Immigration looms as sticking point in health-care legislation

By David Montgomery
Washington Post Staff Writer
Monday, November 16, 2009

The 31-year-old woman creeping gingerly into Adventist HealthCare's free-standing emergency department in Germantown was obviously in pain, and physician Orlee Panitch quickly diagnosed the problem: gallstones.

The case wasn't an emergency -- yet -- but the woman, who is an illegal immigrant, didn't know where else to go for care.

"Her inability to access care is a problem," Panitch said. "At some point, untreated, she'll need emergency surgery to deal with this."

That question of access to care for some immigrants, and who should pay for it, could well become one of the most contentious sticking points in the coming weeks as members of Congress sit down to reconcile the health-care bill passed by the House on Saturday with the yet-to-emerge Senate version.

The controversy centers largely on whether illegal immigrants should benefit at all under a revised health-care system. Democratic leaders had vowed that only legal residents would receive subsidies to buy insurance. And after Rep. Joe Wilson (R-S.C.) famously shouted "You lie" at President Obama when he made that vow to Congress, both the White House and the Senate Finance Committee went a step further. They pledged that undocumented workers would be barred not only from receiving subsidies but also from buying insurance through federally sponsored exchanges -- even if they used their own money.

Last week, when some House Democratic leaders pressed to match the Senate Finance Committee version, Hispanic lawmakers threatened to revolt and ultimately prevailed: Under the bill approved by the House, illegal immigrants would not be barred from the exchanges.

That stark debate, however, has largely obscured the distinct challenge raised by immigrant families as reformers try to provide coverage to as many Americans as possible. Because so many of the nation's 38 million immigrants -- legal and illegal -- live in households that include both categories, families must often rely on a patchwork of care and funding. And while the legislation could have a significant impact on how millions of immigrants obtain care, it is clear that large gaps in coverage will remain, not only across immigrant communities but also even within individual families.

Maria Salmeron, for example, is a legal resident from El Salvador who has insurance through her job in the kitchen of a nursing home. But her husband, a construction worker who is trying to legalize his status, has no insurance. Their youngest child, Isabella, a 2-year-old citizen in pigtails, requires a ventilator to breathe. Her medical needs are covered by state and federal programs.

On a recent fall day, Salmeron took Isabella to a pediatric clinic in Falls Church, where a bilingual pediatrician, Albert Brito, checked her for a cold and helped her mother make an appointment with a kidney specialist for the child.

Meanwhile, the nurse who comes to the family's home to help take care of Isabella has no insurance. J. Katan, a legal resident from Nigeria, said she cannot afford the premiums for the plan offered by her nursing agency.

"If I need to see a doctor," she said, "I go myself, and I pay."

Locally and nationwide, roughly two-thirds of working-age immigrants who are legal residents are insured, and more than one-third of illegal immigrants also have insurance, according to a new study by the Migration Policy Institute, a Washington think tank. The group estimates that as many as 2.8 million uninsured legal residents of working age could benefit from reform, by qualifying for expanded Medicaid or proposed subsidies to purchase insurance. Nearly 1 million uninsured legal immigrants also work at firms that could be required to provide insurance. And 1.8 million uninsured illegal immigrants work for firms that may be required to provide insurance, according to the institute.

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