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Health Care Special Issue: Foreign Bodies

Last October, Dr. Jack Ludmir, the head of obstetrics and gynecology at Pennsylvania Hospital, oversaw the emergency-room treatment of a young woman who was seven months pregnant, hypertensive, and convulsing. Although her condition was, according to Ludmir, "rarely seen in the United States," his team diagnosed it quickly: She was suffering from eclampsia, a severe pregnancy- related disorder that can lead to premature birth, seizure, stroke, even death. In this country, the condition is usually caught in its early stage known as pre-eclampsia, which can often be managed with prenatal care; but, with the mother already in the ER, doctors had no choice but to deliver the baby prematurely.

Over the next three months, the newborn was threaded with respiratory tubes while doctors flushed the mother's brain of excess blood three times. "You can't imagine the costs," says Ludmir. For as little as a few hundred dollars worth of prenatal care, he says, this tragedy--and at least

$250,000 of medical care--could have been avoided. Unfortunately, this was not an option. The mother was an undocumented immigrant and therefore was ineligible for publicly funded prenatal carein Pennsylvania.

The one health care issue that Republicans and Democrats agree on these days is that illegal immigrants like Ludmir's patients should not have access to publicly funded health care. Republicans see this as a facet of the immigration issue--House Minority Leader John Boehner recently issued a press release charging that providing health care to illegal immigrants "increase[s] the tax burden on American families," while conservative commentators like Michelle Mal- kin are more naked in their hysteria, warning that the United States is in the midst of becoming "the land of the limit-less health care handout for 'undocumented immigrants.'"

The Democrats, meanwhile, are too cowed by the anti-immigration lobby--and the prospect of losing support for their individual health care plans--to defend the undocumented. Hillary Clinton and John Edwards have already decided to exclude illegal immigrants from their universal-coverage proposals, while Barack Obama has held his tongue on the issue. As a result, doctors such as Ludmir are likely to continue to see undocumented immigrants when their medical situation is most dire--and costly to society.

This isn't the first time that the combination of Republican hostility and Democratic timidity on the immigration issue has adversely shaped policy. In 1996, as part of welfare reform, Republicans insisted on banning legal immigrants from receiving Medicaid and s-chip (which assists families that make too much to qualify for Medicaid) for the first five years of their residencies. President Clinton grudgingly agreed to the provision in order to shepherd the welfare-reform bill through Congress. The Republican argument that cheap public health care was attracting impoverished illegal immigrants into the country has since been called into question: In 2000, a study from Health Affairs found that less than 1 percent of undocumented immigrants "cited obtaining social services as the most important reason for immigrating." But, although its foundation has rotted, the policy still stands, setting the tone of the current debate: If we don't provide publicly funded health care even to some legal immigrants, why extend it to illegal ones?

There are currently 12 million undocumented immigrants in the United States-- the majority of whom are uninsured. Among all immigrants, both documented and undocumented, less than 40 percent receive employer-sponsored coverage. The only federal health care program that covers undocumented and newly arrived legal immigrants is known as "emergency Medicaid." Under this program, the government will pay for emergency hospital care for the pregnant, elderly, and disabled, and for children or the parent of a child. (Although what, exactly, qualifies as an "emergency" is ambiguous: The federal government recently informed New York state that it would no longer fund chemotherapy.) Those who do not qualify for emergency Medicaid must pay for their treatment out of pocket, or the hospital must write it off as uncompensated care for which it should eventually be reimbursed, at least in part, by the federal government.

While it is true that the ER expenses of immigrant children are greater than the per capita average, probably because they are sicker when they finally seek care, immigrants tend to spend less money on health care than their U.S.-born counterparts. (One study in the American Journal of Public Health found that, in 1998, the average health care expenditures of a Hispanic immigrant, documented or undocumented, totaled

$972. For a white, U.S.-born citizen, they were over $3,000.) Part of the reason for this discrepancy is because immigrants are, on average, younger and healthier than citizens. This would seem to be an argument for keeping the current system rather than expanding coverage, which tends to raise expenses as patients become insulated from the costs of their care. But, although immigrants may arrive in this country healthier, they regress toward the mean, developing many of the chronic conditions, such as heart disease and diabetes, endemic to U.S.-born citizens. They are also aging as a population. As a result, the number of disabled and elderly illegal immigrants is on the rise, and a recent study of North Carolina's emergency Medicaid system found that "[t]he largest spending increases [among the undocumented] ... are occurring among the elderly and disabled groups."

The obvious way to contain these costs is to insure the undocumented, so that they have access to preventive care before they degenerate into the tax siphons conservatives already claim them to be. And there is an additional reason to take this step: public health. Just a few unvaccinated individuals can threaten a whole community, a threat that is particularly acute among the undocumented, since they often work in the food service and agricultural industries. Unfortunately, Democrats continue to conflate the health care issue with the immigration one. Clinton and Edwards claim the health care problem will solve itself after they pass comprehensive immigration reform with a path to citizenship. But this is unlikely to happen anytime soon, and, by the point it does, the benefits of incorporating the undocumented population today, while it's still largely young and healthy, will have expired.

In the regrettable absence of comprehensive federal legislation, there are some smaller, more feasible measures that should be considered. One is to extend publicly funded health care to all legal immigrants. The second is that more states should extend prenatal care to the undocumented. On this front, the federal government has already done its part: In 2002, President Bush expanded s-chip eligibility to fetuses, giving states the option to cover the prenatal care of mothers ineligible for Medicaid, including undocumented immigrants. Disappointingly, most states, including a majority of the so-called "new-growth states"--those states whose immigrant populations grew most quickly in the 1990s--have not accepted the federal government's offer and provided the necessary matching state funds.

This is unfortunate, because there are compelling reasons to do so. A study by researchers in Colorado, a new-growth state, found that only 52 percent of the state's undocumented women received prenatal care during the first trimester, as opposed to 83 percent of all other women. Consequently, 40 percent of undocumented mothers experienced a complication of delivery, as opposed to less than 30 percent of all other mothers. And, beyond the moral imperative, there's an economic one. Researchers in California, the epicenter of undocumented immigration, have estimated that one dollar in prenatal care can save over three dollars in postnatal care. (California, as it happens, is one of the 15 states that provides prenatal care to its undocumented residents. ) Prenatal care isn't just a drop in the bucket of spending on the undocumented either: Over 80 percent of emergency Medicaid spending on the undocumented in North Carolina, whose immigrant population nearly quadrupled in the 1990s, was for childbirth and complications of delivery.

Jack Ludmir's patient would certainly have benefited from this limited expansion of preventive health care. Her eclampsia left her partially paralyzed, in poor condition to care for a sickly child--one who, it's worth noting, is a U.S. citizen whose continued care taxpayers must now fund.