Sep, 25, 2012— -- Many poor and uninsured patients, a disproportionate number of whom are chronically ill as a result of not having regular medical attention, turn to the emergency room as a main healthcare provider.
And federal law requires hospital emergency rooms to evaluate and stabilize all patients regardless of their ability to pay.
But the Affordable Care Act, President Obama's healthcare overhaul, cuts aid hospitals use to pay for emergency care, a move that hits undocumented immigrants particularly hard.
While the Affordable Care Act sets up state exchanges to reduce the cost of health insurance, people are required to prove citizenship or legal immigration status to use them.
Healthcare and Deferred Action Recipients
The Obama administration recently ruled that undocumented young people granted deferred action, renewable, two-year reprieves from deportation, will not be eligible for taxpayer-subsidized healthcare under the Affordable Care Act.
This means that such young people, many of whom are Latinos brought into the country as small children, will not receive access to Medicaid or CHIP, which insures poor children.
Immigrants granted deportation relief would generally be categorized as "lawfully present," which would allow them to apply for government subsidies to buy private insurance as part of the new healthcare law, but they have been specifically left out of that category by the administration.
Jennifer Ng'andu, deputy director of the Health Policy Project with the Hispanic advocacy group National Council of La Raza says deferred action recipients have traditionally been considered to be lawfully present in the country, and should continue to be.
"We are not calling for anything other than what has been set forth," Ng'andu said.
"I think it's a real challenge in terms of the Affordable Care Act, because it's sending mixed messages to the Latino community," she said. "Latinos are highly confused about what is in the law for them."
"It reinforced the notion that when it's politically convenient, the administration is catering to Latinos, and when it's politically inconvenient, they're more than happy to put restrictions in place so it sends mixed signals," she said.
Calling the deferred action program a "half measure," Ng'andu says recipients are exactly the type of people the country should want in the healthcare system.
"They're by definition young, they're going to be working, they're getting higher education, or they're in the military…all things that indicate they're likely to be prosperous and healthy, and giving them the ability to have access to health insurance would benefit the entire country."
Such immigrants will still be able to receive health insurance through employers, but obtaining coverage will be difficult if they do not have a job that provides it, notes the New York Times.
The federal government spends about $20 billion each year to reimburse these hospitals, reports the Times, for treating more than their fair share of the uninsured, including undocumented immigrants. But the new healthcare law cuts that funding in half, based on the idea that fewer people will lack health insurance under the new law.
Emergency Rooms as Primary Care
A report by the New England Healthcare Institute estimates that the nation spends as much as $32 billion each year treating chronic and non urgent problems with emergency care instead of primary care. According to the organization, the same care costs two to five times less at a primary care doctor.
Rachael Kagan, a spokeswoman for San Francisco General Hospital, says it's too early to judge the potential impact of the Affordable Care Act.
She says it's still unclear whether expanding Medicaid, which in California's case is Medical, will lead to a reduction in Disproportionate Share Hospitals funds, which support, in part, emergency rooms at hospitals that serve a disproportionate number of low-income, including undocumted, patients.
Right now, according to Kagan, about 31 percent of San Francisco General's in-patient population is uninsured, while another 39 percent are Medical, and about 22 percent have Medicare. Only three percent have private insurance, and six percent fall under the "other" category which includes incarcerated patients and those covered by worker compensation.
San Francisco General offers not only emergency services, but urgent care clinics and a variety of primary care options to all patients, regardless of their insurance status, which makes them somewhat unique.
But San Francisco offers more opportunities for healthcare to undocumented immigrants than most cities, and emergency rooms are not just serving the poor and uninsured.
Emergency rooms "are currently the only place in the U.S. health care system where an individual has access to a full range of health care services at any time, without regard to ability to pay or severity of the condition," reads a statement from the NEHI.
They are also open at all hours and staffed with highly paid specialists.
And it's expensive for taxpayers. The costs of providing people social services, including programs such as Medicare and Medicaid, and unpaid emergency room bills are absorbed into increasing healthcare prices and insurance premiums.
Many hospitals are cash-strapped and struggling to provide care, and several major public hospitals have closed over the last decades, leaving those without other care options to travel further or to skip treatment altogether. According to a report by the Kaiser Family Foundation, Philadelphia General Hospital closed in 1977, St. Louis City Hospital closed in 1987, DC General Hospital closed in 2001, and Los Angles' Martin Luther King Jr. Hospital closed in 2007, partially due to a lack of adequate institutional safety nets, all of which had served particularly vulnerable patients.
It's important to point out that the president's Council of Economic Advisers has estimated that undocumented immigrants pay $80,000 more in taxes per person than the consume in government benefits over their lifetimes, reports the New York Times. Mitt Romney's Take
But James Edwards, a fellow at the Center for Immigration Studies, an anti-immigration group, says deferred action recipients should not be granted access to government-subsidized programs such as Medicaid or CHIP.
"It's a temporary program and to include them would cause a number of problems," he said. "It would work as a kind of a disadvantage to the lawfully present, the legal immigrants who abided by the rules."
"We're talking about finite federal dollars funding a number of health programs," he said. "And there's also the fact of 'What happens at the end of two years?' Say there's a new administration. Then you have a class of people who would've benefited for awhile but then all of a sudden it's taken away."
He added that 'none of that's to say that anybody would advocate depriving anyone of access to emergency care. Emergency care will continue to be available to the legal, illegal, and otherwise."
He pointed out that the healthcare law will increase funding for community health clinics, many of which serve undocumented immigrants.
Edwards isn't alone in suggesting undocumentd immigrants turn to emergency rooms for medical care. Mitt Romney recently suggested that the emergency room serves as a good substitute for the uninsured during a 60 Minutes interview.
"Well, we do provide care for people who don't have insurance," Romney said. "If someone has a heart attack, they don't sit in their apartment and die. We pick them up in an ambulance, and take them to the hospital, and give them care. And different states have different ways of providing for that care."
"Some provide that care through clinics. Some provide the care through emergency rooms. In my state, we found a solution that worked for my state. But I wouldn't take what we did in Massachusetts and say to Texas, 'You've got to take the Massachusetts model,'" he added.
Ng'andu cautions against relying on emergency rooms, though, and says people need other options. Community health providers are a good start, she added, but there just aren't enough.
"Emergency rooms are used as a measure of last resort," she said, "and people are often more likely to come in sicker, with more exacerbated condition, and because of that, they're more expensive to treat."