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Healthcare and 12 Million Elephants in the Room: Undocumented Immigrants

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During his recent speech before the joint session of Congress, President Obama set out to make the details of his health care blueprint more clear and correct the false points that Republicans and special interests have raised in their opposition to reform. One of those fallacies was the notion that the President's plan wouldn't allow undocumented immigrants to be qualified for federal funding to obtain insurance. This led to Rep. Joe Wilson (R-SC) to shout out "you lie!" at the president, making him thousands of friends and millions of foes.

As the media began covering the outrage that ensued following the event, they focused almost exclusively on the act itself rather than the subject that led to the bad behavior: undocumented immigrants. In fact, not only the media, but most politicians and citizens from across the political spectrum seem to have agreed that they don't want to talk about undocumented immigrants in the context of health care reform. But undocumented immigrants constitute a significant element that will directly affect the success of reform, so we can no longer close our eyes and pretend the issue is not there. We need to begin talking about it.

There are nearly twelve million undocumented immigrants in this country. They live in the shadows and most do not pay taxes while having to endure abuse from employers who don't have to uphold federal labor standards. But what makes illegal immigration relevant in the health care debate is that when an undocumented immigrant visits an emergency room, the hospitals are still obligated to provide them with service without asking for documentation. Such visitors--like documented American residents without insurance--often do not have the financial means to visit a doctor when the first signs of symptoms arise. When their health care problem forces them to finally visit a hospital, not only is there a much higher risk for action and lower chances of lasting improvement, but the medical services to address the same condition at such a late stage cost much more than if the patient had been able to address the problem earlier.

One of the aims of President Obama's health care reform plan is to help insure everyone (either through an insurance exchange or a public option to compete with private insurance companies), allowing people to visit their doctors in a timely manner, which could significantly bring costs down.

What makes the issue of illegal immigration a difficult one in the context of health care reform is that covering and not covering undocumented residents both lead to unfavorable outcomes. If they were not to be covered, then even if the reform leads to most legal residents obtaining some kind of insurance (either public or private), we will continue to have millions of immigrants without insurance who will continue to go to hospitals. This will impede the ability of reform to bring health care costs down while creating a system that channels public funding to cover the expenses for the treatment of conditions and problems that could have been taken care of long before they forced the patient to make the ER visit.

But unlike what many refuse to acknowledge, there are also legitimate problems with allowing federal funds for undocumented residents. As far as the larger issue of illegal immigration is concerned, it is first important to note that no sensible person would advocate throwing 12 million people out of the United States. But the fact of the matter is that this is a country of laws. What makes the United States one of the most prosperous countries in the world is not the color of its residents' skin, religion or genetic superiority, but its political system and constitution.

As a country, we have borders, and it is completely reasonable to expect our government to defend our borders and confront those who break our laws. Most undocumented immigrants come from poor countries to the U.S. to work and realize their own American dream. But that is no justification for breaking our laws, and it is reasonable for American tax-payers to not want to fund care for those who do not contribute to the system through taxes and other duties of a citizen. Yes, they work hard and do important work, but Americans do that too. Every person who breaks the laws of a democratic country makes that country a little worse off. There has to be a difference between those who go through the legal processes to have a chance to live in America and those who break its laws to get there. As for those who are already here, they most certainly should not be rewarded with free health care service that's paid for by the rest of the citizens.

These two bad options should lead us to thinking about a possible solution. One would be for us as a country to decide that we no longer want to be a country, because we will not be a country if we decide to not enforce the protection of our borders. We can then also allow anyone in the world who wants to vote in our elections to do so, because if anyone can walk into this country and take advantage of all the benefits that our legal residents enjoy, the notion of having certain rights solely because we are Americans, and in fact the very notion of being an "American", no longer make any sense.

Alternatively, if we decide that we do want to remain a country and understand that being a country entails, among other things, affording its legal residents special rights (which is this blogger's recommendation), our policy-makers should take up the issue of immigration reform as soon as they pass health care reform. The focus of an ideal immigration reform will allow those who are already here to get in line and make their case for becoming legal U.S. residents, make legal immigration more possible and faster, and make illegal immigration (or smuggling of narcotics) less possible through strong enforcement and punishment for those who break our laws. Those who then become legal residents should be afforded the same rights that current legal citizens enjoy.

We cannot have this rigorous debate about health care reform in a bubble. If we truly want to address the issue of high health care costs and lack of access, we must address the impact that illegal immigration has on the system, whether we like it or not. And when we do decide to talk about illegal immigration, we are not going to go anywhere if we don't recognize that we can neither systematically throw out 12 million undocumented immigrants, nor completely ignore the fact that they have broken our laws and immediately provide them with all the benefits of living in the United States without expecting them to recognize their duties to this country. Doing so will only create incentive for more illegal immigration and transform the problem from bad to worse and perpetually doom health care reform in the long run.