The Patient Protection and Affordable Care Act (ACA), in spite of its major expansion of coverage for people in the United States, has neglected a large portion of immigrants.  Many immigrants will not meet the qualifications to enroll because they remain outside of the scope of coverage.  The Affordable Care Act was considered the signature domestic policy accomplishment of President Barack Obama that was designed to advance the original program signed into law in 1965 by President Lyndon B. Johnson which introduced the Medicaid and Medicare programs which started a quest for universal coverage.

 

Undocumented or “illegal” immigrants were not factored into the Affordable Care Act.  This plan explicitly excluded undocumented immigrants from buying health care plans through the ACA.  Many politicians argue that this decision was political.  When the Affordable Care Act was enacted, several citizens were concerned about the price of purchasing mandatory health care.  The argument was made that if undocumented immigrants were included in the Affordable Care Act, who would pay for it.  In addition, undocumented immigrants continue to be ineligible for most public forms of health insurance coverage and would not benefit from any Medicaid expansions carried out by the states (Wallace, Torres, Sadegh-Nobari, Pourat, & Brown, 2012).

 

Initial data in 2009 taken in California demonstrated that undocumented immigrants did not suffer from the health issues that were associated with people that were born in the United States.  Although the literature suggests that immigrants in general have better health status and lower rates of risky health behaviors compared to the US-born, factors such as limited access to quality health care, low income and occupational status, and legal status may erode the health advantage of the undocumented at a faster pace than their documented counterparts.  Findings from the 2009 California Health Interview Survey provide mixed evidence for the health advantage of undocumented immigrants. Specifically, after adjusting for age and 2 gender, we found that undocumented immigrants in California were significantly less likely to have ever been diagnosed with asthma than naturalized and US-born citizens. However, there are no significant differences in diagnoses of heart disease, diabetes or high blood pressure for undocumented immigrants compared to other groups. Undocumented immigrants are also significantly less likely to report excellent or very good health compared to documented immigrants, naturalized citizens and US-born citizens (Wallace et al., 2012).

 

There is an estimated 11.2 million undocumented immigrants living in the United States.  Many Americans have different views as to whether this has a positive or negative impact on the country’s economy, healthcare infrastructure, and society.  Under the Affordable Care Act, undocumented immigrants are not eligible to buy health insurance within the state or federal agencies, they are not provided sponsorships to purchase health insurance plans, and they do not qualify for Medicaid coverage.  This means that the majority of undocumented immigrants are uninsured.  Like many Americans that were uninsured before the Affordable Care Act, many undocumented immigrants will delay taking care of ailments until the issue is critical, and thus harder and more expensive to treat.  This factor distributes expenses on the emergency rooms and safety net clinics that provide the majority of this group’s health care needs, which coincidently, the patients cannot afford.  The cost of treating undocumented immigrants is hard to calculate and estimates vary widely, although the Center for Immigration Studies puts the total for uninsured undocumented immigrants around $4.3 billion per year. What is generally agreed upon, however, is that the foreign-born (especially the undocumented) use disproportionately fewer medical services and contribute less to health care costs in relation to their population share (Stoughton & Hampton, 2019).

 

Massachusetts, in 2011, was said to have the highest insurance costs in the nation.  The Affordable Care Act was welcomed to help offset this crisis, but it was not the first plan implemented to help with the increasing costs of medical expenses due to uninsured people living in the state.  In April of 2006, Massachusetts Governor Mitt Romney signed into law ‘An Act Providing Access to Affordable, Quality, Accountable Health Care’ designed to achieve universal access to health insurance for all Massachusetts residents (Stephens, Ledlow, Sach, & Reagan, 2017).  It was not recorded how many of the uninsured people living in Massachusetts were undocumented immigrants, but it was suspected to be low due to the state’s history of not being an area heavily populated by undocumented immigrants with Mexican descent.  Along with the decrease in pricing came am increase in requested care.  Healthcare medical providers experienced difficult effects from the new healthcare law. Utilization of physician services in Massachusetts was reported to be higher than in the nation with nine in 10 nonelderly adults reporting they had had a doctor visit in the past 12 months compared with only 63% nationally. It can be debated that the supply and demand effect was not adequately considered during the development of the new law (Stephens, Ledlow, Sach, & Reagan, 2017).  The Massachusetts Health Care Reform rules were slightly different that the Affordable Care Act.  To be eligible to purchase what was termed “RomneyCare,” with or without a premium tax credit or other subsidy under the ACA, a non-citizen had to have an immigration status on the list of statuses defined as Lawfully Present.  If you were an undocumented woman who was pregnant, you would be covered under subsidy of the Massachusetts policy.  The remaining undocumented immigrants were not covered under this policy.

