The Affordable Care Act promises to bring insurance to millions of Californians who don’t have coverage today. The law will help the poorest of the poor, middle-income families and people who have been denied coverage because of pre-existing health conditions.

But Congress explicitly excluded one very large group of US residents: undocumented immigrants.

They are not eligible for the expanded access to Medi-Cal, the state and federal program for the poor, and they can’t get subsidized insurance through the new online marketplace known as Covered California. They can’t even buy insurance on the exchange if they want to use their own money.

By the time the Affordable Care Act is fully phased in, experts say, about 40 percent of the remaining uninsured in California will be undocumented immigrants. That’s more than 1 million people.

The politicians who voted for the exclusion gave at least two rationales. One was that since undocumented immigrants are, by definition, in the country illegally, allowing them to participate would reward unlawful behavior. The other is that taxpayers shouldn’t be asked to subsidize their care when some of the needs of U.S. Citizens and legal residents are going unmet.

But excluding undocumented immigrants from the Affordable Care Act does not make the cost of their health care go away. It only hides those costs. And it might even make them higher.

Contrary to conventional wisdom, illegal immigrants are actually healthier than the general population, or at least they are when they arrive. Think about it. These are generally people who come here seeking work, and they know they will be doing manual labor. They tend to be younger and stronger than the general population, and many of them hike long distances to reach the border. They are not infirm.

A recent study by the Center for Health Policy at UCLA found that undocumented immigrants use health care services less than US citizens do.

“The piece that shocks everybody, is that undocumented immigrants in general go to the emergency room half as often as people in the same age and health status as they are,” said Steven Wallace, the center’s associate director. “If you took two people off the street who were identical in all ways except that one was an undocumented immigrant and one was a U.S.-born citizen, the undocumented immigrant is half as likely to use the emergency room over the course of a year.”

Still, the lack of regular health care and the generally poor living conditions that these immigrants endure wears on them, and, over time, their health advantage disappears.

The most common place for undocumented immigrants to get preventive care is probably at a community clinic. These clinics typically charge on a sliding scale according to a person’s ability to pay. When a patient can’t afford to pay for the full cost of their care, the rest of the bill is absorbed by the clinic and eventually covered by state and federal funds.

And when an undocumented immigrant has a serious health problem and goes to a hospital emergency room, some of the cost is shifted to paying patients in the form of higher rates charged to insurance companies. The rest is either absorbed by the hospital or recouped through state and federal funds directed to hospitals that deliver high levels of uncompensated care.
Wallace of UCLA argues that it would make more sense, and be more humane, to acknowledge these hidden costs and pay for them up front.

“It’s a classic penny-wise and pound foolish situation,” he said. “By excluding undocumented immigrants from health insurance you are saving a little money now. But to the extent that someone does not get their blood sugar checked, they wait until they have a reaction, end up in a diabetic coma, then you have somebody in an emergency situation who will end up in a public hospital generating a very high level of medical expenses because they didn’t get the care that could have kept their condition under control.”

The political reality is that extending the Affordable Care Act’s provisions to undocumented immigrants is not going to happen any time soon. But there are other policy changes that might have an impact.

There are already a handful of government-funded preventive screening programs that are open to everyone and have been shown to be effective. A cervical cancer screening program run by the Centers for Disease Control is one example. Similar programs could be started to catch other diseases before they reach the chronic stage.

Another change might come by way of immigration reform. While the major reform bill pending in Congress would deny health benefits to immigrants who are given a path to citizenship, the bill would allow these immigrants to make short visits to their home countries and then return. Currently, undocumented immigrants with health problems are essentially trapped in the US, because they fear that if they leave, they will not be able to come back. This change would allow some of them, especially those from Mexico, to go home to be treated for major conditions.

The bottom line, though, is that even if the Affordable Care Act delivers everything its backers hope to see, more than 2 million Californians will still be without insurance and a dependable source of health care. And nearly half of those people will be undocumented immigrants.

Cross-posted at HealthyCal.