Punishing People by Denying Them Health Care

What if someone proposed a law to deny federally subsidized health insurance coverage to anyone who has violated a federal law?  And to make sure the punishment really hurts, to make it impossible for their children to get health insurance?  And to prohibit them from buying private health insurance at their own expense? And to impose such punishments even if they haven’t actually been charged and convicted of a crime?

The result would be tens of millions of U.S. residents losing access to health insurance coverage–from college students who use marijuana to CEOs who don’t report all of their income to the IRS to airline passengers who refuse to follow lighted signs and placards, each a violation of federal law.

If such a law were proposed, my guess is that most people would be outraged.

But denying access to healthcare for the millions of persons who are in the United States in violation of federal law (undocumented persons) is exactly what is being proposed by amendments being offered this week to a bipartisan Senate immigration reform bill. (To be accurate, being present in the United States in violation of federal immigration law is not, standing alone, a crime, although entering the U.S illegally can be a misdemeanor or a felony, depending on the circumstances.)

The Senate’s bipartisan immigration reform bill would create a pathway for undocumented persons to transition to provisional legal residency status and then to permanent legal residency and later, if they meet all of the bill’s many conditions, become citizens. How their immigration status would affect access to federal health care programs has become a flashpoint in the debate.

The bill as introduced would continue current federal laws that make undocumented persons ineligible for non-emergency Medicaid coverage, Medicare, or subsidized coverage under the ACA.  But once those previously undocumented persons achieve permanent legal residency status, they would, after a waiting period, be able to apply for federal health benefits, like any other permanent legal resident with a green card.  The bipartisan group of Senators that put together the bill generally agree with the principal that people in the U.S. who are not legal residents should not have access to federal health benefits, but after they gain permanent legal residency, they should be treated like anyone else who has the same legal status.

But several amendments up for debate this week would punish undocumented persons by, on the one hand, forcing them to buy health insurance they can’t afford, and then on the other hand, making it harder and longer for them to qualify for federal health benefits even after they attained permanent legal residency status.  The American College of Physicians, in a letter sent on Monday to the entire U.S Senate, pointed out the deleterious impact such amendments would have on immigrants’ access to health care and specifically, ACP made the following recommendations:

“ACP opposes legislation that would subject persons with registered provisional immigration status to the requirement that they purchase health insurance when they will have no ability to obtain subsidies to make such coverage affordable. According to the Institute of Medicine’s Insuring America’s Health report, inability to afford coverage is the primary reason people are uninsured. The College believes that to be successful, a requirement to purchase health insurance (i.e. an individual mandate) cannot exist on its own – it must be established along with comprehensive health insurance reforms that include subsidies to make coverage affordable for the uninsured, reforms to stabilize costs and ensure access, and an enforcement mechanism to guarantee compliance. The ACA established these reforms along with the requirement that individuals purchase health insurance. The College strongly believes that the individual mandate should only be established along with appropriate subsidies to help people purchase and afford quality coverage. Under the current reforms and proposed legislation, individuals with registered provisional immigration status would not be eligible for the ACA subsidies, including premium tax credits and lower co-payments. Therefore the College would oppose enforcing the individual mandate on individuals with registered provisional immigration status. Imposing this requirement would likely put undue financial strain on these individuals to purchase insurance that is beyond their financial means.

ACP supports allowing undocumented persons, as well as those with registered provisional immigration status, the ability to buy coverage through the ACA’s health exchanges at their own expense, without federal subsidies or an individual insurance requirement. As discussed above, the College would oppose requirements for individuals with registered provisional immigration status to purchase health insurance. However, the College supports allowing these individuals to purchase insurance through the ACA’s health exchanges using their own funds. The College opposes policies that prohibit persons, regardless of their residency status, from paying out-of-pocket for health insurance coverage through the health exchanges.

ACP supports treating all lawfully permanent residents the same when making determinations on qualifying for the ACA’s subsidies, access to exchanges, Medicaid coverage under the ACA, and other federal health benefit programs. Persons who have transitioned from registered provisional immigration status specifically should not be subjected to longer waiting periods or other benefit restrictions, other than those already imposed on lawfully permanent residents.

ACP opposes legislation that would make it practically impossible for undocumented residents to ever achieve a status that would enable them to qualify for federal health benefit programs that are available to lawful permanent residents, once such undocumented persons achieve lawful permanent residency status. The College also opposes polices that would deny them the ability to achieve provisional or lawful permanent residency based on a determination that they would likely receive government benefits including health coverage under the ACA, Medicaid, CHIP, or other federal health programs.”

The College’s letter noted that immigrants contribute more to funding federal health programs than they take out in benefits. “A recent Health Affairs article found that immigrants, particularly noncitizens, heavily subsidize Medicare through several ways including self-employment taxes and payroll taxes. Researchers found that in 2009, immigrants contributed $13.8 billion more to the Hospital Insurance Trust Fund than it paid out on their behalf. In addition, immigrants, especially non-citizens, use less health care and spend less on health care than do the U.S.-born.”

ACP concluded that, “in balancing the needs of our country, it is imperative that immigration reform legislation addresses access to health care for all immigrants. Access to health care for the immigrant population is important to the overall population of the U.S. ACP is strongly committed to advocating for increased access to quality health care for all, regardless of race, ethnicity, socio-economic status, or other factors.”

Yet as important as this issue is for access to healthcare, it seems like much of organized medicine, unlike ACP, is sitting this one out.  Where is the AMA?  State and county medical societies?  Other specialties?  Where are the individual and collective voices of physicians in expressing to their Senators that the medical profession is united in opposition to laws that limit a patient’s  access to health care in order to punish them for violations of immigration laws?

The Institute of Medicine has found that tens of thousands of U.S residents die because they lack health insurance.  Making it harder for immigrants to get coverage, then, is not just a slap on the wrist, but can be a form of capital punishment for what is, after all, usually just a misdemeanor offense under federal law. 

Today’s question:  Do you think more physicians should speak out against proposals to punish undocumented persons by denying them access to health care?