Beazley Institute for Health Law & Policy, Loyola University Chicago, Masters of Law 2019
Every time we turn on the news, someone is either talking about immigration reform or health care reform. Health care and immigration are two major areas that President Trump promised to address and is attempting to tackle within his first two years in office. Although most would not consider that these two issues would overlap, in today’s American health care system, Americans need immigrants. Immigrants contribute a great deal to our medical research, make up a large percentage of our health care providers, and subsidize health insurance premiums.
The Healthy Subsidize the Unhealthy
One of the goals of the Patient Protection Affordable Care Act (the “ACA”) was to increase Americans’ access to insurance at an affordable rate. The ACA provided healthcare access to individuals who would typically not be eligible for insurance coverage due to pre-existing health conditions. The ACA’s individual mandate made this possible by requiring individuals to enroll in health plans. In an effort to maintain affordability under with the individual mandate, the ACA provides a subsidy tax credit for those within a particular range of the federal poverty level. If a person earned enough money, and insurance was affordable for them, those who did not enroll were subject to a monetary penalty.
The individual mandate would essentially scare people, particularly healthy people, into the insurance exchange in order to balance out insurance risk pooling. Providing a balanced risk pool is beneficial to both the insurer and the insured. For the insurer, it allows them to control their risks by allowing the healthier people to offset the higher costs of the less healthy. For the insured, pooling risks allows affordability to enrollees by stabilizing insurance premiums and allowing higher risks, or less healthy enrollees costs to be subsidized by the lower risk, healthier enrollees who continue to pay premiums but do not use the insurance as much as the less healthy enrollees. Under the ACA, and its many components, the goal of increased accessibility to affordable insurance was accomplished through the individual mandate and subsidies allowing the uninsured rate of Americans to drop to record lows.
Who Is Subsidizing Who: U.S. Citizens or Immigrants?
Contrary to some news reports, immigrants subsidize U.S. citizens’ public and private health insurance. According to a 2018 study conducted over the past few years, immigrants’ overall healthcare expenditures were one-half to two-thirds of US-born individuals’ own expenditures. Some immigrants were eligible under the ACA to purchase health insurance from the health insurance exchanges. Immigrants that purchased insurance within the exchanges paid monthly premiums but did not spend nearly as much as U.S. citizens, therefore subsidizing citizens’ healthcare. Immigrant annual premiums surpassed their total care expenditures by $1,123 per enrollee totaling $24.7 billion, offsetting a deficit of $163 per US-born enrollee. The surplus of premiums from 2008-2014 totaled $174.4 billion. Moreover, unauthorized immigrants contributed a surplus of $35.1 billion into the Medicare trust fund from 2000-2011, prolonging the life of the fund.
Upon assessing undocumented immigrants, they demonstrated the lowest healthcare use. Undocumented immigrants, although they account for five percent of the United States population, only used 1.4 percent of total medical expenditures. Similar to the healthier enrollees subsidizing the unhealthy, immigrants contributed to the affordability of insurance as they created a low risk pool by paying for insurance within the exchange and not using as much as U.S. citizens.
Public Charge and Its Negative Impacts on Health Care
The public charge was expanded in the 1990s to include people who received cash-based welfare as a potentially barring factor to receive a visa or green card. Individuals who accessed the welfare deemed a public charge. The Trump administration has recently proposed a new public charge to determine whether someone who is seeking permanent residency is completely self-sufficient. The proposed rule seeks to penalize visa or green card applicants and will affect lawfully present immigrants by using a new expanded list that includes non-emergent Medicaid, CHIP, insurances through the ACA marketplaces, non-cash assistance like SNAP, WIC, and housing programs. In some cases, if an immigrant becomes a public charge within its first five years of being in the United States, he/she could possibly be arrested and deported.
Implementation of the proposed public charge can burden the federal government and our health care system in a number of ways. The public charge will likely dissuade immigrants from using public services as it might jeopardize immigration status and ability to become naturalized citizens. The rule could possibly cause U.S. insurance premiums to rise and jeopardize the Medicare Trust Fund. Immigrants tend to be healthier than Americans are, as they do not use much of the insurance. If the tactic is effective, and immigrants opt out of public and private health insurance, risk pools will likely become high-risk pools as U.S. citizens continue to use high amounts of their coverage thus making insurance unaffordable as insurance prices spike. Considering the projections that the Medicare Trust Fund will be depleted in the next eight years (by 2026), any surplus contributed is pertinent. Potentially subtracting the $2.2 to $3.8 annual surplus contributed by unauthorized immigrants could expedite the depletion process.
Moreover, if the proposed public charge is implemented, hospitals, especially safety-net hospitals where Medicaid reimbursement accounts for at least fifty percent of its income, will also be in jeopardy. Hospitals will be financially burdened if immigrants are not able to access some public services. Hospitals are required to see uninsured individuals, including unauthorized immigrants, in emergent situations if they appear in the emergency room. Consequently, the public charge is likely to cause immigrants to prolong their healthcare needs to their own detriment, effecting public health, as well as the safety-net hospitals detriment because the cost of care is higher for sicker patients thus dipping further into allotted Medicaid funds.
Hospitals that receive Medicaid reimbursement will need to implement strategic planning to elongate their allotted Medicaid funding and prevent the hospitals from taking on costs themselves. Medical professionals, both within the c-suite and medical providers, will need to develop lines of communication within the hospital in order to monitor uninsured patient’s care. In order to prevent any patient, whether immigrant or US-born, from delaying necessary medical treatment, it would behoove all parties to implement policies to continue care for the patient on a preventative care basis. Beginning preventative care now will likely preserve some of Medicaid funding for the next patient. Further, low rates of insurance for undocumented immigrants evidence their independent ability to pay for medical care out-of-pocket. Hospitals should provide preventative care to immigrants in non-emergent situations without the concern of becoming a public charge or threat against citizenship eligibility.
Ultimately, the public charge should not be any more burdensome than it is currently. Considering the state of the American healthcare system, removal of immigrant subsidies will have negative implications on U.S. citizens. If immigrants have shown their ability to contribute to the system in a positive manner, they should not be restricted from doing so.