In Tennessee, an undocumented man in his 50s sat in a crowded waiting room at a Vanderbilt emergency room. As time passed, patients with trauma or chest pain passed him on stretchers for treatment. The treatment this man needed, dialysis, is as lifesaving as emergency surgery, but as inappropriate for an emergency room as the cut on his toe. But Tennessee doesn't provide undocumented immigrants with the insurance they need to use outpatient dialysis centers, so emergency rooms are the only place they can receive treatment.
I took care of this gentleman who worked at the Shade Tree Clinic as a medical student at Vanderbilt University. Shade Tree Clinic is a student-run clinic that helps uninsured and undocumented Tennesseans receive free primary care. But after years of no preventive care due to being in the country illegally, the blood pressure and diabetes management we provided him was too late for his kidneys, and he was sent to Tennessee three days a week for dialysis. I had no choice but to visit the emergency department.
In Massachusetts, where I am currently a primary care resident, the story is much different. An illegal immigrant in his 20s reported to the clinic seeking free services. When he came from Colombia, he heard that insulin was rationed because supplies were limited and there were no prescribers in the United States. However, he is a patient of mine because he is covered by MassHealth Limited, which is insurance for illegal aliens paid for by state taxes under Massachusetts Medicaid (MassHealth). Because he has insurance, he can receive treatment for his diabetes and a prescription for insulin, preventing unnecessary and costly emergency room visits, hospitalizations, and even time in the intensive care unit. Here, state resources can be used to keep patients like him out of the emergency room.
Unfortunately, most states are like Tennessee. Undocumented immigrants have limited options for low-cost preventive care in clinics, leading to costly reactionary care in emergency departments and hospitals. Ultimately, the cost of this hospital treatment will be covered by taxes, similar to state-run insurance for undocumented patients. Ironically, emergency medical care costs even more. But Massachusetts has become a model for other states, using tax dollars more effectively to provide routine care to undocumented immigrants and avoid more costly emergency room visits. It shows that it can be used.
There are several barriers to collecting data on potential cost savings. People understandably try to keep their undocumented status private, and comparisons of direct costs between states are confounded by the burden of chronic disease, density of ambulatory health workers, and other local measures. But there's a lot we do know for sure.
First, nationwide, one-third of undocumented immigrants are no longer able to access regular medical care. Progressive chronic diseases due to lack of preventive care result in a significant economic burden of $4 trillion, including treatment costs and lost economic productivity. Second, hospital treatment is more expensive than office treatment, and lack of insurance is strongly correlated with emergency department visits, many of which are preventable. Eliminating preventable emergency visits could save $4.4 billion annually.
States pay for health insurance for undocumented immigrants because the majority of these people receive federal Medicaid (which covers low-income households, including children and pregnant women, and people receiving Supplemental Security Income) or This is because they are not eligible for insurance through Medicare (which covers people receiving Supplemental Security Income). It covers people over 65 or younger people with certain medical conditions, such as Lou Gehrig's disease. A few states, including Massachusetts, offer insurance options to undocumented immigrants through state-funded Medicaid. But 50% of undocumented adults remain uninsured, compared with about 5% of U.S.-born citizens, according to a report by the Kaiser Family Foundation. And it explains why 40% of undocumented adults say the emergency room is their only option for medical care.
Expanding health insurance for illegal immigrants will of course cost money, but it's important to remember that illegal immigrants actually pay taxes. Illegal immigrants from Mexico alone pay more than $12 billion in federal and state taxes, including taxes reported through Individual Taxpayer Identification Numbers (an alternative to Social Security numbers), payroll deductions, and sales tax. This data reflects that 96.7% of Mexican immigrants are employed (Mexican immigrants make up over 11% of the US agricultural workforce). It's also important to recognize that tax dollars are already being spent on medical care for illegal aliens. We just don't do it as efficiently as we could.
Hospitals suffer losses due to large unpaid bills resulting from hospitalizations and emergency room visits for low-income Medicaid and uninsured patients, including U.S. citizens and illegal immigrants, and Medicare and Medicaid payments to hospitals account for a high proportion of medical costs. partially offset by These patients. In 2016, about 65% of the $38 billion in unpaid health care costs was covered by federal subsidies. A program called Emergency Medicaid reimburses hospitals for emergency treatment of undocumented immigrants, but standards for what qualifies as an emergency vary by state, and many hospitals do not reimburse for treatment. is. That means we're spending our tax dollars on emergency treatment for problems that can be prevented or treated with routine treatment in the doctor's office, like my patient's end-stage renal disease in Tennessee.
With the number of undocumented immigrants in the United States growing to more than 11 million and hospitals often already over capacity, we need to be strategic about redistributing health care from hospitals to clinics. Although it may seem counterintuitive, providing insurance options for undocumented immigrants can divert care for undocumented immigrants from the emergency room, saving money and making it easier for everyone. patient experience will be improved.
States that have not expanded Medicaid and still have significant uninsured populations, including Americans, offer important lessons. The sickest of these patients typically qualify for Medicare or Medicaid by other criteria. For example, citizens with end-stage renal disease who require dialysis or certain disabilities can qualify for Medicare in any state. At the very least, state Medicaid would be able to do the same for undocumented immigrants who meet similar criteria. For example, Utah's legislature recently created “alternative eligibility requirements” to cover undocumented children under the state's Medicaid.
Such moves are a reminder that health care access and cost is a bipartisan issue. Providing health insurance to illegal immigrants ultimately benefits us all by lowering costs and creating capacity to respond to genuine medical emergencies. At this time, there is no clear path to expanding federal Medicaid to include coverage for undocumented immigrants. Therefore, it will continue to be up to states to choose preventive rather than reactive treatment by expanding insurance to cover illegal immigrants.
As a physician who has practiced in states that have chosen to expand coverage and states that have not, the right choice is clear to me. I hope more states follow the Bay State's lead.
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