Aging undocumented immigrants pose costly health care challenge

Teresa Wiltz at Stateline pointed out another costly problem, which I had to start this post because of the upcoming fight on immigration. Early on a recent morning, men huddle in the Home Depot parking lot, ground zero for day laborers on the hunt for work. Cars pull into the lot, and the men swarm.

Among them is Marcos, at 65, wiry and bronzed with a silvery smile. He’s been in the country illegally for 20 years. When he’s sick, he just rests, because — like most undocumented workers — he doesn’t have insurance.

“I don’t know if I have high blood pressure,” he said. “Because I don’t check. Doctors, you know, are expensive.”

For decades, the United States has struggled to deal with the healthcare needs of its undocumented immigrants — now an estimated 11 million — mainly through emergency room care and community health centers. But that struggle will evolve. As with the rest of America, the undocumented population is aging and developing the same health problems that plague other senior citizens.

Many undocumented adults lack health insurance, and even though they’re guaranteed emergency care, they often can’t get treated for chronic issues such as high blood pressure. What’s more, experts predict that many forgo preventive care, making chronic conditions worse — and more expensive to treat.

“They’re hosed. If you’re an undocumented immigrant, you’re paying into Social Security and Medicare, but can’t claim it,” said Steven Wallace of the UCLA Center for Health Policy Research.

When uninsured people end up in the hospital, that pushes up rates for those who have insurance. Or public programs like Emergency Medicaid pick up the tab. This contributes to a game of shifting costs, Wallace said.

“It’ll place a strain on the entire health care system,” Wallace said.

Growing numbers

Approximately 10% of the undocumented population is over 55 now, according to the Migration Policy Institute, but researchers agree that their numbers will rise.

“The unauthorized immigrant population has become more settled, and as a result is aging,” said Mark Hugo Lopez of the Pew Research Center.

Estimates vary on how many undocumented immigrants lack insurance. The Kaiser Foundation estimates 39 percent are uninsured, while the Migration Policy Institute, which analyzes U.S. Census data, estimates as many as 71 percent of undocumented adults do not have insurance.

Like Marcos, older undocumented people tend to be poor. The Affordable Care Act doesn’t cover them, and they don’t qualify for Medicaid, Medicare or Social Security, even though many pay taxes. Few can afford private insurance.

That means most must turn to emergency rooms or community health centers, which provide primary care to poor people, regardless of immigration status. But community health centers can’t provide extensive care, Wallace said. And because Congress has yet to fund them, their future is precarious.

Leighton Ku, professor, and director of the Center for Health Policy Research at George Washington University said immigrants, both authorized and unauthorized, are much less likely to use health care than are U.S. citizens. Until that is, they’re quite ill.

“Their numbers are going to grow and we’re going to have an epidemic on our hands,” said Maryland state Del. Joseline Peña-Melnyk, a Democrat. “Who’s going to pay for it?”

A 2014 report by the Texas Medical Association found that undocumented immigrants with kidney disease face considerable barriers to care. By the time they do get help, they need dialysis, costing Texas taxpayers as much as $10 million a year.

Stepping in to help

Many cities have tried to step in. A 2016 Wall Street Journal story noted that 25 counties with large undocumented populations provide some non-emergency health care to these immigrants, at a combined cost of what the paper estimated is more than $1 billion each year.

Washington, D.C., Los Angeles and San Francisco are among the places where undocumented immigrants can usually get routine care, thanks to locally funded programs.

In Los Angeles, Dr. Christina Hillson, a family practice doctor at the Eisner Health Clinic, said she’s seeing a growing number of elderly undocumented patients, whom she’s treated for everything from ovarian cancer to amputations resulting from untreated diabetes.

Patients who are critically ill are considered emergencies and can get treated at hospitals, she said. Sometimes Hillson will send patients who aren’t as ill to the ER because it’s the only way they can see a specialist.