 

When politicians campaign against insuring undocumented immigrants, they fail to include very important facts.  What is less talked about is what undocumented immigrants pay into the health care system. New findings suggest that this population contributes billions of dollars per year. The study, which looked specifically at Medicare, found that undocumented workers contributed $35.1 billion more between 2000 and 2011 than they received in care. Most pay taxes, but never become eligible for Medicare because of their status. Though undocumented immigrants rely on emergency and safety net services—not Medicare—for most of their health care (Sammen, 2015).  This is evidence that insuring undocumented immigrants who would then have affordable access to preventative health care would actually lower health care costs.

 

There are some states that have taken action to individually extend benefits to undocumented immigrants because of the data that has demonstrated insuring this population would not only be beneficial to the people, but also a way to lower costs.  California and New York are finding ways to offer coverage through temporary work visas. Several other states offer coverage to various subsets of the undocumented immigrant population—such as children or pregnant mothers—although Colorado is not among these (Sammen, 2015).  The costs are most evident in emergency department usage.  Fewer health services are used by undocumented immigrants than US-born citizens or other immigrant groups. After adjusting for age and gender differences between groups, it was estimated that undocumented immigrants in California were significantly less likely to have any doctor visits in the past year compared to naturalized and US-born citizens (Wallace et al., 2012).  Because if the type of care and materials needed, critical care patients require more time, more specialty procedures, and more time to recover than those who come in for routine examinations or minor injuries.

 

While the Affordable Care Act was designed to be a “Medicare for all” program, many people living within the United States do not have the option to benefit from it.  A significant proportion of adults remain outside the ACA coverage expansion because of their immigration status. Undocumented immigrants are summarily excluded from all coverage expansion provisions in the ACA. The foreign born who do not meet the five-year residency requirement are ineligible for Medicaid (Pandey, Cantor, & Lloyd, 2014).  They are viewed as a drain on the economy.  What is not being considered is the labor conducted by these individuals for much less pay than their citizen counterparts and the taxes they pay without being able to reap any benefit from it.  For 2010, the Social Security Administration estimated that unauthorized immigrants and their employers paid $13 billion in required social security payroll taxes.  Unauthorized immigrants create demand for goods and services while an estimated 50 to 75 percent pay taxes.  Due to cheaper labor, they contribute to lower prices in the industries where they work, such as agriculture, restaurants, and construction.  An employer may benefit from the illegal status of a migrant who is desperate for work and therefore prepared to accept poor pay, usually below local norms. If paid under the table rather than using an ITIN, hiring an illegal worker also brings the employer the advantage of paying less in the way of welfare contributions and other non-wage costs.  Nearly every dollar earned by illegal immigrants is spent immediately, and the average wage for US citizens is $10.25/hour with an average of 34 hours per week. This means that approximately 8 million US jobs are dependent upon economic activity produced by illegal immigrant activities within the US (Rothstein & Coughlin, 2019).  The economic impact of removing undocumented immigrants from this country would be far more detrimental than providing health insurance for them.

 

For many years there has been a controversy about the economic effects of providing health care insurance to undocumented immigrants.  The Affordable Care Act (ACA) prohibits providing Medicare and Medicaid services for undocumented immigrants and for most cases their children as well.  They are also not allowed to purchase insurance through private insurance companies.  So if this is the case, why is healthcare insurance still so expensive?  Healthcare in the U.S. is about twice as expensive as it is in any other developed country. If the $3 trillion U.S. healthcare sector were ranked as a country, it would be the world's fifth-largest economy.  The cost of this huge financial burden for every household because of lost wages, higher premiums, taxes, and additional out-of-pocket expenses are more than $8,000. Even with all this money being spent on healthcare, the World Health Organization ranked the U.S. 37th in healthcare systems, and The Commonwealth Fund placed the U.S. last among the top 11 industrialized countries in overall healthcare.  Why is the U.S. paying so much more for care and not appearing at the top of the rankings (Epstein, 2019)?

