Getting Health Insurance for All: A Paradoxical Problem

What do you do about millions of people who don’t have health insurance at a time when unpaid medical bills are the biggest single financial problem that drives U.S. residents into bankruptcy?

Consumers, workers, business people, community advocates, politicians and the uninsured themselves have been trying to figure out an answer without success. Add to the mixture a large population of undocumented workers, and the problem becomes even more intricate and challenging for a state like California.

Gov. Arnold Schwarzenegger (R) is talking about finding a way to expand health insurance to all Californians. He has a special challenge in places like Los Angeles County, home to numerous immigrants, documented as well as undocumented.

A new study by the Public Policy Institute of California shows just how far outside the insurance mainstream immigrants are, as many from this group work in low-wage jobs at small companies that don’t offer health insurance. And, if they are undocumented, they are ineligible for government health insurance programs.

In Los Angeles County, among all adults ages 18 to 64, about 18% are uninsured. The figure jumps to 32% among documented immigrants and rises even more, to 46%, for undocumented immigrants in the county, the PPIC study noted.

Immigration status makes a huge difference in whether people have health insurance, according to the study by Marianne Bitler and Weiyi Shi of the PPIC, a nonpartisan research organization. Their study focused heavily on the Hispanic population. A survey in Los Angeles County indicated that 38% of Hispanic adults were uninsured, while the figures for white, black and Asian adults ranged from 13% to 18%.

Immigration status accounted for the variation. When immigration status was put aside for adults, “racial and ethnic differences in insurance coverage disappeared,” according to the research by Bitler and Shi.

For children, it also makes a big difference whether their parents are immigrants. Only 7% of Los Angles County children with a U.S.-born parent are uninsured.

If the parent is a naturalized citizen, the rate is also 7%. Among those with a parent who is documented, the figure without health insurance jumps to 19%, but 55% of children of undocumented immigrants are uninsured.

The numbers are surprisingly high for children, Bitler noted.

The research is contained in a draft brief titled, “Health Insurance, Health Care Use, and Health Status in Los Angeles County.” The full report will be issued by PPIC later this month. It was based on a detailed, intensive collection of data from individuals under the Los Angeles Family and Neighborhood Survey conducted in 2000 and 2001. The study looked at the immigration status of the parent who is the primary caregiver, usually the mother.

Los Angeles County, through the Healthy Kids program, began offering coverage in 2003 to all children, regardless of immigration status. Healthy Kids used funds raised from public and private sources to provide another layer of insurance protection, covering children who could not qualify for Medi-Cal, California’s Medicaid program, or Healthy Families, a separate program for children in low- to moderate-income families.

Healthy Kids offered low-cost coverage for children in families with incomes up to 300% of the federal poverty level, regardless of their immigration status. The program was started for children age five and younger, and then expanded to provide coverage for those up to age 18 until a lack of funds forced a cutback in coverage for older children.

Figuring out how to extend health coverage to all residents of California will pose a daunting problem for the governor, the state Legislature, and the bevy of experts who will be working on the problem. If people don’t have insurance at work, if they can’t afford to buy it on their own or if they are illegal residents and can’t receive government benefits, how is their insurance coverage paid?

One of the cliché answers is that medical coverage is provided informally because illegal immigrants are crowding into hospital emergency departments, using them like the waiting room of a doctor’s office. But that’s not true.

A national study of ED usage finds that, “Contrary to popular belief, communities with high levels of uninsured, Hispanic or immigrant residents generally have much lower rates of per-person hospital emergency department use than other communities.” The study was conducted by the Center for Studying Health System Change, a not-for-profit research group.

“The findings are surprising and make it clear that reducing emergency department use defies simple solutions such as restricting access for non-citizens or expanding insurance coverage,” said Peter Cunningham, who conducted the study. He indicated that while “a rapid influx of immigrants may contribute to ED crowding in some individual hospitals — particularly along the U.S.-Mexico border — immigration is not a major contributing factor to ED crowding nationally, even in many communities that have a large population of Hispanic immigrants.”

The nationwide study of 12 communities showed that ED use ranged from a high figure of 40 visits per 100 residents in Cleveland to a low of 21 visits per 100 people in Orange County. About 8% of Cleveland residents are uninsured, and less than 4% are noncitizens. In Orange County, about 18% of residents are uninsured and about 16% are noncitizens.

Bitler found similar results in her survey for Los Angeles County. She questioned people about overnight hospital stays and ED use for children in the previous two years. She found that hospital and ED use “did not vary much by race/ethnicity or immigration status.” The study indicated that “concern about immigrants and their children disproportionately using hospitals and [EDs] may not be well-founded for Los Angeles County.”

There is yet another confusing paradox to the issue of health insurance. Just because you don’t have it doesn’t necessarily mean you get sick more often and have more untreated ailments.

Hispanic immigrants had lower rates of high blood pressure and asthma than U.S.-born residents of Los Angeles County, according to Bitler’s research for PPIC. There could be two very different explanations. One is that immigrants are healthier because “healthy people may be more likely than healthy ones to leave their country,” the research brief noted. Another reason is that the diseases might be there for immigrants just as often as for U.S.-born resident, but the ailments are diagnosed less frequently because the immigrants — being uninsured — are less likely to go to the doctor.

There is a lot we don’t know, and that makes the job of creating an effective approach to health insurance policy even harder.