Without another pool of potential enrollees, the Affordable Care Act likely will face enrollment stagnation — and that could threaten the country’s steadily falling uninsured rate.
Expanding health coverage to undocumented immigrants could help prevent that — and do a lot more. “Road to Reform” this week takes a look at that population and the arguments for and against expanding health insurance to its members.
Nowhere To Go But Down … for Now
After years of increases before the ACA, the rate of uninsured has since plummeted. In fact, CDC pegs last year’s uninsured rate at 11.5%.
But there are still 36 million or so uninsured U.S. residents. And there are fewer sources to “recruit” from.
According to the Urban Institute, the remaining uninsured population mostly comprises young and low-income adults, as well as Hispanics.
Several states last year stepped up enrollment efforts to reach these populations. However, after two rounds of sign-ups, the most eager — and most likely — people to purchase a health plan already have done so. And outreach efforts have largely fallen flat.
For example, in California and New York — which both have large Hispanic populations — enrollment increased by just 1% and 10%, respectively from the first enrollment period to the second.
If the remaining uninsured continue to forego coverage, whether they can’t afford it or are unmotivated by financial penalties or other factors, the pace of enrollment inevitably will plateau, sooner than it would if enrollment efforts were revamped.
Where should states refocus those efforts?
While there are several populations in the U.S. with particularly high rates of uninsurance, there is one untapped source: undocumented immigrants.
Under current rules, though, such individuals have very limited access to health care.
Undocumented Immigrants by the Numbers
By most projections, there are about 11.2 million to 11.4 million undocumented immigrants in the U.S.
A Pew Research Center report shows that the states with the largest undocumented immigrant populations include:
California, with 2.45 million undocumented immigrants;
Texas, with 1.65 million;
Florida, with 950,000; and
New York, with 750,000.
Just six states, including these four, account for 60% of the country’s undocumented immigrants, according to the report.
Of the 11.2 million undocumented immigrants nationwide, 5.1 million are likely to be uninsured by 2016, according to the UCLA Healthy Policy Research Center. That leaves a fairly large source of people to enroll in coverage.
However, undocumented immigrants are explicitly barred from ACA coverage.
The High Cost of Limiting Access
According to the National Immigration Law Center, undocumented immigrants — unlike their documented counterparts — do not have access to:
Private coverage through federal or state exchanges;
Subsidies to help pay insurance premiums; or
Medicare, non-emergency Medicare, or Children’s Health Insurance Program coverage.
Undocumented immigrants do have access to:
Emergency Medicaid coverage if they meet income eligibility requirements; and
Non-emergency care at community health centers and safety-net hospitals.
According to the Migration Policy Institute, more than 7.5 million undocumented immigrants rely on safety-net clinics and emergency departments because they cannot obtain coverage. (States also have some flexibility to expand coverage on the county level).
These emergency services can be costly to the U.S.
In 2009, the Center for Immigration Studies estimated that care provided by safety-net facilities for uninsured and undocumented populations cost the U.S. $4.3 billion per year. Meanwhile, Kaiser Health News reported that in 2013, Medicaid emergency care costs for undocumented immigrants reached about $2 billion annually.
Concerns that undocumented immigrants overuse costly medical services, or even utilize those for which they are ineligible, are common.
But some recent evidence suggests that undocumented immigrants might not place as much of a financial strain on the country’s health care system as previously thought.
One study, published in the Journal of General Internal Medicine, found that undocumented immigrants contributed a $35.1 billion surplus in the Medicare Trust Fund between 2000 and 2011. Each year during that time period, undocumented immigrants paid between $2.2 billion and $3.8 billion more to the Hospital Insurance Trust fund than they withdrew, the study reports. (Payments to HITF are largely made through payroll taxes and interest on past surpluses).
The study concludes, “If unauthorized immigrants had not contributed to nor drawn HITF funds from 2000 to 2011, the HITF would become insolvent in 2029 — one year earlier than is currently predicted by Medicare’s Trustees based on their intermediate cost assumptions.”
In addition, if undocumented immigrants were granted legal status, the report notes, they could potentially contribute a $45.7 billion surplus to the fund between 2012 and 2019, compared with a $44.1 billion without such status.
Meanwhile, a separate study published last year found that undocumented immigrants visit the ED and use other medical services at rates lower than many U.S.-born residents and documented immigrants, despite widespread concern that such individuals overuse emergency services.
Advocates say that helping undocumented immigrants access regular primary care services would decrease their use of EDs and safety-net clinics and subsequently lower costs.
“There are no preventive health measures, so [undocumented immigrants] end up having to use emergency care,” Frank Rodriguez, president of Texas’ Latino Health Care Forum, told the International Business Times.
Expansion Stalling in Face of Opposition
Despite the evidence, persistent concerns are likely to stall any moves to expand insurance to undocumented immigrants.
One concern is the cost to states that do move forward.
In California, Democratic lawmakers were forced to strike from their budget plan a proposal to expand Medi-Cal coverage to all undocumented immigrants in order to reach a deal with other lawmakers and Gov. Jerry Brown (D) who had fought over the high cost. Instead, the state passed a budget that will expand coverage to 170,000 undocumented immigrant children under age 19. But it’s still projected to cost $40 million in the next fiscal year and about $132 million annually following implementation.
Meanwhile, some critics say expanding health care access would encourage more illegal immigration, which, in turn, would further strain the social and emergency programs that already serve undocumented immigrants.
Ira Mehlman, a spokesperson for the Federation for American Immigration Reform, told the Los Angeles Times, “County hospitals are overwhelmed with uninsured people, and they’ve been forced to come up with more money to accommodate these people — largely because they’ve encouraged them to come in.”
Around the nation
Here’s a look at other stories making the news on the road to reform.
Up and up. Citing costly specialty drugs and consumers’ medical needs, some insurers across the country have proposed premium rate hikes for 2016 health plans that range from 20% to more than 40%, Robert Pear writes in the New York Times.
Victory lap. In a recent trip to Nashville, Tenn., President Obama touted the Affordable Care Act’s success and called on states to continue increasing access to health care, such as by expanding Medicaid under the ACA, Darlene Superville writes in the AP/San Diego Union-Tribune.