 

Healthcare in the United States has been one topic of the debates and discussion in the country for many years. The challenge for affordable, accessible, and quality healthcare for most Americans has been on the agenda of federal and state legislatures (Stephens, Ledlow, Sach, & Reagan, 2017).  When President Obama was running for office, one of his biggest campaign promises was universal healthcare.  In order to make this happen within a majority Republican House and Senate, a tremendous amount of lobbying had to take place.  Lobbying is deeply institutionalized in the United States. It is embedded in the first amendment of the Constitution, processed through Political Action Committees (PACs), and empowered by the Supreme Court’s decision in Citizens United v. Federal Election Commission. Donations to PACs are facilitated by the Internal Revenue Service. The Lobbying Disclosure Act of 1995 provides for the disclosure of lobbying activities. Although President Barack Obama tried to curb lobbying practices, he could not ignore the key healthcare reform lobbyists. They had to be appeased in order to avoid their potential activities toward undermining the reforms (Spithoven, 2016).  This meant that healthcare for all only included people who had citizenship or legal status within the United States.

 

There are several contributing factors to the high cost of health care in America, but undocumented immigrants is not one of them.  Undocumented people in this country are generally barred from enrolling in health care plans.  Their children, in most cases fall into this category as well.  Undocumented children do not qualify for Affordable Care Act privileges or the Children’s Health Insurance Program (CHIP).  Six states and the District of Columbia have expanded their Medicaid programs to cover children through 18 years old (California recently approved coverage through age 25), regardless of immigration status. About 16 states cover income-eligible pregnant women, also regardless of residency status.  Many illegal immigrants receive primary care and prescription drugs for a sliding-scale fee at 1,400 federally funded health care centers spread across 11,000 communities. Those centers are required to treat anyone, regardless of ability to pay, and administrators do not ask patients about their citizenship status. The centers serve some 27 million people, but do not have estimates on how many are undocumented (Hoffman, 2019).

 

The cost of providing undocumented immigrants health care is unknown.  Independent experts have not been able to come up with an estimate, nor have the Congressional Budget Office.  Most economist’s feel that the expense would not have a large impact on the budget because providing primary and preventive care would prevent people from waiting until what aliment was bothering them would get to the point of needing to go to the emergency room.  Unauthorized immigrants contribute to the economy by paying sales taxes, income taxes and property taxes.  Although many undocumented immigrants are paid cash and off the record, others do have taxes on their income withheld by their employers and help fund social security, Medicare, and other government programs for which they are ineligible.

 

For the few programs that are eligible to undocumented immigrants, there tends to be underutilization for the health care services provided.  Across communities that line the United States’ southern border with Mexico, U.S. immigration enforcement actions in or near hospitals, clinics, and other health care facilities are putting increasing pressure on medical professionals to compromise patient care. Customs and Border Patrol agents conduct searches in hospital parking lots and hold ambulances at checkpoints while critically ill patients languish inside. Agents arrest patients about to undergo surgery, stand guard and refuse to unshackle patients during medical evaluations, and send undocumented patients into detention directly from hospitals, at times putting safe medical discharge into question (Stoughton & Hampton, 2019).  The Trump administration has increased their vigilance on removing this population through raids and deportations.  These facilities are one of the most susceptible areas for the U.S. Immigration and Customs Enforcement (ICE) to come and search for people who are not in the country legally.  ICE is one of the federal law enforcement agencies that is responsible for customs enforcement and immigration and works directly for the U.S. Department of Homeland Security.  In some households there is a mix of citizenship under one roof.  Some residents may be in the United States on a work visa, while another may have an expired visa and has not returned to their home country, and some may have come into the country illegally and live in hiding.  Approximately 8% (4.1 million) of children in kindergarten through 12th grade live in households in which 1 or both parents are undocumented.  Immigration and Customs Enforcement (ICE) has a sensitive locations policy, whereby it generally avoids enforcement actions in certain sensitive situations, but many unauthorized parents and children lack trust in the immigration system. They may experience such stress or fear about separation from their families that they even decline to receive necessary medical care.  Many fear that if they cooperate with any emergency measures public health officials will learn their citizenship status and report them to local police or ICE (Rothstein & Coughlin, 2019).

