If health policy were to be changed by allowing undocumented individuals to receive coverage via Medicaid and/or the marketplace, would this change be sustainable over the long term? A competing question would be: Are the current health policy environment and programs for the undocumented sustainable?
To review, consider the current environment for undocumented immigrants in the state of New Mexico. Undocumented immigrants (New Mexico Association of Counties, 2014):
- Remain ineligible to receive Medicaid or purchase coverage under the marketplace (Jerome-D’Emilia & Suplee, 2012).
- May seek care at emergency departments under EMTALA, but will probably receive a bill after they’ve been discharged.
- May purchase coverage via their employer if coverage is offered and if individuals are able to pay.
- May be eligible for coverage under the state’s Indigent program.
- May seek care at any FQHC.
- May seek care at free clinics.*
*Regarding free clinics, the sustainability of these clinics should be weighed with questions regarding the current environment. Clinics such as these depend upon volunteers and donations in order to exist – but could such a model be maintained over the long term?
Thinking About Costs
In today’s environment, cost is a significant determinant for sustainability of health policy and programs. (The previous post discusses the financial aspects of Medicaid and funding for undocumented immigrants in more detail.) Alt-White and Pranulis (2011) state that the most common factors of cost are cost benefit, cost effectiveness, and cost utility. In order to fully assess cost factors and variability, additional research and data collection is needed. The following questions must be addressed:
- What are the associated costs for maintaining the current policy and program environment for the undocumented population? To include:
- Use of emergency medical services.
- Use of Indigent care.
- Use of FQHCs.
- Associated costs related to public health (communicable disease outbreaks such as tuberculosis or those associated with the current immunization schedule)
- Is there a net benefit or a net cost in implementing additional healthcare coverage for the undocumented population? What are the benefits/costs per person annually?
Of course, any innovation in health policy related to the undocumented population must also consider the current immigration policy environment.
If the current policy and program environment results in overall net benefits and can be maintained financially over the long term, then innovation may not be needed at this time. However, considering the size and spread of undocumented immigrants across the U.S. a much more thorough analysis is needed. An analysis that consists of difficult questions to address given the sensitive nature of documentation status and the associated fear of being discovered, detained, and deported.
References
Alt-White, A., & Pranulis, M. (2011). Disseminating results as a mechanism for sustaining innovation. In J. Harris, L. Roussel, S. Walters, & C. Dearman (Eds.), Project planning and management: A guide for CNLs, DNPs, and nurse executives (pp. 179-193). Sudbury, MA: Jones and Bartlett.
Jerome-D’Emilia, B., & Suplee, P. (2012). The ACA and the undocumented. American Journal of Nursing, 112(4), 21-27.
New Mexico Association of Counties. (2014, July 9). The future of the safety net in New Mexico. Retrieved from: http://www.nmcounties.org/wp-content/uploads/2014/08/THE-FUTURE-OF-THE-SAFETY-NET-IN-NEW-MEXICO-FINAL-REPORT.pdf
nm health policy: exploring health policy for the undocumented 
Very thoughtful consideration of the costs and policies involved with sustaining health care for the undocumented. I think your final sentiments, regarding the need for larger scale reform inclusive of immigration policy, is where this issue will always end up. In my mind, you cannot financially sustain the medical costs of this considerable percentage of the population, one estimate is 3.5% (Krogstad & Passel, 2014), without fully accepting them into the fold and reaping the financial benefits that come along with such a move. With assimilation of the immigrant population there is hope for increased income tax revenue and hopefully in time, a decrease of those who fall below the poverty line. However, as you said, this issue needs further analysis by those who can look at these economic and policy issues rather than focusing strictly on the political hot button issues that seem to garner our attention with every election cycle.
Krogstad, J. M. & Passel, J. S. (2014). 5 facts about illegal immigration in the U.S. Pew Research Center. http://www.pewresearch.org/fact-tank/2014/11/18/5-facts-about-illegal-immigration-in-the-u-s/
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I agree that financially sustaining a population this size is not possible without further changes in other realms of policy. I think that this will be a long and difficult road to change especially considering that despite the implementation of the ACA there are still U.S. Citizens without insurance. Although data regarding the number of individuals who remain uninsured will not be available until possibly later this fall, I have seen patients in the primary care setting who stated that although they qualified for coverage under the exchange, they still remain uninsured because they can’t afford the monthly payments that go along with the coverage.
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I agree, larger scaled reform is needed. Emergency medical care is the most expensive care provided. Finding ways to keep patients out of emergent care facilities and into primary care is optimal.
This issue tends to bring about heated debates both in the political arenas and across many dinner tables. It will be interesting to watch as it continues to develop and we learn more about the struggles of those who are undocumented.
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