Snapshot of a population

Most undocumented people immigrated here when they were young and tended to be healthier than native-born citizens, Wallace said. But as they age, they lose that advantage.

Undocumented women are more likely to have family in the U.S., who can help care for them as they age, said Randy Capps of the Migration Policy Institute. But men are more likely to be single. Because they often work as manual laborers, they’re more likely to get hurt on the job, Capps said.

“They’re going to age faster and become disabled at higher rates,” Capps said. “It’s going to make for a much tougher old age.”

There’s no one easy solution to helping older residents who live in the United States illegally, health and immigration experts say.

“The policy solution for illegals is to enforce the law and encourage them to return home, thereby avoiding the problem,” said Steven Camarota of the Center for Immigration Studies, which favors limiting immigration.

Joe Caldwell of the National Council on Aging, an advocacy group, said federal immigration legislation providing a pathway to citizenship would allow seniors to access care.

Such legislation is unlikely anytime soon.

Outside the Home Depot, Marcos and his friends gather in the cold sunshine. He’s been paying taxes for years, Marcos said, and he’s got pages of documents to prove it. He’d love to become documented, “but that’s practically impossible,” he said.

A year ago, Marcos said, he had tightness in his chest. He had no choice but to go to the ER, but he hasn’t followed up. He’d rather stalk the parking lot here, looking for work.

“No work,” Marcos said, “no money.”

Local lawmakers introduce a Bill for a single-payer healthcare system in Rhode Island. Supporters of universal health care are renewing their push for publicly-subsidized health insurance for all Rhode Island residents.

State Rep. Aaron Regunberg, a Providence Democrat running for lieutenant governor, is a sponsor of this year’s legislation. He said at a Wednesday news conference that health care is a “fundamental human right.”

The proposal calls for a 10 percent payroll tax to cover the costs of the single-payer system, which would operate similarly to how Medicare, the federal health insurance program for those 65 years or older, works.

“This legislation is about guaranteeing healthcare as a fundamental human right for every Rhode Islander and creating a more efficient system for us all,” Regunberg said. Regunberg says the plan would lead to $4,000 in annual savings for residents once it’s fully operational. Democratic state Sen. Jeanine Calkin, of Warwick, is introducing the Senate version of the bill. Among the bill’s supporters is Physicians for a National Health Program.

“Currently, 47,000 Rhode Islanders are uninsured and many more are under-insured. Those who are fully insured face limited-provider networks and skyrocketing premiums, co-pays and deductibles,” Calkin said. “A single-payer system will ensure that every Rhode Islander has access to the health care they need when they need it.”

State Single Payer Legislation

Single payer advocacy groups in many states are successfully pursuing state-level legislation. This legislation is a constantly moving target. The question is should a single payer system be a state or federal policy?

California-Organization: Healthy California
Bill: The Healthy California Act

Colorado-Organization: Health Care for All Colorado
Bill: The Colorado Universal Health Plan

Illinois-Organization: Illinois Single-Payer Coalition
Bill: Illinois Universal Health Care Act

Maine-Organization: Maine AllCare
Bill: An Act To Establish a Unified-payor, Universal Health Care System

Maryland-Organization: Healthcare-NOW! of Maryland
Bill: Maryland Health Security Act

Massachusetts-Organization: Mass-Care
Bill: An Act for Improved Medicare for All in Massachusetts: Providing Guaranteed, Affordable Health Care

Minnesota-Organization: Minnesota Health Plan
Bill: Minnesota Health Act

Missouri-Organization: Missourians for Single Payer
Bill: Missouri Universal Health Assurance Program

New Mexico-Organization: Health Security for New Mexicans Campaign
Bill: Health Security Act

New York-Organization: Campaign for New York Health
Bill: New York Health Act

Ohio-Organization: Single Payer Action Network (SPAN) Ohio
Bill: Ohio Health Care Plan

Oregon-Organization: Health Care for All Oregon
Bill: Affordable Health Care For All Oregon Plan

