January 31, 2019
By Dean Celia, Contributing Writer
As the nation debates illegal immigration in a tense political climate, New York City and California are offering plans to cover those who are unauthorized. Our experts analyze the pros, cons, benefits, and challenges.
In early January—with the federal government mired in a partial shutdown and the nation debating illegal immigration—California and New York City came out swinging with plans to provide health care access for undocumented immigrants. New York mayor Bill DeBlasio unveiled NYC Care, a $100 million program that will enable undocumented immigrants and others who cannot afford insurance access to primary care services. Meanwhile, California’s new governor, Gavin Newsom, proposed spending $260 million a year to insure undocumented immigrants between the ages of 19 and 26 (the state already funds care for those 18 and younger).
In the current political climate, the question naturally arises: Is this the best way to allocate dollars, or should programs that address the needs of US citizens and legally-documented immigrants come first? We asked four experts to analyze the issue, address its complexities, and predict how the plans might fare.
Norm Smith, a principle payer market research consultant in Philadelphia, was pragmatic, and spoke from experience. “I worked in New York City’s hospital system back in the 1980s. It was overwhelming.” So, he understands De Blasio’s logic. “Delivering up-to-date health care in these ancient hospitals has to be tough. New York City’s large tax base is able to afford some level of care” for undocumented immigrants. The same holds true for California, he noted.
Barney Spivack, MD, national medical director of Medicare case & condition management at OptumHealth, New York, said that states and local municipalities are fed up the federal government’s inaction and are choosing to move on their own. “Practically speaking, both plans will need to be viewed as one component -and not the centerpiece - of an overall effort to improve health care services for all residents.”
F Randy Vogenberg, PhD, RPh, principal of the Institute for Integrated Health Care in Greenville, SC, was frank. “Objectively, as a health care expert, [these moves] make no sense.” He believes there are too many variables to know if the efforts will pay for themselves, and argues that it is potentially throwing good money after bad, with no proof-of-concept. “California is the poster child for devastating budgetary impacts.”
Charles Karnack, PharmD, BCNSP, assistant professor of clinical pharmacy at Duquesne University in Pittsburgh, said he wonders if the proof-of-concept exists overseas. “I agree that at first glance, the plans appear to be impossible to pull off, but they are similar to what’s being done in the European Union,” where the focus is on prevention and addressing fragmented care.
Most of our experts agreed that the moves are politically-motivated. De Blasio and Newsom want to be the progressives who stand up to the controversial policies of the Trump administration. “Both probably want to be president someday,” said Mr Smith.
Beyond politics, some argue that simple math justifies the value of these programs. US citizens, they say, pay one way or another. Undocumented immigrants get sick, and without coverage end up being cared for in the emergency room or after their disease has progressed. So, it’s cheaper to fund care on the front end, and shift it to the primary care clinician’s office, they argue.
Dr Vogenberg said that layering on more plans and proposals isn’t necessarily the best solution. “There are a mishmash of coverages and stopgap programs, none of which address true long-term outcomes.” Dr Spivack said he worries about outreach. He cited an effort in New York City offering half-priced mass-transit cards to poor individuals that is reaching only 30,000 of an estimated 800,000 residents who live below the federal poverty line. Might the same issue hinder De Blasio’s health plan, especially since undocumented immigrants may fear consequences of being recognized as undocumented?
Mr Smith explained that, in theory, it is less expensive to deliver care earlier, but he cautioned that such programs are not panaceas, particularly with more complex conditions, such as rheumatoid arthritis. While undocumented immigrants are offered coverage, “they do not have access to the same standards of care that commercially-insured patients receive.”
Still, offered Dr Karnack, “treating diabetic foot ulcer in the emergency room is certainly costlier than preventing it through primary care visits.” Dr Spivack said he agrees, but added that it “may take years to be able to demonstrate desirable change. It's more likely that initially, there may be much higher expenses [because of] new access to care.”
Looking at the bigger picture, Dr Karnack said that “past and current experiences with immigrant populations often demonstrate outstanding productivity once they are established in welcoming communities.”
While improving outcomes and allowing individuals to thrive are the ultimate success measures, costs and funding have to be considered. De Blasio’s plan will be paid for by savings from emergency room visits, with no additional cost to taxpayers, according to the mayor’s office. Newsom’s proposal requires legislative action and a likely tax increase. Will the New York plan really pay for itself? And are California residents who already experience high taxes willing to pay more?
In New York, “it depends on the stability of the population receiving treatment,” said Mr Smith. If patient turnover is high and clinicians are continuously treating a new cohort, it will be difficult to demonstrate benefit. For this reason, “I like the idea of a membership card to identify and track individuals’ progress.”
Dr Spivack said that the $100 million allocated for the New York program is low in his view. “I am not sure what it will be able to cover.”
Meanwhile, in California, Mr Smith said he sees smooth sailing, but others are not so sure. “Getting legislative approval should be simple,” offered Mr Smith. “Democrats have a super-majority in both houses.” Dr Vogenberg said he agrees, to a point. “You never know with California, but taxpayers there are not happy.”
For that reason, Newsom’s $260 million a year plan is no slam-dunk, explained Dr Spivack. He pointed out that last year a $140 million-per-year proposal to expand care for legally documented young adults died in budget negotiations. He believes that raises questions about whether Newsom can push his plan through.
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