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Immigration Big Roadblock to Health Care Reform

Most presidential candidates are proposing some kind of health care overhaul, but when Congress failed to pass immigration reform this year it may have created a major roadblock to lawmakers' ability to offer medical insurance to all.

So far, none of those proposing fixes to the health care system have said how they would treat illegal immigrants, understanding the furor it would cause on the campaign trail.

Yet, how any health care reform would, or would not, do so is almost certainly going to be a sticking point that would not have been the case had Congress dealt with the overall immigration question already.

Depending on who wins the Republican nomination, the issue could become a real dispute since the general approach the major Democratic candidates have taken to such issues suggests they might favor including illegal immigrants under a health care overhaul.

Any such plan will face obstacles on Capitol Hill in 2009 no matter who wins the presidency. Even if the Democrats keep Congress and win the White House, agreement could be elusive. A divided government would make things even tougher.

There will be disagreements over the size of the government's role in health care, the changes it will require from insurance companies and individuals, and most of all, the cost and scope of coverage.

But, the question of how to deal with the estimated 12 million people here illegally could become a chasm too wide to bridge, especially, as is likely to be the case, once this becomes an issue in the campaign and positions become etched in stone.

Simply put, the politics associated with providing taxpayer subsidies to illegal immigrants so they could buy health insurance might be a very tough sell to many members of Congress and their constituents, especially Republicans, representing much of the Sun Belt, Midwest and Rocky Mountain states.

And, a plan that did not offer coverage and subsidies to illegal immigrants might be unpalatable to many Democrats, especially those from the heavily blue states along the upper Atlantic and Pacific coasts.

The candidates trotting out their various reform plans are not offering the specificity that will be required when their ideas are turned into legislation. But their proposals generally have some government subsidy or financial incentive for low and moderate income families to buy insurance.

About 10 million of the estimated 47 million U.S. residents without health insurance are thought to be illegal immigrants, and the vast majority of them would fall into the eligible income range for subsidies. Currently Medicaid, the federal health program for the poor, pays for emergency care for illegal immigrants, although in some states that has been used to cover treatment for non-emergency room services such as chemotherapy.

It would be easy to imagine the political controversy over whether undocumented workers and their families would be eligible for those same incentives and subsidies as legal residents.

Immigrant advocates, some health care experts and many Democratic officials and interest groups would almost certainly argue that leaving illegal immigrants out of the proposal would be a public health disaster.

In that case, these experts predict the most severe cases among illegal immigrants would flood hospital emergency rooms that by law are required to treat everyone, driving up costs and leading to poorer overall health that could migrate to the general population.

But those who would oppose including illegal immigrants argue that scenario is actually the case now for all U.S. residents without health insurance and reform without undocumented residents would cut that current problem by almost 75 percent.

These groups that stopped the immigration reform proposal advocated by President Bush and bipartisan congressional leaders might well be expected to balk at giving illegal aliens any taxpayer money.

It is worth noting that the question of whether to include illegal immigrants has been a major - although not the only - sticking point in California, where Gov. Arnold Schwarzenegger's health care plan has stalled. And, public opinion in California is probably more likely to favor such subsidies than it is in most states.

The outcome of the GOP presidential race will also be a factor. Former Gov. Mitt Romney and former Sen. Fred Thompson have both criticized front-runner Rudy Giuliani for lax enforcement of immigration laws while New York mayor.

If Thompson or Romney win the nomination, they might be more likely to make the status of illegal immigrants in any health care reform a campaign issue than is Giuliani.

Like all things political, in health care reform, the devil is in the details. And this is one detail that could be very difficult to work out.

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