work against federal efforts to combat illegal immigration; identifying foreign users of publicly funded medical treatment (and their immigration status); establishing guarantees of medical bill payment prior to admission to the country; clarifying existing federal emergency service laws regarding the termination of a hospital's obligation for continuing care after the provision of emergency treatment to stabilize the patient.
It will also require a change in public officials' mindset: Instead of shifting the burden to local taxpayers (often to those least able to pay when confronted with rising insurance premiums and medical bills), lawmakers must squarely face the consequences of immigration policy decisions. Our immigration system must be made consistent with U.S. national needs and priorities.
Yet quite the opposite is occurring. At a time when the country is struggling to provide affordable care to millions of uninsured residents, President Bush's immigration proposal would bring in hundreds of thousands more uninsured—and officially sanction a massive illegal population already here and already draining health care funds from struggling communities.
America's health care system is in crisis: The numbers and proportion of the uninsured are rising rapidly. Costs are skyrocketing—2003 saw the largest increase in employer health care costs in 13 years1—and posing an increasingly difficult burden on businesses and individuals. At the same time, state budget deficits mean states are cutting back public health care funding, and hospitals around the country are being forced to close or cut back services.
In the midst of this crisis, mass immigration is straining the health care system to the breaking point. Indeed, more than half of all counties surveyed by the National Association of Counties say that recent immigration—both legal and illegal—is causing their uncompensated health care costs to rise.2
Non-reimbursed costs also get shifted to patients who do have health insurance, thus increasing the cost of care for everyone. High levels of unpaid medical bills also have forced local health care providers to reduce staffing and services and increase rates. Dozens of hospitals in the counties along the southwest border have either closed or face bankruptcy because of losses caused by uncompensated care given to immigrants.
| "We're running an HMO for illegal immigrants and if we keep it up, we're going to bankrupt the county. We have a $350 million debt as a result of these people receiving medical treatment illegally." —Los Angeles county supervisor Michael Antonovich3 |
As states cut their health care budgets to try to make ends meet, high rates of immigration are causing a major drain on health care resources and taxpayer funds. Due to lack of enforcement of federal immigration laws, state taxpayers are being forced to fund health care services for illegal aliens at a time when they can't fund all their services for the general population.
But the failures of federal immigration enforcement tell only part of the story. In many areas, the magnitude and cost of illegal immigration are also consequences of state and local policies that encourage illegal alien settlement by granting costly benefits to people who violate immigration laws.
Under current law, hospitals must treat and stabilize anyone who seeks emergency care, regardless of income, insurance, or immigration status.4
Yet most hospitals receive little or no reimbursement for the care to legal and illegal immigrants that the federal government mandates that they provide.
Although the Illegal Immigrant Reform and Immigrant Responsibility Act of 1996 (IIRAIRA) approved reimbursement to hospitals for emergency care for illegal immigrants, as well as reimbursement to state and local governments for ambulance services provided to illegal immigrants injured while crossing the border, neither program has been funded.
In 1997, Congress appropriated $25 million a year for four years to supplement funding for state emergency health services for illegal immigrants, in the twelve states with the highest number of illegal aliens. This program has since terminated. Congress is considering legislation that would create a similar program, but at present no such program is active.5
Lawsuits brought by several states against the federal government in the 1990s, seeking reimbursement for the cost of handling the massive influx of illegal aliens that federal authorities had failed to contain, were dismissed on the grounds that the issue was a "political question" and not one for the courts.6
Medicaid and Medicare
The 1996 Personal Responsibility and Work Opportunity Reconciliation Act stopped immigrants from receiving Medicaid for their first five years in the country (with exceptions for those here prior to 1996, children, and pregnant women). However, Congress didn't touch emergency Medicaid, which allows both legal and illegal immigrants to receive emergency medical treatment. (Medicaid funds are drawn from federal, state, and local budgets.)
3.5 million immigrants were enrolled in Medicaid in 2002, and an additional 3.7 million were enrolled in Medicare.7
Our immigration policies have played a significant role in creating our national health care crisis, in which more than 41 million Americans lack basic health insurance.