 

One of the largest gaps in fixing this administration and budget is not facing what is truly raising the cost of health care in America.  Administrative costs, drug costs, the practice of defensive medicine, and wages all seem to contribute extensively to the extremely high costs of healthcare in the United States instead of the undocumented immigrant population.  In the United States, drugs are more expensive, doctors and administrators get paid more, hospital services and tests cost more and managing the facility costs more.  The administrative costs of running our healthcare system are extremely high. About one-quarter of healthcare cost is associated with administration, which is far higher than in any other country.  There are 1,300 billing clerks at Duke University Hospital, which has only 900 beds. Those billing specialists are needed to determine how to bill to meet the varying requirements of multiple insurers. Canada and other countries with a single-payer system don't require this level of staffing to administer healthcare (Wallace, Torres, Sadegh-Nobari, Pourat, & Brown, 2012).

 

An additional significant difference in health care costs between America and every other developed nation is the cost of pharmaceuticals.  Within most countries, the government makes negotiations with the pharmaceutical companies to decrease drug prices.  When Congress created Medicare Part D, it specifically denied Medicare the right to use its power to negotiate drug prices. The Veteran's Administration and Medicaid, which can negotiate drug prices, pay the lowest drug prices. The Congressional Budget Office has found that just by giving the low-income beneficiaries of Medicare Part D the same discount Medicaid recipients get, the federal government would save $116 billion over 10 years (Epstein, 2019).  The United States could have benefited tremendously on savings for drug expenses if all Medicare recipients had the opportunity to benefit from drug prices that were influenced by Medicaid negotiated costs.

 

In the emergency room and throughout medical facilities, physicians are afraid of missing something or misdiagnosing a patient and getting sued.  There are very few emergency room doctors, general practitioners, or specialty physicians that are not mindful when it comes to this expensive behavior.  As detailed as the Affordable Care Act was, it failed to address one of the primary threats to inflated costs in healthcare: trial lawyers.  So many physicians order additional tests even when there has been a definitive diagnosis.  A 2012 survey conducted by the American Academy of Orthopedic Surgeons found that 96% of its doctors reported practicing defensive medicine. Researchers at Vanderbilt University found that the nation's orthopedic surgeons alone spent $173 million a month or $2 billion annually on X-rays, CT scans, MRIs, blood work, medications and other procedures that are not clinically necessary (Oliver, 2017).

 

The wages of medical staff also raise the costs of health care.  Physicians who have specialized in a particular field of medicine demand more pay for their skillset and services.  The overutilization of these specialists compounds the problem.  Several insurance plans will make you see your primary care physician before going to see a specialist, which many times results in a waste of time and resources.  Americans are becoming more educated about who takes care of them.  They want to be seen by staff with proper training and credentials.  Certified imaging technologists, registered nurses, licensed clinicians and so forth have proved mastery of their craft by passing a national registry exam of some sort that is recognized by an accrediting body.  Hiring these individuals requires paying more money for a higher skillset.

 

The Affordable Care Act does not enact a universal policy and health care plan for all.  It does bring to light that there is a problem with access that is not afforded to undocumented immigrants.  Undocumented immigrants are summarily excluded from all coverage expansion provisions in the ACA. The foreign born who do not meet the five-year residency requirement are ineligible for Medicaid. Although they are eligible for health insurance exchange subsidies, exchange plans are not as comprehensive as Medicaid, and unfamiliarity with private health insurance may make it difficult to navigate the health care system. Together, the prevalence of these two immigrant groups (recent arrivals and the undocumented) imposes limits on the ACA’s potential to advance health care access for immigrants (Pandey, Cantor, & Lloyd, 2014).

