Health insurance for undocumented immigrants? It’s only fair to all of us

On the second night of the first debate, major Democratic candidates for president including Joe Biden, Kamala Harris, and Bernie Sanders raised their hands to show that they are in favor of extending health insurance coverage to undocumented immigrants and it now seems that every major Democratic candidate supports this notion. 

This has caused some political observers to wonder if the Democratic Party is stepping on a political landmine. However, at this moment when much of the nation is paying attention to important policy ideas, progressives should articulate their support for this idea in terms of fundamental American fairness. We have an opportunity not only to advance health care for immigrants, but to help restore a more productive way that we view health insurance for all of us.

While fairness can mean many things to many people, a common understanding emphasizes reciprocity.  For instance, if you want to benefit from a system, you should also contribute to that system. And, if you contribute to that system, you should also be able to benefit from it when you are in need. Our current system grossly violates these basic rules of thumb.

Some undocumented immigrants have private health insurance but about half do not. They often work for small businesses that do not provide health insurance to their employees. If they were citizens, they would be able to purchase an individual or family insurance plan on one of the health-care exchanges created by the Affordable Care Act (ACA). And if they could not afford to pay for a full-priced plan, they would receive a tax subsidy to offset a portion of their premium. Unfortunately, undocumented immigrants are excluded from any participation in the mechanisms of the Affordable Care Act. However, they will receive care at a hospital emergency room when necessary. 

Hospital emergency rooms must examine all patients who present for care and cannot discharge them until they are “stabilized” regardless of their ability to pay. The Emergency Medical Treatment and Labor Act (EMTALA) was passed more than thirty years ago to prevent some hospitals from closing their doors entirely to the uninsured and diverting them to competitor hospitals. 

Moreover, it reflects an intuition that we don’t want people to die in the streets. Hospital emergency rooms must take them in and can’t discharge until the danger of dying in the street is no longer imminent. So, we have a policy that requires some services to be provided to patients who are prohibited from paying their fair share for those services through the usual mechanism of paying an insurance premium.

Conversely, undocumented immigrants pay into government safety-net systems that they cannot access. Most undocumented immigrants pay federal and state taxes thereby contributing to the Medicare and Medicaid systems. When an undocumented immigrant suffers, say, a significant workplace injury, he is brought to the hospital which must accept him because of EMTALA. After stabilizing him, the hospital may need to transfer him to less intensive facility for rehabilitation care. However, EMTALA does not require any facility other than hospital emergency rooms to accept an uninsured patient. In many states, Medicaid would cover the cost of a rehabilitation or skilled nursing facility. But as these patients are ineligible for this “benefit” to which they contribute, they are essentially stuck in the hospital which must care for them without compensation. Of course, hospitals recover such expenses through higher charges to patients with private health insurance.

It is clear that undocumented immigrants receive some benefits from a health-care system to which they are prohibited from contributing and do not receive benefits from government insurance systems to which they contribute. These inequities are not only unfair, but they also make our hospitals and health-care system less efficient and effective. Keeping an injured worker in the hospital who can be better and less expensively cared for at a rehabilitation facility is wasteful and disruptive of the health-care delivery system. Moreover, making the emergency room door the main access to the health-care system prevents this population from taking more responsibility for their wellness and seeking care before they become desperately ill and require more intensive resources.

These inequities and inefficiencies stem from viewing health insurance as only an individual benefit. Since the Clinton administration and the bipartisan passage of “welfare reform,” our government has been trying to enumerate “benefits” in order to exclude lawfully present immigrants from them for five years and undocumented immigrants entirely. This project continued through the designing of the ACA and even led the government to exclude DACA recipients from eligibility for federal student loans. But it is a misguided narrative. Health insurance may benefit individuals but it is primarily a benefit to communities.

Imagine excluding a household in a small town from buying homeowners insurance. That home is then hit by lightning and burns to the ground. The family does not have the resources to rebuild and moves on. While they have been denied a benefit, the greater harm is to the community who from the unsightly lot that will drag down the values of the other homes in the community unless they gather their resources to rehabilitate the property.

Similarly, uninsured patients who cannot access the safety net compromise the local hospital that cannot send them to a more appropriate facility. Hospitals have devoted considerable energy in recent years to engineering timely transitions along the continuum of care to deliver the most appropriate and least expensive care. Preventing those transitions damages the system as well as leading to the passing along of the costs of this overly expensive level of care to the insured patients in the community through higher prices. 

The case for health insurance for undocumented immigrants is usually cast either in economic terms or in terms of compassion for sick people. Immigrants tend to be young and healthy and therefore can be ideal contributors to the ACA health-care exchanges who need young subscribers. However, contrary to current perception, the US undocumented immigrant population has been fairly stable with almost two-thirds residing in the US for more than 10 years. Many are beginning to evidence the chronic illnesses of middle age such as diabetes that require significant management. Thus, the compassion case is clearer. But the implications of compassion are always somewhat indefinite. Americans understand the more objective demands of fairness. And promoting fairness strengthens the health-care system for all of us.

Mark Kuczewski Ph.D., is a professor of medical ethics and the director of the Neiswanger Institute for Bioethics and Health Policy at Loyola University Chicago Stritch School of Medicine.