Critics of both the White House and U.S. Senate proposals to reform immigration suggest Washington has gone too far in offering what amounts to "amnesty" to millions of illegal residents. But immigrant advocates and public health officials think the proposals don't go far enough.
Why is this a public health issue? Because the eventual path to citizenship doesn't include a path to Medicaid access. The White House's proposal also lacks a path to purchase subsidized health care coverage through the federal health overhaul law known as the Affordable Care Act. The Senate framework -- introduced Jan. 28 by a bipartisan group of eight legislators -- is silent on that issue.
Starting in 2014, the Affordable Care Act will offer federal tax subsidies to help citizens and lawfully present immigrants who qualify financially -- and are without their own health insurance plan -- to buy a private policy through online health insurance exchanges.
Under current policy, immigrants here illegally won't be able to buy insurance, or get those subsidies. The proposals now being debated would not appear to change that, to the disappointment of those who provide health care to immigrant communities.
Largely, that job now falls to free-care clinics and emergency room physicians, who act as a safety net for those without insurance.
"Everybody who needs emergency care and who comes to our (hospitals) should get it," said Charles Pattavina, chief of emergency medicine at St. Joseph Hospital in Bangor, Maine, and a former board member with the American College of Emergency Physicians.
But treating uninsured populations -- those here legally or otherwise -- costs hospitals and U.S. taxpayers billions a year, pushing some ERs (particularly urban ones) to the financial brink and "reducing capacity and threatening everyone's access to lifesaving care," according to the emergency physicians organization.
Most undocumented immigrant adults lack health insurance. Their children -- who often are U.S.-born citizens, and thus eligible for certain health programs such as Medicaid and the Children's Health Insurance Program -- usually don't have it, either. Even those who possess a green card and reside here legally must generally wait five years before becoming eligible for Medicaid.
As a result, many don't seek health care until an emergency arises. That's why advocates believe Congress ought to consider a health care component, if it indeed undertakes a comprehensive immigration overhaul package.
"I really think that they did miss something," said Pittsburgh immigration attorney Suzanne Susany, who is also a nun with the Sisters of St. Francis.
"The majority of the immigrants are young adults. If they were able to get the (Medicaid) benefit, they would be putting into the program, and they would be taking out very little. ... They would not be bleeding the system."
Expense, naturally, is one concern. The Senate budget committee believes that allowing illegal immigrants to become citizens will add between $120 billion to $200 billion to the cost of the Affordable Care Act in its first decade.
Because the Senate plan's details are still being negotiated, health policy experts hope time remains to discuss health care issues before a bill is written.
"The thing that's always missing in these debates is that we're going to have to pay for (immigrants' care) one way or another," said Sonal Ambegaokar, health policy attorney with the National Immigration Law Center in Los Angeles. The goal of reform is to bring immigrants "out of the shadows" so they can pay taxes and pay into the health care system, spreading cost and risk across more bodies.