Pennsylvania-Organization: Health Care 4 All PA
Bill: An Act providing for a statewide comprehensive health care system

Rhode Island-Organization: PNHP Rhode Island
Bill: The Rhode Island Comprehensive Health Insurance Program

South Carolina-Organization: Healthcare For All – South Carolina
Bill: The Palmetto Comprehensive Health Care Act

Vermont-Organizations: Vermont Workers’ Center, Vermont Health Care for All
Bill: An act relating to a universal and unified health system [PASSED]

Washington-Organization: Health Care for All Washington
Bill: Washington Health Security Trust

Let’s look at some average costs of health care. For example, Andrew Luccock pays about $1,700 per month for health insurance for his family of 5—and still expects to pay more than $25,000 out-of-pocket this year for medical care. That will total around $45,000 for premiums and uncovered expenses in 2018–on top of a similar outlay last year.

“I’m angry. I feel trapped,” the 58-year-old insurance broker form Portland, Ore., tells Yahoo Finance. “I have enough cash flow coming in, but I keeping thinking, how does a normal person pay for this?”

Congress fought some epic battles over health care during the last year—and in the end, did precisely nothing to help a slice of Americans struggling with soaring health insurance premiums and out-of-pocket expenses. The Trump administration, meanwhile, killed a subsidy associated with the Affordable Care Act, raising costs even more for those already facing the sharpest increases.

The most crushing price hikes are hitting people who don’t get insurance from an employer or government program and purchase it individually on the so-called non-group market. These over-the-barrel consumers tend to be small-business owners or independent contractors, and the steepest premiums hit those between 50 and 64. For people getting insurance through an employer, premiums rose just 3% in 2017 on average, according to the Kaiser Family Foundation. But premiums for individual policies rose a whopping 20%, and premium increases in 2018 may very well surpass last year.

That’s happening for a couple of reasons. First, many insurers participating in the marketplaces set up under the Affordable Care Act set premiums too low when the law first went into effect in 2014. They’ve since adjusted upward, with sharp hikes in premiums for some customers. There are rules limiting premium increases under Obamacare itself, and big employers have negotiating leverage that helps keep a lid on the premiums their workers pay. But purchasers in the non-group market have hardly any leverage, so insurers have shifted the biggest price hikes there.

President Trump’s decision last October to end “cost-sharing reduction” payments to insurers probably pushed premiums up even more, since insurers had to find additional ways to offset rising costs. Again, raising premiums on individual policy purchasers is the path of least resistance. Complete data for 2018 isn’t available yet, but Kaiser found likely premium increases ranging from 17% for a low-cost plan offering modest coverage to 32% for a medium-priced plan that covers more.

Obamacare, as the ACA is known, provides subsidies for lower-income people buying insurance through an exchange, so they don’t feel the full sting of higher premiums. But people who earn too much to qualify for subsidies have no such protection and end up bearing the full brunt of all the price hikes insurers are loading onto individual purchasers. There are about 10 million Americans covered by plans purchased on the individual market without ACA subsidies.

Yahoo Finance surveyed more than 1,400 readers on their insurance costs from Jan. 12 – 15, and found more pain among people purchasing individual policies than those covered by any other source. More than 58% of people buying individual coverage said the cost was unaffordable or a major hardship, compared with just 43% overall. And 91% of those purchasing an individual policy said premiums went up this year, compared with just 78% of all respondents.

Luccock, who buys insurance on the individual market, started seeing substantial price hikes in 2017, after his prior insurer pulled out of Oregon, unable to turn a sufficient profit. Monthly premiums rose from $1,050 per month to $1,350 under the new insurer, and then to $1,700 for 2018. Luccock’s 23-year-old son injured his back in 2016, requiring two medical procedures last year. But insurance would only pay for one, forcing Luccock to pay more than $40,000 out of pocket for the other. He paid half upfront last year, with the rest due this year.

