Critics of the White House and the U.S. Senate's immigration overhaul proposals believe Washington, D.C., has gone too far in offering what amounts to "amnesty" to millions of illegal residents, but immigrant advocates -- and public health officials -- think the new proposal didn't go far enough.
How did this become a public health issue?
Because the eventual path to citizenship did not likewise include a path to Medicaid access. The White House's proposal also did not offer a path to purchase the subsidized health care coverage that will be offered through the federal health overhaul law known as the Affordable Care Act. The Senate's framework, meanwhile, was silent on that issue.
Starting in 2014, the Affordable Care Act will offer federal tax subsidies to help citizens and lawfully present immigrants who qualify financially -- and who are without their own health insurance plan -- to buy a private policy through online health insurance exchanges.
Under current policy, immigrants here illegally won't be able to buy insurance at all or get those subsidies, and the proposals now being debated would not appear to change that, to the disappointment of those who are providing health care to immigrant communities.
Largely, that job now falls to free-care clinics and emergency room physicians, who act as a safety net for those without insurance access.
"Everybody who needs emergency care and who comes to our [hospitals] should get it," said Charles Pattavina, chief of emergency medicine at St. Joseph Hospital in Bangor, Maine, and a spokesman and former board member with the American College of Emergency Physicians.
But treating uninsured populations -- those here legally, or otherwise -- costs hospitals and U.S. taxpayers billions a year, pushing some ERs (particularly urban ones) to the financial brink and "reducing capacity and threatening everyone's access to lifesaving care," according to the emergency physicians organization.
Most undocumented immigrant adults lack health insurance. Their children -- who often are U.S.-born citizens, and thus eligible for certain health programs such as Medicaid and Children's Health Insurance Program -- usually don't have it, either. Even those who are in possession of a green card and reside here legally must generally wait five years before becoming eligible for Medicaid.
As a result, many don't seek health care until an emergency arises. That's why advocates believe Congress ought to consider a health care component, if it indeed undertakes a comprehensive immigration overhaul package.
"I really think that they did miss something," said Pittsburgh immigration attorney Suzanne Susany, who is also a nun with the Sisters of St. Francis.
"The majority of the immigrants are young adults. If they were able to get the [Medicaid] benefit, they would be putting into the program, and they would be taking out very little. ... They would not be bleeding the system."
Bleeding the system or not, it's a tough political sell -- even if it might make economic sense.
As Patrick J. Glen, former Georgetown University Law Center adjunct, put it in a paper on the subject, "The question of whether health coverage should be extended to illegal immigrants will continue to rankle in the political arena for the foreseeable future."
Expense, naturally, is one concern. The Senate budget committee believes that allowing illegal immigrants to become citizens will add between $120 billion to $200 billion to the cost of the Affordable Care Act in its first decade.
And that's just the cost once the undocumented immigrants gain lawful permanent residence (or a green card). If they were given access to care prior to citizenship, during their probationary lawful status as advocates hope, the cost would go up further.
Because the details of the proposal unveiled Jan. 28 are still being negotiated, health policy experts hope there is still time to discuss health care issues before a bill is written.
"The thing that's always missing in these debates is that we're going to have to pay for [immigrants' care] one way or another," said Sonal Ambegaokar, health policy attorney with the National Immigration Law Center, based in Los Angeles. "The goal [of overhaul] is to bring them out of the shadows," so that they can pay taxes and pay into the health care system, spreading cost and risk across more bodies.
The federal government and President Barack Obama, immigrant advocates note, have now missed several opportunities to expand base-level health insurance to the immigrant underclass.
In August 2012, the White House ruled that the young immigrants who will be allowed to stay in the country as part of the government's new policy will not be eligible for coverage under state-based Medicaid or CHIP policies.
Nor would they be eligible for the federal subsidies that will allow low-income households to buy individual policies in the health insurance exchange marketplace. They can't buy the policies at full cost, either.
At the time, the White House and the U.S. Department of Health and Human Services said the law enforcement issue -- whether sons and daughters of illegal immigrants should be prosecuted and deported -- was separate from the health care access issue.
The issue is all the more pressing for the illegal immigrant community as provisions of the Affordable Care Act begin to take effect. While the net effect of the law will likely be an increase in the number of Americans with health insurance, illegal immigrants could suffer.
That's because the health care overhaul could actually cut services to the country's estimated 11 million illegal immigrants.
If, as has been predicted, an extra 32 million Americans end up with health insurance, hospitals and clinics -- in theory, anyway -- will have fewer "indigent" and "charitable care" cases, which is why the federal government is planning to cut its funding for uncompensated care.
Bill Toland: email@example.com or 412-263-2625.