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Health insurance and immigrants: Weapons of mass distraction found

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By Peter Costantini - Seattle, Washington

When Congressman Joe Wilson disrupted President Barack Obama's September 9 speech to Congress on health care, he was just exercising his "freedom of screech," in satirist Stephen Colbert's words. The First Amendment and Wilson (R-SC) are the richer for it.

Theatrically dissing the first African-American president appeared to play well with his base as contributions passed one million dollars. But his Democratic opponent Rob Miller also saw a comparable fundraising bounce.

Killing two bugbears with one stone, Wilson targeted his grito at immigrants as well as the President. The congressman yelled "You lie!" after Obama said of his health insurance plan: "The reforms I'm proposing would not apply to those who are here illegally."

For anyone interested in legislative reality, Section 246 on page 143 of H.R. 3200 (the House of Representatives bill), entitled "No Federal payment for undocumented aliens", reads: "Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States."

A report by the non-partisan Congressional Research Service confirms that unauthorized immigrants would be barred from receiving subsidies for health care. Although the bill does not specify a mechanism to verify immigration status, the CRS points out that Section 142(a)(3) assigns responsibility to the new Health Choices Commissioner to administer the "individual affordability credits ... including determination of eligibility for such credits."

But Wilson's outburst was aimed at those who seemingly inhabit a parallel universe. In it, the Rush wing of the Republican Party (if any other wing still exists) has discovered the alchemical powers of certain talismanic phrases. The invocation of "death panels" transmuted a leaden policy debate into talk-show gold; "socialism" and "government" became magical expletives in their daily talking points.

Reaching for a perennial favorite, Wilson evoked the ever-powerful specter of the "illegal alien", which alloys the horror movies of the 50s with the marauding hordes of Pancho Villa, to divert the debate from the actual substance of health care, insurance, and immigration.

As overheated as their rhetoric may sound, Wilson and his allies have displayed a keen political imagination. They have liberated themselves from the need to provide any factual basis for what they say: the point is to change the subject. Just make up any evidence-free story - try "Illegal aliens brought the swine flu into the country", as Michelle Malkin or Michael Savage did. Each time they or Sean Hannity or Sarah Palin interject some new paranoid delusion, many of the talking heads and editorial boards, and not just on Fox News, dutifully launch into a debate about the interruption and forget about what was interrupted.

These weapons of mass distraction have worked well so far for those who want to kill health insurance reform and punish immigrants.

After the dustup, the debate shifted to whether Wilson should apologize, whether he or his opponent gained more political capital, and how well Obama and the Democratic leadership handled the insult. The substance of Obama's statement, Wilson's outburst and the questions they raised have been trampled in the stampede of the 24-hour news cycle.

This latest distraction, though, is particularly ingenious in yoking health-care hysteria with the venerable tradition of scapegoating immigrants. Since before the birth of the Republic, the Germans, the Irish, the Chinese, the Italians, the Jews and the Japanese (apologies if I've missed anyone here) have all had their turn before the currently popular Arabs and the Mexicans. For a right wing that is addicted to blaming its problems on some swarthy "other" with a foreign accent, immigrant bashing seems to be an endlessly renewable resource of political energy.

Undocumented immigrants, and legal immigrants for their first five years, have long been excluded from Medicaid and Medicare, and the proposed health care subsidies continue that limitation. Current incentives for immigrants, as for citizens without coverage, encourage them to wait until a health problem becomes a crisis and then go to an emergency room. Medical facilities are legally required to offer some emergency care to the indigent without regard to immigration status. But this is a costly and ineffective way to provide care.

The devil of this legislation is in the details of whether immigrants, legal or not, are excluded from buying health insurance with their own money in the new exchanges proposed by the President's plan. Currently, there is no citizenship or immigration status requirement for purchasing personal health insurance.

The health-insurance exchanges would be organized by a public authority, but would allow consumers to compare and purchase private insurance plans (and the fiercely debated public option, if it survives Congress).

In such a system, people would buy insurance with their own money, and nearly everyone would be required to purchase health insurance or pay a penalty. Those not poor enough to qualify for Medicaid, but below a certain income level, would be receive a sliding-scale subsidy to help pay for it. That subsidy, like Medicaid, would not be available for immigrants without papers under any proposed plan. Even legal immigrants would be barred from claiming tax credits for health insurance for their first five years in the country.

Republicans and some Democrats argue that even allowing undocumented immigrants to buy their own health insurance under any new plan is tantamount to giving them government aid. To avoid this, they call for verifying everyone's citizenship before allowing them to buy healthcare.

In a recent speech to the Congressional Hispanic Caucus Institute, Obama said: "I want to be clear: If someone is here illegally, they won't be covered under this plan. That's a commitment I've made. But I also want to make this clear: Even though I do not believe we can extend coverage to those who are here illegally, I also don't believe we can simply ignore the fact that our immigration system is broken. That's why I strongly support making sure folks who are here legally have access to affordable, quality health insurance under this plan, just like everybody else. ... If anything, this debate underscores the necessity of passing comprehensive immigration reform and resolving the issue of 12 million undocumented people living and working in this country once and for all."

The President did not clarify exactly what he meant by "coverage". H.R. 3200 would not impose restrictions on authorized or unauthorized non-citizens using their own money to purchase health insurance through the exchanges. But the initial Senate bill drafted by chairman Max Baucus of the Finance Committee placates the immigrant-bashers by explicitly excluding undocumented immigrants from participating in the exchanges and requiring that all applicants prove their citizenship.

At the same time, though, the chairman's mark requires nearly all citizens and immigrants not on Medicaid or Medicare to purchase health insurance or pay a substantial penalty, and unauthorized immigrants are apparently included in this provision. So if you can't find that birth certificate, apparently you're not allowed to buy health insurance on the exchanges, but you're still required to purchase coverage somewhere. It's a safe bet that it's going to cost you an arm and a leg (and that the amputations will not be covered).

