A Simple, Inexpensive Way to Achieve Universal Coverage

by Dave Schuler on September 11, 2009

By the standards that the New York Times editors are holding to in their editorial in support of the idea that healthcare coverage, in the form that it assumes in the bills making their way through the Congress, will not apply to illegal immigrants:

Mr. Obama didn’t lie. The bills before Congress declare illegal immigrants to be ineligible for subsidized benefits. It is impossible to imagine any final bill doing otherwise. Mr. Wilson was a boor, but some Republicans still insist that he was right because the bill doesn’t ensure that the undocumented have no insurance.

The standard is declaration without implementation or enforcement and it suggests a simple, inexpensive way to achieve universal healthcare insurance coverage in the United States. It can be done in just a few words:

The United States has universal healthcare insurance.

See? Just seven words. On to the next problem.

For some reason I don’t think that’s going to satisfy too many people.

There are intrinsic contradictions in the discourse on healthcare reform. Those who genuinely believe that healthcare is a right and that the United States should have universal healthcare coverage to effect that right must also believe that healthcare should be extended to immigrants, legal or illegal and should pay for abortions. Without those provisions it wouldn’t be universal. I don’t see any compromise that can reconcile that view with the view that we shouldn’t cover illegal immigrants and we shouldn’t pay for abortions out of the public purse.

{ 9 comments… read them below or add one }

PD Shaw September 11, 2009 at 9:29 am

James Joyner made a good point yesterday when he pointed out that the Supreme Court required Texas to educate illegal immigrants in Plyer v. Doe. “The inability to read and write will handicap the individual deprived of a basic education each and every day of his life.” Poor health will handicap the individual no less, maybe more.

The issue with mandating healthcare coverage, and a government insurance plan (if it comes to dominate certain segments of the market) is that the government action will be subject to serious Equal Protection and Due Process claims.

The House Bill mandates that illegal immigrants obtain healthcare coverage. It may be a violation of due process to criminalize an incurable omission. Seems like an odd result, but once the government action in area becomes this extensive, the government action will be scrutinized to unknown ends.

Sam September 11, 2009 at 10:01 am

Seems to me that explicitly saying this bill is not for illegal immigrants is more than enough for a HEALTH CARE BILL. Illegal immigration is a much bigger issue, one that should be tackled in, oh I don’t know, an immigration bill?

PD Shaw September 11, 2009 at 10:31 am

sam, Max Bauchus announced yesterday that they would put in a proof of citizenship requirement to participate in the new health exchange, something the Democrats had not allowed to get out of committee when the Republicans proposed it.

I agree that healthcare is not the place to police the borders. I am concerned that if we don’t at least take nominal stands against healthcare for illegal immigrants that we could exacerbate the immigration issues and the healthcare shortages.

Jimbino September 11, 2009 at 1:36 pm

How can I become an illegal immigrant so that I can be left out of Obamacare? Or how can I become Amish so that I can be left out of Social Security too?

Brett September 11, 2009 at 2:05 pm

I don’t see any compromise that can reconcile that view with the view that we shouldn’t cover illegal immigrants and we shouldn’t pay for abortions out of the public purse.

I have a more narrow “societal” view – society is responsible for helping to ensure universal coverage for all citizens and legal residents. We don’t give payments to hospitals to cover the ER treatment used by illegal immigrants out of some sense that they are “owed” it – we do it because it helps the hospitals, and because it’s easier than simply requiring proof of citizenship or legal residence every time someone shows up at the ER.

The standard is declaration without implementation or enforcement and it suggests a simple, inexpensive way to achieve universal healthcare insurance coverage in the United States.

Personally, I’d just have it so that you have to get some type of ID or other card with your name on it and the like (and preferably one of those newer, hard-to-tamper-with cards), which you can only get if you provide proof of citizenship and/or legal residence.

PD Shaw September 11, 2009 at 2:20 pm

Speaking of legislating by declaration, have we any idea yet how these mandates are going to be enforced? Jimbino doesn’t want to buy insurance, but how will they identify and stop him?

steve September 11, 2009 at 9:15 pm

I think the economics dictate a lack of sense in putting verification of citizenship into the bill. It will probably end up there because of paranoia. Why would illegals risk getting caught? I wrote the following at my own place.

I think there is little reason to see illegals applying for this insurance, so adding millions in verification costs makes no sense. As a practical matter, there is no way to verify status when people present for emergencies. Therefore, we will keep providing emergency care to illegals. Some of those will result in big bills and long stays, but I see no practical way to avoid that.

The estimates I have seen for total uncompensated health care run about $20-25 billion a year. The exact percentage of that going to illegals is harder to determine, but I have seen low estimates of $1 billion and a high of $8 billion. Total health care expenditures in the US for 2007 were about $2.2 trillion. If you let me use 2 billion, for ease of math, that means we are spending about 0.1% of our health care money on illegals which make up about 4% of the population (12 million out of 300 million).

I always tell my medical students to make sure the numbers match up with your observations and experience. In this case, they match my experience. To the knowledge of my hospital administrators and my billing people, we have never done a CABG on an illegal. We have not done elective brain surgery, joint replacement or back surgery. None of the big ticket stuff. We have seen illegals on the trauma service and on OB. We have a large Hispanic population where I live with quite a few illegals, so I know they are out there.

We already do verification for Medicaid. Makes sense as Medicaid is free. Now, suppose an illegal wants to buy insurance. In order to get a subsidy, he will need proof of income (W-2), a Social Security number and a legal address. Given that the large majority of these people work off the books, how will they show a need for a subsidy?

So, if I want to buy this insurance, why should I have my liberty infringed upon to prove my citizenship? I find it offensive to have to bring my “papers” everywhere. If there was a significant risk of illegals getting into this program it might be worth compromising my liberty. Based on my numbers, and I am open to new data if you have some, I see no need for my compromise.

Steve

Our Paul September 12, 2009 at 8:41 am

Nice comment Steve, do you have links to the estimates of uncompensated health care?

May I introduce a slightly different perspective, which was stimulated by this passage:

There are intrinsic contradictions in the discourse on healthcare reform. Those who genuinely believe that healthcare is a right and that the United States should have universal healthcare coverage to effect that right must also believe that healthcare should be extended to immigrants, legal or illegal and should pay for abortions.(My italics

Why not explore the concept that government’s function is to provide for the common good?.

You must pardon my use of the bold function, Dave, it is really not my style. Too much like a quick jab to the jaw (take that, you cur).

It is very hard to hold a reasonable discussion on health care when “rights” and “illegal immigrants” are raised as subjects that deserve consideration. Nobody is seeding the discussion with these terms around the impending flue epidemic and the government’s involvement in paying for the development of the vaccine, monitoring the outbreak, or (gasp) recommending triage procedures.

One can always go Roman and play the reductio ad absurdum card and insist that no illegal immigrant or any of their children should receive the flue vaccine. After all, there is no universal right to flue vaccine. Public health measure be damned, it’s the principle that counts.

steve September 12, 2009 at 3:52 pm

Paul-The numbers I cited were from an older blog post. When I reposted those numbers one of my fellow blogger gave me the link below, which is a little more recent. It is from the Kaiser group which is usually pretty good. This is actually a pretty often cited study and I am not sure why I did not use it initially. My bad. it list total uncompensated care at about $40 billion, with $8 billion of that physician fees, which is often not included in these analyses.

Steve

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