 

Another gap that the U.S. could work on to help people seeking a better life by coming into this country is providing basic logistical information.  The top information needs for longer established immigrants include: health information; employment information; educational information; political information and current events (especially news about the country of origin); language learning information; information about transportation; information about identity construction. As a result, a shift occurs in the environment, and provides information they would not have access to at all (Batuchina, Saveljeva, Viksne, & Staneva, 2018).  With this information, immigrants can have the opportunity to make better decisions and choices about coming into this country.  The opportunity to educate younger Latino adults about health care services available to their family who have legal status is also a gap.  Compared with Whites, Latinos were less likely to have employer-provided private coverage because of income and immigration status.  Latinos, for instance, were more likely to have jobs, such as part-time or seasonal work, with no insurance provided by employers (Chen, Bustamante, & Tom, 2015).

 

A solution has to be found to extend health care benefits to undocumented immigrants.  This is a challenging issue, and one that needs a lot more civil dialogue so we can develop real solutions. It’s important that we find a way to make our health care system inclusive that makes sense both fiscally and ethically. A way that allows undocumented immigrants to get the care they need when they need it, without increasing costs to other patients or the system, and without reducing access or care quality overall. Of course, there is no easy answer, but continuing to exclude undocumented immigrants from the health care system entirely not only hurts their health, but our economy as well (Sammen, 2015).

 

The Affordable Care Act (ACA) specifically addresses non-inclusion for undocumented immigrants.  This decision was influenced by political views and the uncertainty of the financial impact the country would endure if this population being included under the ACA.  The public was lead to believe undocumented immigrants are a drain on the economy.  Through political influence, citizens have been lead to believe this group is responsible for increased unemployment and crime.  Over time, undocumented immigrants have been given less and less right.  Unlike prior generations, the current residents cannot vote and have limited power to fight back politically.  The current healthcare reform has cause more financial strain by not insuring undocumented immigrants.

 

The ability of providers to practice evidence-based medicine is hindered by U.S. immigration enforcement actions that disrupt or impede patient treatment. In addition to forcing clinicians to compromise their ethical obligations, these actions may also violate U.S. laws and policies intended to secure fundamental ethical and legal protections for everyone, including non-citizens. These basic rights include non-discrimination and protections to ensure patient privacy and confidentiality (Stoughton & Hampton, 2019).  The impact of not getting preventive care and regular doctor visits for check-ups causes unnecessary emergency room expenses.  When immigration enforcement officials come to clinical care settings, it detours current and future patients from coming in to seek medical care until their condition becomes critical.

 

What it costs to treat undocumented immigrants differs widely and is hard to estimate.  Even if the patient comes in without health insurance, most medical facilities do not ask citizenship status.  The Center for Immigration Studies puts the total for uninsured undocumented immigrants around $4.3 billion per year.  What is less talked about is what undocumented immigrants pay into the health care system. New findings (PDF) suggest that this population contributes billions of dollars per year. The study, which looked specifically at Medicare, found that undocumented workers contributed $35.1 billion more between 2000 and 2011 than they received in care. Most pay taxes, but never become eligible for Medicare because of their status (Sammen, 2015).  Immigration reform is one of the key topics of elections and campaigns will either be data driven or fear driven.

 

Healthcare in the United States has been one topic of the debates and discussion in the country for many years. The challenge for affordable, accessible, and quality healthcare for most Americans has been on the agenda of federal and state legislatures (Stephens, Ledlow, Sach, & Reagan, 2017).  Almost all republican candidates and officials feel that the government should not insure illegal immigrants, while most democrats feel we should.  The thought process is trying to distinguish if the decision is economically sound versus morally sound.  Many researchers have determined that it can be both by insuring them and having a Medical for All health care system.

 

Many Americans are lead to believe that all undocumented immigrants are on welfare or other types of government assistance when in reality they are not eligible. They work, pay taxes, and contribute to the economy like everyone else.  Unauthorized immigrants are also prevalent in the US labor force. They constitute approximately 4.8% of the total US workforce, mainly working in low hourly wage jobs that lack benefits such as sick pay and job security. Furthermore, unauthorized immigrants comprise nearly one fourth of the total US workforce in agriculture and home health care (Rothstein & Coughlin, 2019).  There are some individuals who are paid off record with cash, but for those who are employed on record, they have the same federal and state taxes withdrawn from their income that for many cases is substantially lower than their coworkers who are U.S. citizens.