Immigrants are two and a half times as likely to lack health insurance as natives.8
Thirty-three percent of immigrants—one in three—have no insurance (compared to 13 percent of the native-born). One out of every four uninsured people in the United States is an immigrant, show Census data. (This is a dramatically disproportionate share, as immigrants comprise 11.5 percent of the total population.)9
When the National Association of Counties surveyed its members in 2002, 67 percent of counties cited an increase in immigration as a cause of the rise in uncompensated health care expenses and all of the responses indicated that newly arrived immigrants are among the predominant users of uncompensated health care.10
Why are immigrants disproportionately uninsured? Because of illegal immigration and because U.S. immigration policy slants toward admitting relatives rather than immigrants with needed workplace skills, our immigration system literally imports poverty. Sixteen percent of all immigrant households live below the poverty level, and one out of every five households of non-citizens is poor (versus eleven percent poverty among native households). The median household income for immigrant households is 13 percent lower than that of native households, and, for the households of non-citizens, it is 23 percent lower.11
In immigration-heavy states, the effects are even more pronounced. Nearly three-fifths of all poor children in California are immigrants, and the poverty rate of the state's immigrant children (29 percent) is significantly higher than that of its native children (17 percent).12
Among full-time wage earners, 51 percent of non-citizen immigrants had employment-based coverage, compared with 76 percent of naturalized citizens and 81 percent of U.S.-born residents. Among the lowest-wage full-time workers (earning less than $15,000 annually), 27 percent of non-citizen immigrants have employment-based coverage, compared to 58 percent of U.S.-born residents.13
Because of the uncompensated expense of treating uninsured patients, communities with high rates of uninsured residents "are more likely to reduce hospital services, divert public resources away from disease prevention and surveillance programs, and reallocate tax dollars so that they can pay for uncompensated medical care," according to an Institute of Medicine of the National Academies of Sciences report.14
In 2001, public funds made up for up to 85 percent of the $34-$38 billion shortfall in unreimbursed expenses incurred by the uninsured.15
The problem is on the rise: Immigrants (legal and illegal) who arrived between 1994 and 1998 and their children accounted for 59 percent (2.7 million people) of the growth in the size of the uninsured population since 1993.16
| Emergency in the E.R. Between 1992 and 2001, visits to U.S. hospital emergency departments increased by 20 percent, while emergency departments shrank by 15 percent—resulting in longer waits before patients receive treatment.17 Sixty-two percent of hospitals nationwide are receiving patients at or over the operating capacity of their emergency departments.18 As emergency rooms fill up, ambulances are rerouted—possibly with deadly consequences. At least two states, California and Massachusetts, are investigating patient deaths during ambulance diversions.19 Almost one in ten hospitals are in diversion status 20 percent of the time.20 "This rapid escalation in losses has created an enormous burden on the remaining emergency departments," reports the California Medical Association. "The drain on the system has led to longer waits for treatment, and left entire communities without a local emergency facility. Increasing patient volume and a decline in the number of emergency rooms has made multiple hour waits for emergency care the norm."21 |
Yet it's not only recent immigration contributing to the problem: More than a third (37 percent) of immigrants who entered in the 1980s have still not acquired health insurance, and more than a quarter (27 percent) of immigrants who entered in the 1970s remain uninsured.22
When the 3.5 million immigrants receiving insurance through publicly-funded Medicaid are factored in, almost half of immigrants have either no insurance or have it provided to them at taxpayers' expense.23
Lack of insurance leads many immigrants to forego or postpone medical care, especially preventive care. Because this can cause medical conditions to deteriorate, it often ultimately increases the cost of treatment. Many immigrants end up using hospital emergency departments—the most expensive source of health care—as their primary care provider.24
Because emergency rooms must treat patients regardless of their ability to pay, high rates of uninsured patients can spell financial disaster for hospitals. The cost of caring for these patients is absorbed by the counties or hospitals obligated to provide treatment, and some is passed on to insured patients.
