GovRx: Prescription for immigrant healthcare

Regardless of nationality, people from all over the world are treated in American hospitals. You don’t have to be a U.S. citizen to purchase private health insurance in the U.S. nor do you have to be a citizen to pay to see a doctor. The U.S. has a private healthcare system that is open to everybody, who pays.

Unfortunately, the cost of health care and insurance can be as much as a family annual income depending on the type of work you do. So why do some wait until a health problem requires the most expensive emergency room care to treat it? One reason is the federal law. In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) sought to reduce federal spending. This law has had the opposite effect.

Some who are uncertain of their immigration status do not apply for benefits because they are afraid.

Under this legislation, undocumented immigrants became ineligible for Medicaid and other federally-funded social services, and only eligible for emergency medical assistance. The Act also requires that all state and federal welfare agencies report any illegal immigrants who apply for benefits to the Immigration and Naturalization Service (now the Department of Homeland Security) unless it’s health care delivered in the emergency room.

Emergency Medicaid is predominantly a program for childbirth coverage, although use and spending are shifting toward non-pregnant adults, particularly those who are elderly and disabled. Whether or not a person is eligible for Medicaid will depend on the State where he or she lives. Medicaid spending for emergency care, of recent and undocumented immigrants (although a small proportion of the total Medicaid budget) is increasing in some states. While states are not required to identify or report their Medicaid expenditures specific to undocumented aliens, some states do provide data suggesting that most of their emergency Medicaid expenditures were for services provided to undocumented aliens.

According an article in the Journal of the American Medical Association, treatment of unauthorized immigrants contributes to uncompensated care costs, but the main reason such costs are increasing is the rise in the number of people who lack health insurance. Immigrants represent only about 20% of the uninsured.

We now have a growing, uninsured, aging population. We need a better alternative to our current system because in the end, we are all paying for this expensive emergency room care. Here are a few suggestions.

  • Reduce costly healthcare expense by creating legislation that does not direct people to the emergency room
  • Encourage the sharing of aggregate, non-confidential provider data to track expense trends
  • Consider alternatives to voluntary, ad hoc state reports in guiding national health policy
  • Focus on reducing government expense and not enforcement in the healthcare setting

Immigration detention by the numbers

Department of Homeland SecurityThe American prison system is thriving in our shrinking economy. By 2010 immigration detention is expected to cost taxpayers over $1.7 billion. Some people believe we helped create this situation, relying on immigrant labor to fill low-wage, low-skill jobs. Now it appears that we want to criminalize the people who helped fuel the U.S. economy.

It may come as a surprise that the U.S. lacks effective screening tools to identify serious criminals when making an alien arrest. After an alien is arrested, both criminals and non-criminals are all held in the same county, state and federal facilities. As conditions become more crowded, inmates are moved without regard to where their lawyers and warrants are located. This leads to inefficiencies in managing cases and identifying the criminals. The time aliens languish in the already overburdened system increases.

The number of individuals held in custody by Immigration and Customs Enforcement (ICE) in the just-ended FY 2009 is now estimated to have reached 369,483 detainees, more than twice what the total was in FY 1999. ICE runs a decentralized network of detention facilities that hold aliens pending proceedings or deportation. Immigration proceedings are civil proceedings and immigration detention is not punishment.

Because ICE lacks facility space for this growing population, they contract with local governments and private businesses such as Corrections Corporation of America (CCA). Since 2004, revenue at CCA, (which has a contract with the Department of Homeland Security) increased from $1.1 billion to $1.5 billion. The success of the private prison sector is an externality that fuels the pressure to grow an ever increasing detention population.

The administration recently appointed an expert to try to fix the system. She drafted a report and then left her position after one month. Her report detailed the following. Of the aliens in detention on September 1, 2009, 66 percent were subject to mandatory detention and 51 percent were felons, of which, 11 percent had committed violent crimes. The majority of the population is characterized as low custody, or having a low propensity for violence.

Nevertheless, in its fiscal year 2009 report to Congress, ICE requested an additional $72 million to support a planned increase in staffing and bed space to house mostly non-violent aliens. This increasing use of detention is placing a significant strain on government resources. If we were to jail every illegal immigrant, it would cost $1.6 billion dollars a day and that does not include legal or court costs. This is an absurd result to a problem which could be solved by efficient screening and categorization.

In October 2009, Department of Homeland Security set a deadline for ICE to develop an assessment tool to identify aliens suitable for Alternatives to Detention (ATD). ATD costs substantially less per day than detention: the most expensive form of ATD costs only $14 per day compared to the cost of detention.


  • The government needs to do a better job at managing aliens entering the system.
  • A short term strategy to control costs should include effective screening prior to detaining aliens, implementing less restrictive conditions of control. Given the current daily census of detainees, the cost difference between jail and the alternative is $52 million versus $5 million per day, at an annual savings of $564 million dollars a year.
  • Long term efforts would be more efficiently spent on stopping smugglers on the border. The government should investigate repeated migration patterns, identify the countries where smugglers originate and focus preventive efforts to stop aliens before they enter the detention system. A review of court cases reveals aliens repeatedly re-enter the detention and court system at great government expense.
  • Of the 89% non-violent detainees in the system, select out non-criminals with ties to the community (citizen family members and legal employment) to remain under surveillance with monitoring devices and avoid the expense of custody altogether.

Re-inventing immigration and citizenship

Our federal government is responsible for immigration and citizenship. We would all benefit from a system that worked well.

It doesn’t help that only a small fraction of government funding pays for citizenship training and outreach with uncertain effectiveness. When applicants wait a very long time to process their applications (not knowing why) this doesn’t encourage new people to stand in line and work within our system. We could use a measurable and effective strategy to educate and integrate people to live in our country.

It is harder than ever to become an American citizen. The forms are long and complicated. Fees have gone up. There is a new, more difficult, citizenship exam. The government has posted a lot of new material in English on its website to try and help.

In 2007 the federal government received over 1,000,000 citizenship applications representing more than one-half of a billion dollars in fees. In 2008, applications abruptly dropped 50% from over one million to 525,786. Some believe the increased fee and complexity of the new exam are the cause.

This year a $1.2 million government grant was distributed to thirteen groups, in eleven states. The money is for citizenship training. No group receiving funds was required to specialize in teaching ESL or exam preparation. The government set no pass rate targets. There is no place where exam pass rates are reported. No data are available on outcomes achieved in these federally-funded or non-federally funded programs.

If fees increase, it’s harder to pass the exam and there is no measure of success in training, the system needs to be evaluated and changed if the result is preventing people from integrating.

Here are a few suggestions:

1. Begin measurable, effective citizenship training. For example, require agencies receiving grants to report back on their effectiveness with the number of people in their program who have enrolled and passed the new exam. While funded groups may be worthy of support, are they best qualified to teach citizenship and English?

2. Post pass rates for the new citizenship exam on the USCIS website and include statistics on the percent who are eligible (five years as lawful permanent residents) but do not take the exam. Many people are afraid to spend money on an uncertain outcome.

3. Coordinate better service with other agencies in the federal government. When an applicant pays their application fee, takes and passes the exam it may take from 8 months to several years to naturalize. This is usually because of FBI “name check” delays. In some cases, applicants have to pay extra money to hire a private attorney to sue the government to force them to process their application because of delays in deciding whether to approve it or not.

If we held our federal government accountable, we could observe how effective our integration efforts really are and perhaps benefit from the change.