Since Luccock is an insurance broker who understands how the market works, he’s contemplating alternatives to traditional insurance. “I’m thinking I could put $4,000 or $5,000 a month into an investment account and eventually be able to cover most medical expenses myself,” Luccock says. “In the worst case, if something terrible happened, I’d just go bankrupt. How crazy is it for somebody like me to even contemplate self-insuring?”

Going without

Others are giving up on insurance altogether. Mark Viator, a retired statistician living in Crofton, Md., had been buying insurance on the individual market since he left a government job in 2005. But with his premiums due to rise 40% from 2016 to 2017, he decided to go without. “That’s just an astonishing rate of growth,” he says. “That stunned me. For me, it’s the costs being out of control.” Viator, 61, has a condition that will require some orthopedic work on his hand, but he figures he’ll negotiate a cash price with doctors—and otherwise simply wait it out until he qualifies for Medicare in 4 years.

Brian, a 60-year-old business owner who lives near Ft. Lauderdale, is also looking ahead to the moment he qualifies for Medicare—but with a lot more trepidation. His wife suffers from multiple sclerosis and requires costly medication; so going without insurance isn’t an option. Monthly premiums for the two of them have risen from about $1,800 per month in 2014 to $3,140 per month this year—a 74% increase during that time, or 19% per year. Including deductibles, the cost of insurance is about $31,000 per year.

“That’s a crazy amount of money,” says Brian, who asked that we not use his last name. Paying that much for insurance leaves less to put into retirement funds or invest back in his business, and fellow business owners he knows face the same crunch. “We don’t have any buying power as a group,” Brian says. “We feel like we’re underheard and underrepresented. Nobody talks about it any more.”

Focus on killing Obamacare

The big fight in Congress last year wasn’t about solving the problem of runaway costs that millions of Americans face. That battle was strictly about killing Obamacare, which would have checked a Republican wish-list item but also would have axed insurance for millions, while doing little to rein in costs. Three Republican-led efforts to kill Obamcare failed.

Obamacare is, in fact, partly to blame for the predicament individual insurance buyers face. By establishing minimum coverage levels and phasing out subsidies at certain income levels, the 2010 law left an island of consumers in the individual market uniquely vulnerable to rising costs. But the law also did a lot of good, and repealing it outright would leave 20 million people or so without insurance.

The Trump administration made two changes last year that will probably affect insurance and medical costs in the future—but not favorably. The tax cuts President Trump signed in December included a repeal of the individual mandate requiring all Americans who can afford health insurance to purchase it. That will save money for people who choose not to buy insurance, provided they don’t get sick or hurt. But it will probably push premiums even higher for individual insurance purchasers, because there will be fewer healthy people in the insurance pool and a larger portion of sick people requiring costly care. Inevitably, those hikes in premiums and out-of-pocket costs will flow to the individual market.

Trump also plans to allow the sale of “association health plans,” which tend to offer stripped-down benefits at a lower cost than typical plans. That could lower costs for some, but these plans are controversial because they’ve been associated with fraud in the past. They could also siphon off healthy consumers from broader insurance pools, which, again, would push rates higher for those who remain.

There are better ways to address spiraling costs. The U.S. system is riddled with middlemen and incentives that reward the amount of care provided, rather than the effectiveness of care. There are many sound ideas for how to better control costs, if Congress were interested in real solutions. The government could even provide last-resort catastrophic care to those who can’t afford a traditional policy but want minimal coverage in case of disaster—an idea once backed by conservative icon Milton Friedman, but rejected now by conservatives seemingly opposed to any government role in anything. For the time being, meanwhile, health reform in the United States is more likely to go backward than forward.

Looking at those numbers and the amount that our country spends on healthcare is non-sustainable. So, what is a Single Payer system and are there more than one system out there to choose? There is the healthcare system that Democrats like Bernie Saunders touts-Medicare for all. But is this the only choice and how do we pay for it or who will pay for it?

Next, Medicare for all!!

And for those who care my new book goes to print this week-“Searching for Excellence in Clinical Process Improvement.”