The problem is particularly pronounced in communities near the southwest border, where there are high populations of illegal aliens. Border hospitals reported losses of almost $190 million in unreimbursed costs for treating illegal aliens in 2000 (about one-fourth of the hospitals' total unreimbursed expenses).25 Had the report included physician and ambulance fees and follow-up services, the total price tag for illegal aliens would have been about $300 million, according to the report's authors.26
The U.S.-Mexico Border Counties Coalition studied the 24 counties next to the Mexican border and concluded: "The disproportionate burden placed on southwest border counties for providing emergency healthcare services to (illegal aliens) is compounding an already alarming state of affairs."28
| "I don't understand why I have to bear this expense. Border control is supposed to be a federal problem, not a Schaefer Ambulance problem; it's just not fair." —I.M. McNeal, owner of Schaefer Ambulance Service (Imperial County, Calif.), which has written off more than $620,000 over the last six years for uncompensated services provided to illegal aliens27 |
In some hospitals, as much as two-thirds of total operating costs are for uncompensated care for illegal aliens.29 The increase in such costs has forced some hospitals to reduce staff, increase rates, and cut back services.30
The problem has become so out of hand that some Mexican ambulance companies are now instructing their drivers to take uninsured patients across the border to the United States. The ambulances simply drive across the U.S.-Mexico border's many unguarded crossings. The National Advisory Committee on Rural Health notes that the drivers face little resistance at border crossings.31
Dozens of hospitals in the counties along the border face severe losses caused by uncompensated care provided to uninsured immigrants32:
Arizona, facing a $1 billion state budget shortfall in FY 2004, is considering cutting 60,000 children from of the State Children's Health Insurance Program.33 Yet in December 2001, the legislature approved $3 million to cover kidney dialysis and chemotherapy for illegal aliens.34
California, in addition to Emergency Medicaid, provides both legal and illegal aliens with prenatal care, and nursing home care.45 Additionally, locally funded initiatives in Los Angeles, San Bernardino, San Francisco, San Mateo, and Riverside counties now pay for health insurance for illegal immigrants in those jurisdictions.46
| Border Patrol agents often take injured illegal immigrants who were apprehended trying to enter the country and drop them at the nearest hospital for treatment, instead of returning them to Mexican authorities or a medical facility in Mexico. However, the INS bears no responsibility for funding their treatment.49 |
Texas, facing a $10 billion two-year state budget shortfall, plans to roll back Medicaid and coverage for children under the State Children's Health Insurance Program to the minimum levels mandated by law.54 In 2001, Texas attorney general John Cornyn issued a legal opinion stipulating that federal law bans hospitals from using tax dollars to provide non-emergency care to illegal immigrants. However, Harris County—the state's largest county, which includes Houston—announced it would ignore the opinion and continue to provide taxpayer-subsidized non-emergency care to illegal aliens.55
| Los Angeles: Code BLUE Los Angeles, a magnet for legal and illegal immigration, is a prime example of immigration overwhelming a health system. Since the early 1990s, the Los Angeles County Department of Health Services (LACHS) has been on the verge of collapse several times, saved only by bailouts from the federal government. LACHS bears the burden of providing treatment for two million people without health insurance and faces an anticipated $300 million deficit, accumulating to nearly $800 million over the next five years.57 One-third of the patients treated by the Los Angeles county health system each year are illegal aliens, according to county health officials.58 In 2002, the county spent $350 million providing health care to illegal aliens, according to the Department of Health Services. Officials said that if that money had been available, the county could have avoided the closure of 16 health clinics and possibly two hospitals, as well as cuts in services.59 LACHS is sharply curtailing services at dozens of county clinics, hospitals, and emergency rooms, which serve primarily the working poor and indigent. If no additional state or federal funds are forthcoming, county health officials have proposed closing emergency, trauma, and in-patient services at three hospitals, along with two-thirds of the county health center clinics and 100 private outpatient clinics. "If these critical county trauma centers are closed, there is absolutely no doubt that injured people, both with and without medical insurance, will die unnecessarily because the other trauma centers are simply too far away," says Dr. Robert Hockberger, chair of Harbor-UCLA's Department of Emergency Medicine.60 In the midst of this, county leaders are making public services more accessible to illegal immigrants. Over the last several decades, and despite the severe fiscal crises faced by local and state government, political leaders continued to promote policies that encourage illegal immigrants to take up residence in the county by explicitly accommodating people who violate immigration laws. A 1979 ordinance, known as Special Order 40, prohibits Los Angeles police officers from asking detained people about their immigration status. Similarly, the city continues to spend scarce money to build and maintain day laborer hiring sites, despite the fact that most of the people who seek work at them are illegal aliens. And in 2002, the county adopted a policy of accepting the Mexican consular ID card (used almost exclusively by illegal aliens) as a valid document for accessing public services, including non-emergency health care. |
In Florida, if Medicaid costs continue to increase at the current rate, the costs would consume the entire state budget by 2015.65
