Shout Draws Focus to Illegal-Immigrant Issue

By Alec MacGillis
Washington Post Staff Writer
Friday, September 11, 2009








It is estimated that there are 6 million to 7 million illegal immigrants without health insurance and that several million more have obtained coverage through employers or on their own. Taxpayers already subsidize health care for illegal immigrants -- Medicaid reimburses hospitals for emergency treatments for undocumented immigrants, most notably for childbirth. But studies have found that illegal immigrants spend much less on health care than others in the United States, partly because they are wary of interacting with the medical system and the government -- a fear that experts say would keep many of them from trying to exploit the new system.

The Democratic proposals call for covering most of the uninsured by getting them to buy plans on a new "exchange" where they could choose among private plans -- and possibly a government-run plan -- with the help of subsidies for those with low and modest incomes. Illegal immigrants would neither qualify for subsidies nor be required to buy insurance, as everyone else would be, though they could purchase plans on the exchange.

Tax policy experts say it would be difficult for illegal immigrants to obtain subsidies, because eligibility would be based partly on people's tax returns. It is true, they say, that many illegal immigrants pay payroll taxes using phony Social Security numbers, but they rarely file tax returns, and those who do almost always use "personal identification numbers" from the IRS, which essentially flag them as illegal immigrants. That is why it is very hard for them to obtain the earned-income tax credit.

"It would be exceedingly difficult for undocumenteds to game the system" by using a bogus Social Security number to apply for subsidies, said Alan Berube of the center-left Brookings Institution.

Activists fighting illegal immigration and House Republicans pushing for stricter rules want the legislation to mandate proof of legal status, such as requiring a birth certificate or using the Systematic Alien Verification for Entitlements, or SAVE, database, which tracks legal immigrants. They say such measures have prevented large numbers of illegal immigrants from enrolling in Medicaid.

Health-care reform proponents disagree, noting that few illegal immigrants enrolled in Medicaid even before proof of citizenship was required and that such requirements have disqualified tens of thousands of eligible citizens because they lack ready birth certificates.

That is why congressional Democrats have since moved to loosen that requirement for Medicaid. Reform proponents say adding back such rules for Medicaid or for the subsidies on the exchange would be costly and would apprehend relatively few illegal immigrants, at the risk of raising hurdles for those who are eligible.

They say that federal regulators may well end up using the SAVE database but that for Congress to impose strict standards now could result in overly blunt measures.

"Everyone agrees that [illegal immigrants] shouldn't be covered, and they're not going to be," said Edwin Park, a health-care expert with the left-leaning Center on Budget and Policy Priorities. "There's no clear evidence that the system is so vulnerable, so this would be a solution to a problem that doesn't exist but that causes problems for eligible people."

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