An 800-Pound Invisible Gorilla, and Healthcare

by Deane on March 28, 2012

There is an 800-pound gorilla sitting on healthcare, and it is invisible. Truthfully, it is highly visible, but we choose to ignore it.

The gorilla is made up of 12-15 million illegal residents of our country, some who have been here for decades. Washington has turned a blind eye toward them and their health care. However, you can only ignore an 800-pound gorilla for so long. Eventually, it WILL make its presence known.

Fact #1: The GAO study on Uninsured Americans reported 45 million with that status, of which 12-15 million were illegal (undocumented) residents.

Fact #2: Federal law requires that any patient presenting to a Federally funded hospital who requires urgent or emergent medical care must receive that care, regardless of ability to pay and without regard to immigration status: legal or otherwise. Thus, an illegal resident having a heart attack will get care, while the facility and providers will receive no reimbursement.

To deal with this huge loss (expenditure with no compensating revenue), hospitals must revenue-shift. This means they charge others more in order to avoid going out of business. This is not a problem for insurers, government or private, as they pay nothing for care for illegals. To give a sense of magnitude, such uncompensated care accounted for 15% of the total annual budget of my own institution. That was $125 million the hospital had to “find” somewhere else or close its doors.

Fact #3: I believe that the Patient Protection and Affordable Health Care Act of 2010 (PPAHCA, now shortened to ACA) excludes illegal residents from the penalties imposed for failure to acquire health insurance, the so-called individual mandate. (I write “I believe” because the law’s language is so ambiguous that it can be interpreted in multiple ways.)

Fact #4: Even before ACA, 24% of all uninsured Americans qualified for free Federal health insurance assistance programs but did not sign up. Whatever their reasons for choosing not to obtain free insurance, they received medical care – mandated but unfunded – at no cost to them but at a cost (to others – that is you and me) well in excess of $50 billion per year nationally.

So, if I understand things, the following is true and constitutes an 800-pound readily visible but ignored gorilla.

a)              Under ACA (if upheld by the Supreme Court) a legal U.S. resident (citizen) can be penalized for failing to purchase health insurance. An illegal resident cannot. This is equitable…how?

b)             As ACA does not change the laws pertaining to unfunded mandates both legal and illegal residents, with or without insurance, will get urgent/emergent care. The need for cost- (really revenue-) shifting goes unresolved, and…

c)              ACA adds additional cuts to Medicare reimbursements, so there is even less money that hospitals can shift to cover uncompensated care.

What new incentives exist to make illegal residents sign up for insurance when they have not in the past? There are none in the ACA. If illegals do not sign up, then what happens to the savings that were supposed to come from people getting earlier, preventative and therefore less expensive care because “everyone” would have insurance?

The  gorilla analogy embodies two fundamental, inter-related issues: freedom and personal responsibility.

Are there any limits to Federal government control of our personal lives? Are illegal residents more free and more entitled than citizens?

Is there any personal responsibility in healthcare? If insurance is available to all and a person refuses to sign up, can health care providers deny that patient care? If not, then personal responsibility does not exist in health care.

The gorilla will remain an 800-pound problem until we take off the cloak of invisibility and deal with him (or her). We cannot go much longer emulating the ostrich.

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