| "Florida hospitals are seeing a dramatic increase in costs associated with caring for uninsured non-U.S. citizens. Providing care to these individuals places a huge financial burden on hospitals' already limited financial resources." —Florida Hospital Association70 |
The problem isn't confined to states traditionally thought of as high-immigration-impact areas. For example:
Hospitals frequently absorb not only the cost of any follow-up care for illegal alien patients but also pay to return them to the home county. For example, one Florida hospital spent $347,000 to treat one illegal alien patient for respiratory distress, to care for him after he stabilized while a doctor in his home country could be found to accept responsibility for him, and to return him and his wife to Colombia. In another case, the facility spent $150,000 to give an illegal alien surgery for progressive curvature of the spine and then return him and his family to their homeland.81 The president and chief executive of Jamaica Hospital, in Queens, New York, says the facility sees immigrants head straight to the hospital after arriving in the United States. The hospital has started buying plane tickets and sending some of the ill immigrants back home, sometimes buying extra tickets for nurses to serve as escorts.82
| The State Department has acknowledged problems with the abuse of the so-called medical visa program, citing a number of instances in which foreign nationals who received visas for temporary medical treatment ultimately incurred six-figure medical bills at public hospitals. In one such case, a young leukemia patient's parents applied for a visa for him, presenting the consular officer with a letter from a Maryland doctor agreeing to care for him. The child received a visa and traveled to the United States, where the Maryland doctor promptly referred him to Children's Hospital. The child's treatment is expected to cost $650,000—nearly the entire sum raised by columnist Bob Levey in the Washington Post's annual fundraising campaign to support charity care at Children's Hospital for area residents.83 |
Tennessee has removed 208,000 people from its expanded Medicaid program, including 55,000 children. Connecticut has eliminated Medicaid benefits for 23,000 adults and 7,000 children. Oklahoma has discontinued its "medically needy" program, eliminating Medicaid coverage for 8,300 people who had catastrophic medical costs.84
In all, 49 states have implemented Medicaid restrictions for the 2003 fiscal year: 25 states have reduced benefits, including restricting or eliminating dental coverage and in-patient hospital days; 27 states have frozen or reduced provider rates; 45 states have enacted prescription drug cost controls; 27 states have enacted eligibility cuts and restrictions; and 17 states have increased beneficiary co-pays.85
Struggling hospitals are curtailing services left and right, closing maternity wards and trauma centers, laying off staff, and limiting the drugs that will be offered to patients.86, 87 In July 2002, the University of California Medical Center at Irvine announced that it would refuse care to anyone who lives more than a few miles from its facilities (except in emergency cases).88 In West Virginia, two hospitals have closed their maternity wards and several hospitals no longer have either neurosurgeons to treat head injuries or orthopedists to mend broken bones.89 In El Paso, some clinics for low-income populations now manage conditions on an outpatient basis that would get an insured patient hospitalized.90
| "Health care costs and insurance premiums are rising, due in part to burgeoning levels of uncompensated care. Rising health insurance premiums are threatening business' ability, particularly small business to offer employees affordable health care benefits. High liability costs and lost levels of compensation are threatening the viability of emergency rooms and emergency transportation providers along the border. Some counties with high rates of uncompensated care can no longer afford to provide 'charity' care for local needy residents. In some instances, high levels of unpaid medical bills related to undocumented immigrants have forced local health care providers to reduce staffing, increase rates, and cut back services." —U.S.-Mexico Border Counties Coalition, September 200299 |
Some states are beginning to tackle the problem. In March 2003, Colorado became the first state to remove legal immigrants from Medicaid rolls, saving $2.7 million.91, 92 Massachusetts is considering following suit by changing Medicaid rules to make 9,500 illegal aliens ineligible, by which it hopes to save $13 million a year.93 Minnesota is considering healthcare cuts that would remove 4,500 illegal aliens from the General Assistance Medical Care coverage.94 New Mexico is considering eliminating some emergency medical services for illegal aliens, to save $2 million.95
Washington state, facing a $2.6 billion budget deficit, stopped covering 29,000 illegal aliens with Medicaid in October 2002 and expects to save $25 million a year as a result. However, local hospitals are now footing the bill: Children's Hospital & Regional Medical Center in Seattle paid $200,000 in the following two months to care for 600 illegal alien children.96 And the state, like eleven others, continues to pay for prenatal care for illegal aliens, at a cost to Washington taxpayers of $23 million a year; state lawmakers also set aside about $20 million in 2002 to provide low-income immigrant families with subsidized health insurance.97, 98
The escalating burden incurred by hospitals and other health facilities for the uncompensated treatment of aliens is driven by both rampant illegal immigration and an admission system for legal immigration that has become distorted from its original intent. The health care system increasingly is confronted with foreigners legally resident in the United States who either cannot or choose not to pay for their medical treatment and foreigners illegally in the United States who have no other recourse for medical treatment.