 

The Emergency Medical Treatment and Labor Act (EMTALA) requires that any individual coming into the emergency room, regardless of citizenship status or ability to pay, has to be seen, stabilized and treated.  Hospitals are required by federal law to treat those with life threatening conditions without regard to insurance coverage. As a result, the costs of emergency care and other treatment for undocumented immigrants without insurance usually becomes uncompensated care. This will be an increasing concern under the ACA since supplemental payments to Disproportionate Share Hospitals (DSH) will decline which have historically assisted with uncompensated care costs (Wallace, Torres, Sadegh-Nobari, Pourat, & Brown, 2012).

 

Immigrants accounted for $39.5 billion in health care expenditures. After multivariate adjustment, per capita total health care expenditures of immigrants were 55% lower than those of US-born persons ($1139 vs $2546). Similarly, expenditures for uninsured and publicly insured immigrants were approximately half those of their US-born counterparts. Immigrant children had 74% lower per capita health care expenditures than US-born children. However, emergency department expenditures were more than 3 times higher for immigrant children than for US-born children (Mohanty et al., 2005).  Because the Affordable Care Act does not cover this population, the debt that is being acquired by hospitals through their emergency departments will continue to grow.  The ACA specifically prevents non-lawfully present immigrants from enrolling in coverage through the exchanges [section 1312(f)(3)]. And they are also not eligible for Medicaid under federal guidelines. So the two major cornerstones of coverage expansion under the ACA are not available to undocumented immigrants (Norris, 2020).  Taxpayers and politicians express their concern on the potential burden of insuring undocumented immigrants but the burden of not insuring them will cost more.

 

Expanding health care coverage has been the focus of reformers for more than fifty years.  Legislation must find a way to be inclusive to everyone that lives and pays taxes in the United States.  Even if you were not born in the United States, you have paid into the system and government that funds healthcare by paying taxes.  Having a population of individuals who are considered illegal residents pay into a system that Americans benefit from and expect them not to receive the same benefits is irrational.  The ACA is the government’s attempt to rationalize this decision against undocumented immigrants.  The foreign born who do not meet the five-year residency requirement are ineligible for Medicaid. Although they are eligible for health insurance exchange subsidies, exchange plans are not as comprehensive as Medicaid, and unfamiliarity with private health insurance may make it difficult to navigate the health care system (Pandey, Cantor, & Lloyd, 2014).  This creates a huge gap in medical coverage and the attempt to lower the cost of health care.  Compared with Whites, Latinos were less likely to have employer provided private coverage because of income and immigration status, and thus might be less likely to benefit from the Affordable Care Act (Chen, Bustamante, & Tom, 2015).

 

There are assumptions that undocumented immigrants are here to sell drugs and commit crimes.  This stigma has been set by several politicians, social media, and news reporting.  People have been migrating in all times primarily in search of better living conditions and/or sources of income. However, in recent years, it has become particularly acute in the case of military conflict in countries, also due to labor shortage and the need for labor migration (Batuchina, Saveljeva, Viksne, & Staneva, 2018).  Americans have been told that illegal immigrants are criminals and should all be detained and deported immediately.  This misrepresentation will take time to erase.

 

For now free and charitable clinics in several states are the only options for undocumented immigrants.  These clinics are defined as “gap-fillers”.  The provision of health care to immigrant populations is a gap everywhere in the United States.  Immigrant populations are ineligible for care supported by federal funding. An individual may meet all the requirements for publicly assisted care – low income, residence in a community, etc, but lack of legal residency excludes them from coverage (Epstein, 2019).  Many illegal immigrants receive primary care and prescription drugs for a sliding-scale fee at 1,400 federally funded health care centers spread across 11,000 communities. Those centers are required to treat anyone, regardless of ability to pay, and administrators do not ask patients about their citizenship status. The centers serve some 27 million people, but do not have estimates on how many are undocumented (Hoffman, 2019).