Because the Baucus mark includes no public option, its effect would be to force all consumers to contribute to the revenues of for-profit health insurance companies. Without a public plan to restrain prices, the subsidies to consumers that the bill theoretically provides could well be passed through and end up as subsidies for the insurance industry.

U.S. Representative Luis Gutiérrez (D-IL) criticized the Obama administration's response: "Mr. Wilson won, with his insults, with his attacks, with the outrage that he committed that night," he told Univisión, the Spanish-language news channel (my translation). "He won, because what did the administration do 72 hours later? It gave him exactly what he wanted. His purpose was to damage our immigrant community and he won." There is no issue into which conservatives don't inject their "anti-immigrant venom", Gutiérrez lamented, but "we've heard these voices in the past. They've failed and they will fail in the future."

Other House progressives as well have pushed for inclusion of immigrants in health-insurance reform. Congressman Michael Honda (D-CA), chair of the Congressional Asian Pacific American Caucus, asserted: "American taxpayers are already paying for the health care costs of immigrants when they use emergency and social services. Americans currently pay $56 billion annually to ensure the uninsured's use of emergency care. The fiscally prudent response, then, would be to seize the opportunity to have the uninsured help pay for their own health care, instead of spreading the cost to others."

To cave in to bullying by the right on this point would be against the interests of the majority of health-insurance consumers. Introducing the new bureaucratic hurdle of proof of citizenship would likely make obtaining it difficult for many citizens and legal immigrants as well.

Instead, as many people as possible, including undocumented immigrants, should be encouraged to buy health insurance in the proposed exchanges. An expanded pool would share risk among more people and help bring down costs.

Immigrants, particularly undocumented immigrants, are younger and healthier than the rest of the U.S. population, and their inclusion would help to reduce the average expense of insurance. Studies have found that health care costs for the average immigrant are 55 percent lower than costs for the average native, and those for non-citizens were 51 percent below those for citizens. Although recent immigrants made up 5 percent of the population, their public medical expenditures were only 1.4% of the total.

Including immigrants in the exchanges would also reduce the number of people forced to depend on emergency rooms, thus reducing overall health care costs.

The overall health of the nation is best protected by ensuring that all residents have access to medical care. Public health threats, such as swine flu, do not check immigration papers before striking people. Any system that excludes major groups of residents from regular preventive health care leaves everyone else more vulnerable.

Trying to restrict access for immigrants by verifying the immigration status of everyone who buys insurance is costly and ineffective, prone to excluding some citizens and legal immigrants and hurting them more than undocumented immigrants. The experience of Medicaid has demonstrated this.

The Deficit Reduction Act of 2005 tightened Medicaid requirements by demanding that all applicants present official documents proving their citizenship, a demand that some lower-income and elderly citizens had trouble meeting. Prior to that law, applicants could simply attest to their citizenship under penalty of perjury. A 2005 report by the Inspector General of the Department of Health and Human Services found no evidence that false claims of citizenship were a problem.

A 2007 study concluded that a Medicaid provision requiring all applicants to show proof of citizenship, intended to prevent undocumented immigrants from obtaining coverage, actually caused a much greater decline in enrollment for white and African-American children than for Hispanic children.

A report by a House committee found that the Medicaid documentation requirements denied coverage to some citizens and cost taxpayers millions of dollars. The declines in citizens covered appeared to be large in some areas: one state reported 18,000 people whom it believed to be eligible citizens, but who could not provide the necessary documentation.

In the six states that provided data, total Federal and state spending to implement the new documentation requirements was $16.6 million. Out of 3,655,500 Medicaid enrollees, the states identified eight (8) undocumented immigrants, saving a total of $11,048 dollars. In other words, finding each undocumented immigrant cost a net of more than $2 million. It would have been more economical to buy each immigrant a mansion and staff it with an attending physician.

As the bills go through the legislative meat-grinder, there is a serious danger that an initiative touted as providing affordable health care to all could fall far short. In the worst case, it could end up failing to reduce the cost of private insurance enough to make it affordable for many working people, while spawning an impenetrable bureaucracy that levies large fines on those who are priced out. The right is lobbying hard to make sure that this is what comes out of Congress by trying to kill the public option and weakening the exchanges.

Adding insult to injury, the cumbersome citizenship-verification process favored by Baucus and the right would shut out immigrants who could help reduce costs. It would also risk wrongfully excluding an estimated 11 to 13 million citizens and legal immigrants with no driver's license, birth certificate, or passport.

Under these restrictions, health insurance reform could end up being perceived by many citizens as "big government" making their lives harder - which is of course one reason why the right is pushing them.

Even with a plan that included undocumented immigrants in the exchanges, the hard economic reality is that it's uncertain how many could take advantage. Currently, although they can legally buy health insurance, the numbers who can afford to may not be large because so many work in low-wage jobs.

Perhaps reductions in the cost of health insurance brought by effective exchanges could make it affordable for more working people, including immigrants. But the Baucus mark, and the demands of the right, would prevent the undocumented from buying their own insurance even when they could afford it.

As the Immigration Policy Center points out in a recent report: "When health care costs are distributed across a broader pool of people, the overall costs for everyone goes down. Inclusion of legal immigrants, who are generally younger and healthier than U.S. citizens, can have a positive effect on overall costs because it will encourage more preventive care and add additional payments to the system."

The same is true for undocumented immigrants. Ironically, we may need immigrants in a reformed insurance system as much as they need insurance. The more of them, legal or not, who buy into the health-insurance exchanges, the better they will work for everyone.