Should ACA provide health coverage to undocumented immigrants?

Chelsea Clinton recently suggested that undocumented immigrants gain access to (unsubsidized coverage). Predictably, she drove the social media world nuts.

On the merits, it’s actually a messy issue. There are real possibilities for adverse selection given the cost of coverage and the lack of an individual mandate in this population. There is no satisfactory policy in the absence of comprehensive immigration reform. That’s not going to happen for awhile. In the meantime, we should…well here is my personal take at

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Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect,, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

13 thoughts on “Should ACA provide health coverage to undocumented immigrants?”

  1. On the merits it's not messy, unless you're talking emergency medical treatment, to stabilize them for the long bus trip ahead, which there's indeed a humanitarian case for.

    On the merits, the only thing illegal aliens are owed is deportation. And ought to expect be billed for it.

    If they've been here for decades, they've been violating our laws for decades. They haven't achieved some sort of right of adverse possession in citizenship. The failure of administrations hostile to the rule of law to enforce it doesn't entitle them to similar misfeasance from future administrations. In essence they simply had part of the government as a co-conspirator against the legal populace, who were all that time demanding enforcement.

    1. A small point, Don.

      If it takes months for a plant to be up and running at full staff you may not have "crippled" it, whatever that means, but you have surely done some serious damage. Besides the loss of output from the time it takes to get new workers on board, there will be a loss from the time it takes them to get up to speed.

      So let's not oversimplify.

  2. There are some practical issues that Brett overlooks that should be considered. Guess who picks your strawberries and prepares the restaurant food you order?

    1. Not an American, because Americans are undercut by illegal aliens who have squat in the way of negotiating power, being subject to deportation if they complain about wages or working conditions?

      Yes, I'd call rampant high unemployment among lower skilled Americans a practical issue. There are lots of practical issues revolving around illegal immigration. You have to be pretty selective to think they all militate in favor of it, or even most of them.

  3. Brett is a libertarian, which means he strongly believes in individual responsibility. In most things he is a conservative in the old-fashioned sense of the word. I.e., he is not an advocate of many of the ideas of today's religious right, but rather the old conservative ideals of saving for a rainy day, spending within our means, and doing the right thing, rather than the expedient thing. I am a flaming liberal, but I also believe in all the things in my previous sentences. Brett and I disagree about how much should be expected, or can be expected, of individuals to live up to our ideals, and how much we owe our fellow humans if they can't. That, in turn, influences our difference of opinion of what's right or wrong for us, collectively, as a country.

    I don't think Mike's reply addresses those differences. I can't believe that either Brett or I would think the price of our strawberries would change our opinions of what's right and wrong.

    1. Perhaps not the price of just strawberries, but owning up to the benefits that many citizens and documented residents get from there being a group of roughly 10 million people, mostly of prime working age, who aren't the beneficiaries of wage-and-hour laws, safety regulations or guarantees of organizing. (Not to mention laws governing safety and nondiscrimination in housing and a bunch of other laws.) Many of whom pay taxes with no expectation of a return.

      On the practical side, large chunks of the US economy would simply cease to exist; on the moral side, two wrongs…

  4. Not meant as a direct criticism of Brett, but in my experience most who want to limit government action in the name of personal responsibility end up with a view of government as a sort of nanny whose primary job is to enforce personal responsibility rather than to solve problems. Result: they want the government to ignore ways to solve problems that are least burdensome to its own citizens.

    To take the present case, I would like to be able to eat out without fear that someone who can't take a day off has brought a healthy helping of rhinovirus to my salad or breathed on my silverware, and I want to be able to get emergency help at an emergency room if I have a medical emergency. The problem with leaving emergency rooms as the only place for those who are uninsured (for whatever reason) to get medical help is that they are always crowded with people who might not actually have needed to be there talking to expensive, highly trained emergency personnel. I'm fairly sure that, while we're waiting for immigration reform to get done, it would be a net savings to provide some kind of basic access to medical care for *everyone* so that the woman lying on a gurney in the hallway with a bullet wound, waiting for a room to come open, and the WWII veteran who may have had another stroke wouldn't have to wait for the five-year-old whose spiking fever wouldn't be hitting dangerous levels if it had only been taken care of two days ago when he started to feel sick, and so that all three of them wouldn't have to wait for a room full of people, many of whom could be taken care of at a different facility, if such a facility existed, and if they had access to it.

  5. There are regular attempts in the UK to get migrants to pay something towards health care on the NHS. The latest is a – wait for it – £200 one-off surcharge for (legal) migrants from outside the EU. (Note that if employed they will pay income taxes anyway). As far as I can see, it's all ineffective. GPS have a clear financial incentive to register anybody who shows up: they get a capitation fee for each registered patient. Hospitals don't have the billing systems or staff to chase up foreign patients who should theoretically pay, and the medical culture is hostile to such red tape. Hospitals can define "emergency" how they like, though pregnancy is always an emergency.

  6. "The Reality-Based Community
    Everyone is entitled to his own opinion, but not his own facts."

    I guess this site doesn't like facts to be posted. Four of my comments stating facts were deleted.

      1. I would, of course, disagree. My posts touched on different aspects of Illegal Aliens/Immigration pertaining to the OP and others' comments here. If they were redundant, then at least one could have stood. Only one other person here posted any facts.

        I suppose one can't have too many facts on this site. Only opinions are wanted.

        1. Well, no, what you can get away with depends on your ideology.

          It's a 'liberal' site, not a conservative one. That means they're looking for an excuse to delete any comment they disagree with, and you gave them an excuse, by posting a bunch of comments at once.

          OTOH, the proprietor doesn't like to think of himself as a censor, so if you're very careful, you won't get deleted. Not like some liberal sites I've been to, where the very fact you disagree is enough reason. You avoid giving an excuse, you should be ok.

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