 

Lobbying is deeply institutionalized in the United States. It is embedded in the first amendment of the Constitution, processed through Political Action Committees (PACs), and empowered by the Supreme Court’s decision in Citizens United v. Federal Election Commission. Donations to PACs are facilitated by the Internal Revenue Service. The Lobbying Disclosure Act of 1995 provides for the disclosure of lobbying activities.  Although President Obama tried to curb lobbying practices, he could not ignore the key healthcare reform lobbyists. They had to be appeased in order to avoid their potential activities toward undermining the reforms.  Consultations, negotiations, compromises, and deals with collective lobbying organizations kept most of them on board (Spitoven, 2016).  This lobbying did not take into account the financial burden the emergency departments would suffer by treating undocumented immigrants who could not treat their initial illnesses due to a lack of health insurance coverage and wait until the condition becomes critical.

 

A resolution to this crisis would be to adopt a similar health care system used in the United Kingdom.  Simply by virtue of existing on the soil of the United Kingdom—whether employed, retired, disabled, or a foreign visitor—every person residing in the country is entitled to receive tax-supported medical care through the National Health Service (NHS).  The great majority of NHS funding comes from taxes. As in Canada, the United Kingdom completely separates health insurance from employment, and no distinction exists between social insurance and public-assistance financing. Unlike Canada, the United Kingdom allows private insurance companies to sell health insurance for services also covered by the NHS (Bodenheimer & Grumbach, 2016).  The healthcare system in the United Kingdom is not a perfect system.  The wealthier residents have better access to health care through private insurance companies than those who come from a poorer background. 

 

While the commitment to universal access to health care financed on the basis of solidarity is a shared European one, the NHS has been a reference point as a strongly integrated model of public purchasing and provision with most care free at the point of use.  Although there have been substantial improvements in major health indicators such as amenable mortality over the past decades, there remains considerable scope for further improvement. Important health disparities remain between socioeconomic groups, and the gap between the most deprived and the most privileged continues to widen, rather than close.

 

The United States protects anyone on its soil from being turned away from an emergency room in a critical situation.  The basics of the Emergency Medical Treatment and Active Labor Act (EMTALA) may be simply stated and are easy to understand. The law requires that an individual who comes to an emergency department be medically screened to determine if he or she suffers from an emergency condition. If an emergency condition is diagnosed, the hospital will either treat or stabilize and transfer the patient in accordance with specific requirements (Moffat, 2018).  Not providing the necessary pathways for this population living in the United States to receive proper health care will result in many hospitals with emergency room services to go bankrupt. 

 

The Affordable Care Act also excludes insurance coverage for immigrants who are not legally in the United States. As some commentators have pointed out, continued access by uninsured immigrant populations seeking medical treatment could potentially lead to a situation where hospitals initiate a balance calculus of whether to treat the patient or not.  Public hospitals that face a practical decision of closing the emergency department and/or facing bankruptcy, or paying the fines under EMTALA, may weigh the costs against their ability to continue to operate.  Emergency medical costs associated with treating people who are in the United States illegally can be especially high because these patients often do not seek treatment until the situation has become severe (Moffat, 2018).  The two options are to either include undocumented immigrants in the United States for health care coverage or omit them from EMTALA guidelines.  To omit an entire population from a federally mandated law because of their immigration status is discrimination and would subject the country to law suits.  The only feasible solution would be to provide health insurance.

 

Since persons not legally resident in the United States are excluded from coverage by the ACA, the reduction in Disproportionate Share Hospital (DSH) funding can become a significant part of the controversy surrounding illegal immigration reform. Some commentators have pointed out that hospitals in Southwestern border-states cannot afford to wait for adequate compensation under the reduced DSH program.  It is likely that emergency room access by a large number of illegal, uninsured immigrants will continue, and if so, there will be an ongoing need for the mandates provided under EMTALA (Moffat, 2018).  The original purpose for EMTALA has been manipulated to meet political views.  It has been forgotten that EMTALA was designed to prevent "patient dumping" from private hospitals to public ones.  It was not intended as immigration legislation.

