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Amelia Valenzuela, Affordable Health Care Coverage for Mexican Immigrants in the Southwest: State-initiated Reform in the Private and Public Sectors, 44 Arizona State Law Journal 1777 (Winter 2012) (Student Comment) (177 Footnotes)
[Emergency Rooms] are the U.S. health care system's “safety net” for individuals without health insurance. Mandatory ER medical attention for the uninsured and for patients otherwise unable to pay for care was established in the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA), which requires hospitals receiving Medicaid reimbursements to maintain an open-door ER policy. This means that emergency medical care is universally accessible at no up-front cost. In the decades subsequent to EMTALA, however, hospital ERs struggle to remain financially solvent under the weight of the mandatory provision of ER care coupled with changes in the health care system, and ER closures have proliferated throughout the country. From 1990-2009, 1,041 ERs closed, constituting twenty-seven percent of all hospital ERs operating in nonrural areas.
One source of staggering ER operating costs is from uninsured immigrants who can gain initial access to the ER thanks in part to EMTALA. Among the uninsured, Mexican immigrants are a particular concern because (1) they are by far the most numerous immigrant group in the United States, and (2) they encounter obstacles in the health care system that uninsured U.S. citizens do not. EMTALA requires hospitals to treat uninsured Mexican immigrants with emergency conditions, but federal law bars all undocumented Mexican immigrants, and documented Mexican immigrants residing in the U.S. for five years or less, from qualifying for Medicaid. In addition, most cannot afford private health insurance. Thus, uninsured Mexican immigrants are stranded between federal policy and financial barriers, leaving hospitals with medical bills ineligible for private insurance or federal reimbursement.
Hospitals in southwestern border-states have accrued enormous costs from uncompensated health care. The twenty-four counties along the U.S.-Mexico border spent $832 million on uncompensated care, one-fourth of which is attributable to undocumented immigrants. Non-border jurisdictions did not experience high rates of uncompensated hospital costs from undocumented immigrants. For example, Texas public hospitals reported spending $717 million on uncompensated care in 2008 and California spent $941 million on emergency Medicaid for uninsured immigrants in 2007. In contrast, Oklahoma reported it spent $9.7 million on undocumented immigrants in 2006, or less than one percent of its total health care costs. North Carolina spent less than one percent of its state Medicaid on uninsured immigrants in 2004. Southwestern border-state hospitals have reduced staff, increased rates, cut back on services, and decreased or ended charity care to their communities. State and local governments, largely responsible for public service costs from health care, have also been financially impacted. High costs have forced border-states such as Arizona to reduce state Medicaid funding to its poor and vulnerable populations.
Southwestern border-states cannot afford to wait for the federal government to change its policies or to adequately compensate hospitals for mandatory care given to uninsured immigrants under EMTALA. They have large Mexican immigrant populations that will likely continue accessing the health care system primarily through ERs absent changes to health policy. The 2009 Affordable Care Act (ACA) does not offer much help to solve this particular problem. Though ACA will help millions of U.S. citizens purchase health insurance, ACA largely excludes immigrants from its benefits. Hospitals in Arizona, with its large Mexican population, would greatly benefit from increasing the number of its insured Mexican immigrants. To alleviate significant financial burdens on hospitals and their ERs, southwestern border-states should consider increasing their number of insured Mexican immigrants by adopting (1) a private binational health insurance program for documented Mexican immigrants and (2) a public health insurance program for undocumented Mexican immigrants.
This article will explore two new health care policies Arizona can institute for uninsured Mexican immigrants and the challenges inherent in each approach. Part II describes the reasons why Mexican immigrants are largely excluded from the mainstream U.S. health care system and how this affects hospital ERs. Part III describes the private binational health insurance system initiated in California to increase health care coverage for documented Mexicans residing in the state. Part IV discusses how Arizona can reduce uncompensated hospital costs by increasing its number of insured Mexican immigrants through the two policy approaches noted above. Part V explains why Arizona must garner political support and assiduously market these health care plans to Mexicans residing in Arizona if it wishes to reduce ER costs from uncompensated care.