This is the latest in an occasional series about implementation of the Affordable Care Act. Click here for the initial story in the series.

Fred Bauermeister has watched them pass through his clinic doors for decades: chronically ill, uninsured men, women and children who have delayed medical care because they are in the country illegally.

But now a political deal may be in the works that after many years could bring health benefits to millions of undocumented people.

A bandwagon of endorsements last week by congressional Republicans have aligned with vows by President Obama and Senate Democrats to establish comprehensive immigration reform. A road to citizenship for people who entered the country illegally seems more likely by the day, but what is less clear is how the health care landscape of California and the nation would also change.

Would California’s estimated 2.5 million undocumented immigrants become eligible for health benefits? How would an already burdened health system absorb them?

“We’re very interested and very concerned with how this is all going to work out,” said Bauermeister, executive director of the Free Clinic of Simi Valley, a California provider that seeks to keep immigrants out of expensive modes of care like emergency rooms.

Obama’s commitment to move an estimated 11 million undocumented immigrants nationally “out of the shadows” would not end there. Under current law, it would also slowly open the door for them to qualify for public programs, including health reform’s massive coverage expansions.

Obama’s plan would have immigrants wait at least eight years before they qualify for health benefits. A congressional plan spearheaded by two Republican senators, Marco Rubio of Florida and John McCain of Arizona, pushes the wait to at least 10 years.

Some experts believe both scenarios would create an interim period in which even wider gaps developed between the haves and have-nots of health care.

If health reform works as intended, there will not only be a boost in the number of new people covered but a steady improvement in their health. Meanwhile, undocumented immigrants sit on the sidelines for, give or take, at least a decade.

“We’re going to create a two-tiered system of health as well as perpetuate disparities in health,” said Ignatious Bau, a San Francisco-based health policy consultant whose clients include insurance giant Kaiser Permanente.

“People who are in the system are going to get better quality and efficiency,” said Bau, who was formerly director of culturally competent health systems at the nonprofit California Endowment. “But [undocumented] people who aren’t in the system are going to go to the ER.”

The haves will continue to pay the health care bill for the immigrant have-nots, Bau said.

A Push for Reform

Several groups, including the California Endowment, are pushing to win immediate health reform benefits for undocumented immigrants. But so far neither President Obama nor Congress has shown any interest.

Rubio has said that immediate health reform benefits for undocumented immigrants would force him to withdraw support for immigration reform.

“Senator Rubio’s position has not changed,” Rubio’s spokesman, Alex Conant, wrote in an email last week. He pointed out that “the White House and Senate Democrats have agreed that undocumented immigrants should not receive Obamacare.”

Some health providers believe that the gradual approach proposed by Washington is the only way to accommodate the undocumented population, particularly in immigrant-heavy states like California.

“From a pure numbers point of view, it would allow the system to ramp up to accept these folks,” said Dr. Martin Serota, chief medical officer of AltaMed, a California clinic network that serves 150,000 families a year.

“It would allow us to build. There’s bricks and mortar and hiring” to be done, he said.

Serota said the health system also needs time to train immigrants as caregivers, filling health reform’s need for bilingual, bicultural medical staff.

Health reform, which becomes fully effective in 2014, consists of two enormous coverage methods.

One is the Medicaid safety net, called Medi-Cal in California, from which undocumented immigrants are generally excluded.

The other is the government subsidized insurance exchange designed to help consumers find affordable health plans of their own choosing. Undocumented immigrants cannot participate in the exchange either.

The exclusions frustrate many health experts, because including currently ineligible immigrants in reform would greatly reduce the ranks of the uninsured.

According to a 2011 study by the UCLA Center for Health Policy Research, 84 percent of California’s 7 million uninsured will qualify for health reform coverage as it currently stands.

If undocumented immigrants were added to the health reform mix, 100 percent of the state’s uninsured would then be eligible for some form of coverage. Still, experts say, because of language barriers and personal choice, it is unlikely every qualified immigrant would apply.

The Congressional Budget Office reported in 2010 that nationally more than 90 percent of U.S. residents could eventually be insured with the boost provided by health reform, leaving about 23 million uncovered. If undocumented immigrants were granted coverage, the uninsured would be slashed by an additional one-third.

The Immigrant Health Paradox

Health experts rarely dispute the long-term fiscal benefits of covering more people.

Studies like “Health Care Reform in Transition” in the Journal of the American Medical Association find the larger the population in an insurance pool, the more stable the premiums. “The healthy subsidize the sick,” the 2010 study found.

Scholars also cite studies showing that immigrants are generally younger and healthier than the U.S.-born population when they first arrive. As they stay in the United States longer, their health begins to decline and become like that of their U.S.-born counterparts, studies have found.

“The recent immigrant (including the illegal immigrant) enjoys better health than aliens who have been living in the United States,” Patrick Glen, a Georgetown law professor, wrote in a 2012 paper titled “Health Care and the Illegal Immigrant.”

Now posted at the Office of Immigration Litigation at the U.S. Department of Justice, Glen emphasized that his scholarly writing was not the opinion of the dpartment.

Sonal Ambegaokar, a health policy attorney for the National Immigration Law Center, agrees with Glen’s findings. Immigrants must be added to the rolls quickly to maximize their potential to spread health costs, she said.

“The longer we exclude immigrants, the higher the costs will be for us,” said Ambegaokar, whose nonprofit works to reduce the backlog of immigrants seeking legal status.

Nevertheless, Obama cites his preferences and the Personal Responsibility and Work Opportunity Act of 1996, which bans green card holders from public benefits for five years, as the timetable for immigrant access to health care reform.

According to a leaked copy of the President’s proposal, undocumented immigrants must go to the “back of the line” and petition to become a “Lawful Prospective Immigrant.” They must remain in that newly created status for at least eight years.

From there, they can be declared a “Legal Permanent Resident” with a green card. But they must hold the green card for at least five years to qualify for public health benefits, including the expanded version of Medicaid created by reform.

The total waiting period to qualify for public benefits will differ greatly, depending on whether immigrants fit the employment and educational needs of the U.S., said Ambegaokar.

Throughout this long process, Ambegaokar said, health care options for the immigrant community would continue to be the emergency room and clinics like Bauermeister’s.

“If everybody else is covered,” Bauermeister said, “then the ones who aren’t are going to be our patients.”

The CHCF Center for Health Reporting is an independent news organization that reports about health care issues. It is based at USC’s Annenberg School for Communication and Journalism and is funded by the nonprofit California HealthCare Foundation.

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