The New Republic

Last October, Dr. Jack Ludmir, the head of obstetrics and gynecology
at Pennsylvania Hospital, oversaw the emergency-room treatment of a
young woman who was seven months pregnant, hypertensive, and
convulsing. Although her condition was, according to Ludmir,
"rarely seen in the United States," his team diagnosed it quickly:
She was suffering from eclampsia, a severe pregnancy- related
disorder that can lead to premature birth, seizure, stroke, even
death. In this country, the condition is usually caught in its
early stage known as pre-eclampsia, which can often be managed with
prenatal care; but, with the mother already in the ER, doctors had
no choice but to deliver the baby prematurely.Over the next three months, the newborn was threaded with
respiratory tubes while doctors flushed the mother's brain of
excess blood three times. "You can't imagine the costs," says
Ludmir. For as little as a few hundred dollars worth of prenatal
care, he says, this tragedy--and at least

$250,000 of medical care--could have been avoided. Unfortunately,
this was not an option. The mother was an undocumented immigrant
and therefore was ineligible for publicly funded prenatal carein
Pennsylvania.

The one health care issue that Republicans and Democrats agree on
these days is that illegal immigrants like Ludmir's patients should
not have access to publicly funded health care. Republicans see
this as a facet of the immigration issue--House Minority Leader
John Boehner recently issued a press release charging that
providing health care to illegal immigrants "increase[s] the tax
burden on American families," while conservative commentators like
Michelle Mal- kin are more naked in their hysteria, warning that
the United States is in the midst of becoming "the land of the
limit-less health care handout for 'undocumented immigrants.'"

The Democrats, meanwhile, are too cowed by the anti-immigration
lobby--and the prospect of losing support for their individual
health care plans--to defend the undocumented. Hillary Clinton and
John Edwards have already decided to exclude illegal immigrants
from their universal-coverage proposals, while Barack Obama has
held his tongue on the issue. As a result, doctors such as Ludmir
are likely to continue to see undocumented immigrants when their
medical situation is most dire--and costly to society.

This isn't the first time that the combination of Republican
hostility and Democratic timidity on the immigration issue has
adversely shaped policy. In 1996, as part of welfare reform,
Republicans insisted on banning legal immigrants from receiving
Medicaid and s-chip (which assists families that make too much to
qualify for Medicaid) for the first five years of their
residencies. President Clinton grudgingly agreed to the provision
in order to shepherd the welfare-reform bill through Congress. The
Republican argument that cheap public health care was attracting
impoverished illegal immigrants into the country has since been
called into question: In 2000, a study from Health Affairs found
that less than 1 percent of undocumented immigrants "cited obtaining
social services as the most important reason for immigrating." But,
although its foundation has rotted, the policy still stands,
setting the tone of the current debate: If we don't provide
publicly funded health care even to some legal immigrants, why
extend it to illegal ones?

There are currently 12 million undocumented immigrants in the United
States-- the majority of whom are uninsured. Among all immigrants,
both documented and undocumented, less than 40 percent receive
employer-sponsored coverage. The only federal health care program
that covers undocumented and newly arrived legal immigrants is
known as "emergency Medicaid." Under this program, the government
will pay for emergency hospital care for the pregnant, elderly, and
disabled, and for children or the parent of a child. (Although what,
exactly, qualifies as an "emergency" is ambiguous: The federal
government recently informed New York state that it would no longer
fund chemotherapy.) Those who do not qualify for emergency Medicaid
must pay for their treatment out of pocket, or the hospital must
write it off as uncompensated care for which it should eventually
be reimbursed, at least in part, by the federal government.

While it is true that the ER expenses of immigrant children are
greater than the per capita average, probably because they are
sicker when they finally seek care, immigrants tend to spend less
money on health care than their U.S.-born counterparts. (One study
in the American Journal of Public Health found that, in 1998, the
average health care expenditures of a Hispanic immigrant,
documented or undocumented, totaled

$972. For a white, U.S.-born citizen, they were over $3,000.) Part
of the reason for this discrepancy is because immigrants are, on
average, younger and healthier than citizens. This would seem to be
an argument for keeping the current system rather than expanding
coverage, which tends to raise expenses as patients become
insulated from the costs of their care. But, although immigrants
may arrive in this country healthier, they regress toward the mean,
developing many of the chronic conditions, such as heart disease and
diabetes, endemic to U.S.-born citizens. They are also aging as a
population. As a result, the number of disabled and elderly illegal
immigrants is on the rise, and a recent study of North Carolina's
emergency Medicaid system found that "[t]he largest spending
increases [among the undocumented] ... are occurring among the
elderly and disabled groups."

The obvious way to contain these costs is to insure the
undocumented, so that they have access to preventive care before
they degenerate into the tax siphons conservatives already claim
them to be. And there is an additional reason to take this step:
public health. Just a few unvaccinated individuals can threaten a
whole community, a threat that is particularly acute among the
undocumented, since they often work in the food service and
agricultural industries. Unfortunately, Democrats continue to
conflate the health care issue with the immigration one. Clinton
and Edwards claim the health care problem will solve itself after
they pass comprehensive immigration reform with a path to
citizenship. But this is unlikely to happen anytime soon, and, by
the point it does, the benefits of incorporating the undocumented
population today, while it's still largely young and healthy, will
have expired.

In the regrettable absence of comprehensive federal legislation,
there are some smaller, more feasible measures that should be
considered. One is to extend publicly funded health care to all
legal immigrants. The second is that more states should extend
prenatal care to the undocumented. On this front, the federal
government has already done its part: In 2002, President Bush
expanded s-chip eligibility to fetuses, giving states the option to
cover the prenatal care of mothers ineligible for Medicaid,
including undocumented immigrants. Disappointingly, most states,
including a majority of the so-called "new-growth states"--those
states whose immigrant populations grew most quickly in the
1990s--have not accepted the federal government's offer and provided
the necessary matching state funds.

This is unfortunate, because there are compelling reasons to do so.
A study by researchers in Colorado, a new-growth state, found that
only 52 percent of the state's undocumented women received prenatal
care during the first trimester, as opposed to 83 percent of all
other women. Consequently, 40 percent of undocumented mothers
experienced a complication of delivery, as opposed to less than 30
percent of all other mothers. And, beyond the moral imperative,
there's an economic one. Researchers in California, the epicenter
of undocumented immigration, have estimated that one dollar in
prenatal care can save over three dollars in postnatal care.
(California, as it happens, is one of the 15 states that provides
prenatal care to its undocumented residents. ) Prenatal care isn't
just a drop in the bucket of spending on the undocumented either:
Over 80 percent of emergency Medicaid spending on the undocumented
in North Carolina, whose immigrant population nearly quadrupled in
the 1990s, was for childbirth and complications of delivery.

Jack Ludmir's patient would certainly have benefited from this
limited expansion of preventive health care. Her eclampsia left her
partially paralyzed, in poor condition to care for a sickly
child--one who, it's worth noting, is a U.S. citizen whose
continued care taxpayers must now fund.

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