Free health care comes at a price
Are illegal residents' medical bills a moral obligation or an undue burden on taxpayers?
Tuesday, September 9, 2008 3:09 AM
By Stephanie Czekalinski and Jill Riepenhoff

THE COLUMBUS DISPATCH

Courtney Hergesheimer | Dispatch
Ohio State dental students Jesse Carmen, center, and Kyle Huish examine a patient who went to a free clinic in Columbus for a toothache. "There are huge numbers of Latinos who have never been to the dentist," said Dr. Henry Fishbach of Clinica Latina.


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The patients began lining up long before the free health clinic near the Ohio State University campus opened. For some, it was the first trip to a doctor.

For many, it was the only way to get routine medical care because they are poor, uninsured and living illegally in central Ohio.

"It is a horrible thing to be without insurance no matter where you're from," said Dr. Cregg Ashcraft, director of Clinica Latina. "And it's devastating if you're not here with the blessing of Uncle Sam."

Volunteer doctors, nurses and students from Ohio State's medical school work at the nonprofit clinic, set up in the late 1990s to serve Latinos.

But their charity could be trumped by a bill pending in the Ohio legislature that would ban the use of tax dollars to pay for routine medical care for anyone older than 14 who lives illegally in the state.

The bill would require Clinica Latina and similar clinics to check the immigration status of its patients and turn away those without documents because it receives financial support from Ohio State University, a public entity. It could continue to treat them if it could raise money from private sources.

The bill could leave illegal immigrants with virtually a single avenue to health care: the emergency room.

The unintended consequence, health-care experts say, is that hospitals and taxpayers would end up paying thousands -- even millions -- of dollars to treat major medical problems such as diabetes, high blood pressure or flu. Those conditions easily are controlled with prescriptions that cost as little as $5.

Federal law requires hospitals to treat patients in emergency rooms regardless of immigration status. State law cannot change that.

But state law can restrict the flow of local tax dollars to people seeking preventive care.

Left unchecked, treatable conditions -- diabetes, high blood pressure or flu, for example -- can become expensive emergencies. At that point, hospitals, taxpayers and people with health insurance foot the bill.

Many medical professionals believe that health care should be expanded, not restricted, because it's cheaper in the long run.

"You can't deny somebody basic human rights because they aren't from your country and they haven't entered legally," said Ashcraft, who also is an assistant professor of clinical medicine at Ohio State. "Health care is a basic human right. That's not the way to stop the immigration problem."

Ohioans aren't so sure.

More than 85 percent said in a Quinnipiac University poll last fall that they do not want government-financed benefits such as Medicare or Medicaid expanded to cover more illegal immigrants.

Economic studies from across the country show that immigrants living here illegally probably do tax the system. Last December, the Congressional Budget Office examined nearly 30 economic-impact studies and found that what immigrants pay in taxes doesn't completely cover the cost of health care, education and criminal-justice expenditures.

The bottom line, office director Peter R. Orszag wrote on his blog summarizing the report last December: "The result is probably a modest negative net impact on state and local budgets."

But no one has studied the economic impact in Ohio.

State Rep. Courtney E. Combs, a Butler County Republican who is sponsoring a bill to crack down on illegal immigration, said his motivation is to force Ohio to take a look at the impact and costs.

"We need some discussion," he said. "It's the elephant in the room."

Since 2003, Medicaid has reimbursed hospitals about $545 million a year nationally to offset the costs of emergency-room visits by an uncounted number of illegal immigrants. Each state's portion is based on the U.S. Census Bureau's 2000 estimate of the number of illegal immigrants, not the number of patients.

In 2000, the Census Bureau estimated that 40,000 immigrants lived in Ohio illegally. In 2006, the Pew Hispanic Center estimated that population had grown to as many as 145,000.

Ohio hospitals collectively have received nearly $1 million annually from the fund; California, $70 million a year.

Another pot of federal money helps hospitals recoup costs of treating the poor and uninsured, a group that also includes some immigrants.

No one knows how much hospitals, taxpayers and patients with health insurance pay to care for immigrants living illegally in Ohio. No agency or office tracks their care.

State and local tax dollars fund clinics throughout Ohio for prenatal care, immunizations and other routine medical services.

Columbus Public Health, for example, provides an array of health care to city residents -- legal or not -- with its $47 million budget.

Nationally, anti- and pro-immigration groups have commissioned many contradictory health-care studies that support their points of view.

But university researchers in North Carolina -- with no known bias -- found that less than 1 percent of Medicaid spending went to immigrants living there illegally. The study was published last year in the Journal of the American Medical Association.

Many doctors, Ashcraft included, say that the consequences of withholding medical care from illegal immigrants are vast.

They can spread disease and increase taxpayer costs when conditions become a matter of life or death. Without prenatal care, babies are at risk of costly developmental problems. Without insulin, diabetics risk amputation, blindness, kidney failure and heart disease.

