The Obama Agenda: Health Care reform and illegal immigrants
As the Obama administration and leaders in Congress push for health care reform, area hospitals and policy experts wonder what will happen to undocumented immigrants who are uninsured.
There are no hard figures on the total number of uninsured people who are also in state illegally. Hospitals don’t ask uninsured patients their immigration status when they come in for treatment. However, Joel Cantor, director of the Center for State Health Policy at Rutgers University, has seen estimates that show approximately 400,000 of the 1.2 million uninsured in New Jersey are undocumented. Currently, illegal immigrants mix in more generally with other uninsured people, Cantor said.
The House bill ensures undocumented immigrants access to a public exchange with their own money, according to findings from The Center for Immigration Studies and news reports. The exchange is a nationwide pool of health insurance providers that would allow individuals and employers to comparison shop for their policies. The Senate’s bill, which would cost an estimated $849 billion over 10 years, would bar illegal immigrants from participating in a health insurance exchange.
Cantor believes most undocumented immigrants will remain uninsured if health care reform goes through, and he wonders what will happen to the funding streams available, such as charity care as well as state and federal dollars, that are used to reimburse clinics and hospitals.
"When a hospital cares for an undocumented patient, they will most likely not be reimbursed for the cost of that care," said Kerry McKean Kelly, spokeswoman for the New Jersey Hospital Association.
Since 2007, nine hospitals have closed throughout the state, 40 hospitals are operating in the red and six have filed for bankruptcy, McKean Kelly said, adding that the shortfalls in the charity care program are one of the contributing factors. New Jersey hospitals run up $1.3 billion in costs annually to treat patients who aren’t covered by private insurance or government entitlement programs but do qualify for the state charity care program,
The Times of Trenton has previously reported. However, the state provides only about $605 million in reimbursements, a figure that remained unchanged in the fiscal year budget that began July 1, even as rising unemployment means more people are losing their insurance.
McKean Kelly said there are other factors that come into play for hospitals losing money or closing. In theory, increasing the number of insured Americans is a good thing for the health care system because physicians and hospitals would be reimbursed better for taking care of these patients. However, the concern is hospitals will be paid the same kind of rates as patients who are insured by Medicare and Medicaid, two federally administered and funded health insurance programs that provide coverage for people 65 and older and low-income families respectively.
State hospitals are paid 89 percent of the total costs of a Medicare patient, and 69 percent for those insured by Medicaid, McKean Kelly has said.
If more people become insured, McKean Kelly said hospitals may lose some of the burden of caring for the other uninsured groups, but the responsibility of taking care of undocumented patients who are uninsured will remain unchanged under the state’s law, which requires hospitals to treat anyone in need of care regardless of their ability to pay.
"The fact is Americans don’t want these people to die in the doorstep of the hospital," said Uwe Reinhardt, a world-renowned authority on health care economics and a Princeton University professor. "But they’re not willing to pay for them up-front so that if someone gets sick in Mexico, they feel entitled (to free health care) once they cross over the border."
Reinhardt said including undocumented immigrants in any health care bill is politically not sellable. "You don’t want to set up an incentive where sick people from around the world smuggle themselves into the U.S." But Reinhardt also thinks undocumented immigrants who are willing to buy their own insurance should be given the opportunity to do so.
There are nearly 12 million illegal immigrants in the U.S. In 2007, almost 60 percent of the adults had no health insurance, more than double the proportion of uninsured adults among legal immigrants and four times the share among U.S.-born adults, according to the Pew Hispanic Center.
Most of the uninsured are working families. They tend to be poorer and in worse health than those with insurance, according to the nonpartisan Kaiser Family Foundation. About 40 percent of non-citizen immigrants who are both legal and undocumented, have private insurance, "but they are significantly more likely to be uninsured" than the 46 million U.S. citizens lacking coverage, according to a September 2009 study by the Kaiser Family Foundation. According to the study, when undocumented immigrants do receive health care, "they tend to rely on safety-net providers, such as community clinics and health centers."
Dr. Margaret Lancefield, medical director of the outpatient clinic at the University Medical Center at Princeton, said about half of the clinic’s 5,000 patients (which translates to 20,000 visits a year) are working poor citizens or permanent residents, the other half have charity care, though it is unknown what percentage is undocumented. Hispanics make up the largest number of non-English speaking patients, but the clinic also treats people from Pakistan, India, China, Poland and other places, Lancefield said.
"We try to find out who they are. We ask for identifications, sometimes they give passports. We never ask if people are documented or not," said Lancefield, who is married to U.S. Rep. Rush Holt, D-Hopewell Township, who is pushing for health carereform in Congress.
"In this country, we don’t take someone with appendicitis and throw them on the street, or tell them to go have their baby at home," Lancefield said, "Right now, Americans are paying to take care of uninsured people. We will ultimately save money if more people are covered with insurance. Wouldn’t it be wonderful if every single human being had health insurance?"
At St. Francis Medical Center in Trenton, about 25 percent of patients are uninsured. Of that, 10 percent qualify for NJ Charity Care and the other 15 percent pay out of pocket, said Jerry Jablonowski, the center’s president and CEO. It is not clear what percentage is undocumented. The direct costs for treating the 25 percent of uninsured patients is between $16 and $18 million, including inpatient and outpatient care, Jablonowski said.
The hospital receives an approximately $10 million subsidy from charity care, leaving them with a $6 to $8 million loss when they care and treat uninsured patients, but the hospital is still running in the red this year, with a projected loss of $2 million, Jablonowski said. If that 25 percent of uninsured patients that come through St. Francis, a teaching hospital, are now insured, it is good in one respect, but if there are cuts to Medicare and Medicaid to fund this, Jablonowski wonders whatt will make up the difference on the other end.
"Those costs are getting greater each year and hospitals have to meet those costs. “We’re trying to promote better outpatient care. Most uninsured people have no access to primary care, and don’t show up until they’re in dire need (of care), which is very costly," Jablonowski said. Speaking specifically about the undocumented uninsured population, Jablonowski said St. Francis will continue to take care of them in a post-health care reform world, "but it puts an increasing financial strain on the organization."
The Henry J. Austin Health Center works with both St. Francis and Capital Health System so that uninsured and undocumented patients can go to the clinics, located in Trenton and Hamilton, for primary care. The center also does not track its undocumented population, but Walter Isaacs, Henry J. Austin’s CEO, said it will be a financial burden and the center may have to cut back on staff if the state cuts back funding for uninsured people.
"I would hope that the money that (federally qualified health centers) receive for uncompensated care for the uninsured would be maintained so as folks become eligible and receive insurance, there’s still money to pay for those that are not able to get insurance," Isaacs said.
