Researchers have found that immigrants tend to use the health care system less than legal residents. Illegal immigrants, in particular, tend to avoid using the health care system until they have to, favoring home remedies first or making cash payments to providers when they need care. That population also is younger, so it generally has fewer health care needs, says Timothy Waidmann, a researcher with Urban Institute.
The think tank, using federal government survey data, estimates that illegal immigrants accounted for an estimated $18 billion of the $1.4 trillion spent on health care in the United States in 2007. That adds up to less than 2 percent of total spending.
Some say excluding illegal immigrants from the overhaul will keep some legal residents uninsured, too. Ambegaokar, the Los Angeles attorney, points to parents who are illegal immigrants but have children who are legal citizens because they were born in the United States.
If the parents are not eligible, they may not know that their kids qualify. And in other instances, if one child is legal and the other is not, the parents may decide not to sign up either to avoid playing favorites.
"The goal is to enroll everybody who is eligible," Ambegaokar says. "But when you make systems complicated and require proof of ID, you're going to inevitably keep out people who should be in."
LOST IN TRANSLATION
Medicaid, which currently covers more than 60 million people, is expected to add about 17 million more people to its program by 2016 if the law is upheld, according to the nonpartisan Congressional Budget Office, which researches budgetary issues for Congress.
But people are still expected to fall through the cracks. That's because the requirements and process for signing up for Medicaid can be confusing. And while the overhaul aims to make the process easier, it won't smooth out all the wrinkles.
The problem? Many people don't realize that they qualify for coverage. And that likely will still be the case, albeit to a lesser extent, after Medicaid expands.
Coverage depends on how someone's income stacks up to federal poverty guidelines, which can be obscure to the average person. Plus, because income can fluctuate, someone could qualify one year but not the next.
"Regardless of how much outreach you do ... you're never going to get perfect enrollment," Matthew Buettgens, another Urban Institute researcher, says.
Staying enrolled can be another hurdle. Medicaid recipients have to re-enroll, sometimes more than once a year. They can be dropped if they miss deadlines, submit incomplete forms or if paperwork doesn't catch up with them after they move — something poor families tend to do more frequently than the average American household.
Leeanna Herman learned this when an unexpected $300 doctor bill arrived in the mail. The Bakersfield, Calif., resident was pregnant and unemployed and didn't know her government-funded health coverage had lapsed.
"I was freaking out," says Herman, 23, who went a month without coverage because she missed the deadline to re-enroll. "How do you expect me to pay that?'"
Experts say online applications and electronic verification of income levels and other things will make this process easier. But deadlines will still matter and some people don't have easy access to the Internet. And there will still be some people who simply won't enroll.
"There will always be that segment that says, 'Aw, the heck with it, I will just wait until I get sick and go to the ER,'" says Stephen Schilling, CEO of Clinica Sierra Vista, a nonprofit that has a network of 27 community health centers in California.
Schilling expects to still see a lot of uninsured patients at the nonprofit group's health centers even if the law is upheld. The center sits in an agricultural area in California's San Joaquin Valley, populated with migrant workers and saddled with an unemployment rate of around 15 percent.
It cares for about 60,000 uninsured people annually, thanks in part to grants and a sliding fee scale for patients based on their family size and income. Schilling says he still expects between 20,000 and 40,000 uninsured patients if the overhaul is implemented.
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