"It's sad that, in this country with all of the resources that we have, there has to exist something like a free clinic," said Ashcraft, whose clinic operates on $12,000 in grants and numerous volunteers. "It's insulting. It's unfathomable."

Delivering higher costs
Maria expects to deliver her second child this month in Mount Carmel West hospital.

As they did two years ago, taxpayers will cover whatever Maria can't pay of her estimated $5,000 bill. She asked not to be fully identified because she fears neighbors will contact immigration agents.

Though Maria's husband works full time in a factory and pays income taxes, he does not have health insurance. The couple moved from Mexico six years ago.

Mount Carmel, with its proximity to two of the largest Latino neighborhoods in Franklin County, is at the epicenter of a Hispanic baby boom. Since 2000, the number of Hispanic births countywide has doubled while births among whites and blacks edged up slightly.

No one can say exactly how many of these births were to mothers without visas, but many of the children were born to low-income families.

The number of Hispanic children receiving government-funded health care in Franklin County has quadrupled since 2000, to more than 8,600.

Medicaid is available to any child born into a poor family in the United States. Children who came with their parents to the U.S. illegally do not qualify.

In addition to Medicaid, Maria's 2-year-old daughter and the baby she's carrying -- U.S. citizens by birthright -- receive help from the Women, Infants and Children nutrition program, commonly called WIC.

During the past 10 years, the number of Hispanic women and children in Franklin County enrolled in WIC has increased tenfold to more than 5,300. Once children turn 5, they no longer are eligible for the food supplements.

In both programs, no one tracks parents' citizenship.

Medicaid coverage for Maria's two children will cost about $3,800 a year for routine pediatric care and immunizations. Maria's newborn will receive about $1,430 in WIC benefits during the first year of life. Her older daughter will receive about $480 a year in dairy products.

All told, Maria's children this year will receive nearly $6,000 worth of help. And that's if they're both healthy.

Maria doesn't comprehend that while these programs are free to her, they come at a cost to taxpayers."I apply just like all Americans," Maria said. "The hospital connects you with everything: WIC, Medicaid."

Advocates for tougher enforcement of immigration laws call people like Maria burdens on taxpayers. If the parents weren't living here illegally, their children wouldn't be tapping into public assistance.

Some Latinos, however, decline any public assistance because they fear it might cause future visa applications to be denied, said Gianella Martinez, executive director of Centro Esperanza Latina, a West Side community center.

"They don't want it on their record that they received anything, including WIC," she said. Without those benefits, however, Maria's children would be pushed deeper into poverty.

Heading off disaster
The Latinos waiting for the free clinic near the OSU campus to open on a balmy summer evening were there because there are few other places where they can get prescriptions for a cough, have a wart removed or have a wound dressed.

For many of them, the treatment of those harmless conditions ends up saving their lives. Doctors often discover much more serious health problems when treating the minor ones.

"The majority of the folks we see are sicker than they should be, but we also see a huge number of people who have absolutely no symptoms," Ashcraft said.

If not for a fall on a construction site, one young Mexican man might have ended up in the emergency room, deathly ill. He went to the clinic complaining of a sore back. Tests of his blood sugar detected diabetes.

"It was off the charts," Ashcraft said. "He had felt bad for a long time, but he didn't have anywhere to go."

In hindsight, the man in his 20s was so sick that he should have gone to the emergency room, Ashcraft said.

Mexicans are prone to diabetes just as blacks are susceptible to sickle cell anemia.

The Ohio Department of Health estimated last year that diabetes was diagnosed in nearly 9 percent of the Hispanic population in the state between 2005 and 2007, compared with 7 percent of whites.

But Ashcraft suspects that far greater numbers of Mexicans are walking around with undiagnosed ailments -- ticking time bombs.

Untreated, diabetes is catastrophic, expensive and potentially deadly. It can lead to blindness, kidney failure, heart attack and gangrene. Those patients typically end up in the emergency room. If they're uninsured, taxpayers and everyone with medical insurance are on the hook for the bill.

"We've got this huge at-risk population, which has innumerable barriers to the resources," Ashcraft said. "It's also a problem for the community as a whole because the costs of the complications are astronomical in proportion to the cost to prevent."

Diabetes generally can be managed with a $5-a-month supply of prescription pills or a $70 vial of insulin. By comparison, kidney dialysis for a month can cost $120,000.

Two weeks after his diagnosis, the construction worker returned to the clinic for a new glucose test. He faithfully had been taking his $5-a-month pills.

"Now he brings back beautiful blood sugar," Ashcraft said.

His diabetes now isn't likely to result in a trip to the emergency room or cost taxpayers thousands to clean his blood, restart his heart or amputate his leg.

sczekalinski@dispatch.com

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