 

Studies have shown that all immigrants, not just undocumented immigrants, are less likely to use emergency services than their citizen counterparts.  Once America becomes an environment that allows everyone, regardless of their immigration status, to visit a doctor’s office and be seen without the fear of being detained or deported, medical expenses will decrease along with the population of chronically ill due to not receiving routine preventative care.  The financial contributions made by undocumented immigrants should entitle them to receive benefits.  In one of the most comprehensive analyses to date on the costs and benefits of immigrants to the US economy, the National Research Council concluded that immigrants add as much as $10 billion to the economy each year and that immigrants will pay on average $80,000 per capita more in taxes than they use in government services over their lifetimes.  The Social Security Administration estimates that workers without valid social security numbers contribute 8.5 billion dollars annually to Social Security and Medicare. Such workers, most of them immigrants, usually receive no eligibility credits for their contributions (Monanty et. al., 2005).  Undocumented immigrants have less access to health care, medications, and treatment than do Americans that are born in the United States.  This is indicative of their lower health expenses.  Insurance coverage increases access to medical care which will ultimately increase the utilization of care.  This will result in improved health outcomes and lowered medical costs in the emergency departments thus demonstrating the need to insure undocumented immigrants.

 

References:

 

Batuchina, A., Saveljeva, R., Viksne, G., & Staneva, Z. (2018).  Information about the host country before immigration: how is it related to immigrants’ basic sociodemographic characteristics?  Regional Formation & Development Studies, 2(25), 5-13.

 

Bodenheimer, T. & Grumbach, K. (2016). Understanding health policy: A clinical approach (7th ed.). New York, NY: McGraw-Hill Professional.

 

Chen, J., Bustamante, A. V., & Tom, S. E. (2015).  Health care spending and utilization by race/ethnicity under the Affordable Care Act’s dependent coverage expansion.  American Journal of Public Health, 105(1), S499-S507.

 

Epstein, L. (2019, July 30).  Six reasons healthcare is so expensive in the U.S.  Retrieved from

https://www.economics.com/articles/personal-finance/080615/6-reasons-healthcare-so-expensive-us.asp.

 

Hoffman, J. (2019, July 3).  What would giving health care to undocumented immigrants mean?

The New York Times, Retrieved from

https://www.nytimes.com/2019/07/03/health/undocumented-immigrants-health-

care.html.

 

Grosios, K., Gahan, P. B., & Burbidge, J. (2014, December).  Overview of healthcare in the UK.  Retrieved from https://www.researchgate.net/publication/299941121_United_Kingdom_Health_System_Review

 

Mohanty, S. A., Woolhandler, S., Himmelstein, D. U., Pati, S., Carrasquillo, O., & Bor, D. H. (2005).  Health care expenditures of immigrants in the United States: a nationally representative analysis.  American Journal of Public Health, 95(8), 1431-1438.

 

Moffat, J. C. (2018).  Afterward: EMTALA and the Affordable Care Act.  The EMTALA Answer Book, New York, NY: Aspen Publishers Inc.

 

Norris, L. (2020, January 27).  How immigrants can obtain health coverage.  Retrieved from https://www.healthinsurance.org/obamacare/how-immigrants-are-getting-health-coverage/

 

Oliver, W. (2017).  Ending defensive medicine is key to containing health care costs.  Invertors Business Daily, 781(2), 9-10.

 

Pandey, S. K., Cantor, J. C., & Lloyd, K. (2014).  Immigrant health care access and the Affordable Care Act.  Public Administration Review, 74(6), 749-759.

 

Rothstein, M. A. & Coughlin, C. N. (2019).  Ensuring compliance with quarantine by undocumented immigrants and other vulnerable groups: public health versus politics.  American Journal of Public Health, 109(9), 1179-1183.

 

Sammen, J. (2015, July 14).  Finding room for undocumented immigrants in the health care system.  Retrieved from http://centerforhealthprogress.org/blog/finding-room-for-undocumented-immigrants-in-the-health-care-system/?gclid=CjwKCAiA1L_xBRA2EiwAgcLKA6vEeH9iILN684rI9kW49IvY_YPeGZJHqspjHxQdKzX-T0o4_YGczBoCFDwQAvD_BwE.

 

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