The first problem is largely the result of an immigration policy that has gone awry: Despite an age-old policy designed to assure that immigrants will be self-supporting, we are allowing large numbers of people to gain permanent residence despite the fact that they are unlikely to be working in jobs with health care coverage or have personal resources sufficient to pay for health services. The second problem—costs stemming from illegal immigration—is a result of the unprecedented nine to eleven million aliens illegally residing in the country who, for the most part, have no health insurance and have few financial resources.
The common element of both of these foreign-born populations is that they are a financial burden on the U.S. health care system and the American taxpayer. Neither the sponsors of immigrants legally present in the country nor the employers of those illegally in the country are held responsible for these expenses.
There is no single policy or program that will reverse the escalating problem of uncompensated medical services provided to immigrants and illegal aliens—other than adopting a flat denial of treatment, which is too draconian to be considered. A better solution would be the combination of short-term and long-term changes detailed below:
Adopting such a system would develop a reliable database on who is using emergency medical services so that appropriate remedial measures could be designed in the public interest. It would allow identification of those legally responsible for reimbursing health care debts and allow the medical facilities to recoup expenses. It would provide information in some instances as to the employer of the emergency medical care user in order to allow follow-up legal efforts to obtain compensation.
Such a system also potentially could evolve into a means for non-emergency medical facilities to address the problem of foreign patients who run up large medical bills that they fail to pay. If Congress were to enact a law that specified that unpaid medical obligations in the United States is a grounds for refusal of a new visa of any type or of entry, abusers of the hospitality of U.S. health care providers would be denied the opportunity to continue to abuse the system and pressure would increase on them to settle their debt. Integral to the success of such a provision would be the identification of the individuals by fingerprints furnished by the health care facility to the Department of State and DHS.
The law provides that prospective immigrants are inadmissible if they are likely to become a public charge.100 Similarly, those who subsequently become a public charge after gaining permanent residence are deportable.101 (The public charge provisions do not apply to refugees or asylees, but they do to other immigrants.)
The major and expanding usage of emergency medical care facilities is largely a byproduct of the enormous growth in the illegal alien population, which has entered and/or stayed in violation of the legal immigration provisions. An estimated nine to eleven million aliens are currently residing illegally in the United States, and further hundreds of thousands of aliens may be in the country illegally for part of the year engaged in seasonal work.
The massive influx of illegal immigrants is not inevitable. Most illegal entrants or entry overstayers violate our immigration laws in order to take jobs and improve their economic opportunity. Congress recognized this when it adopted the system of employer sanctions against hiring illegal aliens in 1986. That system was soon proven to have a major loophole in that employers were not provided the means to verify the authenticity of work-related documents that they were required to accept under the law. Congress acted in 1996 to begin to close that loophole by establishing pilot projects to permit employers to verify Social Security numbers and the work eligibility of foreign-born employees.
The primary verification system, known as the Basic Pilot, is still operating as a voluntary project, and it has been thoroughly evaluated by an outside contractor and found to be operating largely as intended. The program was expanded by Congress in 2003 from a program operating in a handful of states to becoming available nationally. When that system is adopted as a mandatory requirement nationally, it will shut down legal employment opportunities for illegal aliens using fraudulent identification, and it will increase the efficacy of enforcement capabilities against employers who knowingly continue to hire illegal aliens in order to exploit their vulnerability.
When data collected by public hospitals on uncompensated costs reveal a pattern of abuse by nationals of a specific country, the U.S. Department of State must negotiate a medical repatriation agreement with that country. In the absence of such agreement, travelers from that country should be required to obtain private international medical evacuation insurance as a condition of admission. In addition, a port of entry surcharge fee on citizens of that country may be levied in an amount necessary to defray the outlays by the federal government for medical evacuation of indigent citizens of that country.
This is not going to happen because then there would be actual numbers of the total costs. If the general public knew these numbers for fact there would be an uprising in every community against illegal aliens.
Our politicians cannot allow these true numbers to be known for their own safety and the safety of the illegal aliens." Like the 8 to 12 million number, we all know it is a number picked out of the sky but we don't have the means to prove that it is a phony. The number that I've heard whispered last fall was 28,000,000+. This number includes the "anchor babies". (No I will not reveal the name of the person who gave me the number, but he is a federal employee.)
A "running up the health care costs that other Americans don't want to run up" Bump.
Thanks for posting this excellent article Marine Inspector. It should be required reading for anyone wondering why health care costs and medical insurance premiums are spiraling out of control.
Your welcome and I agree.
8'
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