Proposal to expand Medicaid to undocumented immigrants draws criticism from Republicans

The first hearing for a highly anticipated bill to expand Medicaid eligibility to undocumented immigrants in Nevada drew sharp criticisms from Republicans, who suggested the proposal would be costly and worsen provider access issues for all patients.

Senate Bill 419 — dubbed the Health Opportunities, Planning and Expansion (HOPE) Act — would have Nevada expand its Medicaid program to insure non-citizen children and adults who meet all other enrollment requirements.

Undocumented immigrants are federally barred from enrolling in Medicaid or buying insurance through the Affordable Care Act. But states have the option of funding coverage themselves. Eight states and the District of Columbia have already opted to provide Medicaid coverage for income-eligible children regardless of immigration status. A few of those states have extended coverage to income-eligible adults regardless of immigration status as well.

State Sen. Fabian Doñate (D-Las Vegas), who is leading the effort to pass the legislation, on Tuesday told lawmakers on the Senate Committee on Health and Human Services his bill would allow undocumented immigrants to access primary care providers or other non-emergency room facilities, which would ultimately save the state money by keeping them out of costly ERs.

While undocumented immigrants are not eligible for Medicaid coverage, hospitals are allowed to bill the program for emergency services for uninsured patients who would be eligible for the program were it not for their immigration status.

“We are already fronting the bill,” said Doñate.

According to the Nevada Hospital Association, Nevada’s 19 largest hospitals provide $1.6 billion in care annually that is not reimbursed by government programs or individuals. Much of that is related to Medicaid and Medicare reimbursement rates. But some is attributed to care provided to undocumented immigrants who might otherwise be covered by Medicare. A narrowed estimate isn’t available because hospitals don’t track immigration status of their patients.

Dr. John Harwick, who works in emergency medicine for Renown Health, echoed Doñate’s sentiments in his own comments: “We’re not only paying for it, we’re paying more for it.”

Harwick recalled a recent patient who came into the ER with squamous cell carcinoma, a common skin cancer that is often easily treated by removing the lesion.

“This gentleman didn’t have a primary care doctor,” said Harwick. “He didn’t seek care.”

By the time the man saw a medical professional, the cancer had spread into his orbit. He lost his eye, wound up in an emergency department with seizures, and went into a coma.

“You can imagine the cost associated with that,” added Harwick. “Not only the societal cost, and the cost for that individual, but also the monetary cost of that patient and not having a system in place where that patient could seek reliable care.”

The two Republican members of the senate committee were wary of Doñate’s argument.

“Access to care — or the lack thereof — is not limited to any person, no matter how much you make, no matter what your insurance is, where you’re from, whether you’re undocumented or not,” said Republican state Sen. Robin Titus, who is also a doctor serving rural Nevada. “I, as a person who would see anybody walking in my door, couldn’t get them referred to a specialist because there’s not enough of us.”

Titus added that she worried adding potentially 95,000 additional people to Medicaid would further dilute available medical resources.

“This is really about the policy of care to the citizens of Nevada, my constituents, who can’t get into care now,” she told Doñate. “You’re asking us to now dilute that so your constituents can get in and see a provider.”

Doñate responded that there are other bills attempting to address related issues, such as provider shortages and Medicaid reimbursement rates, and noted that SB 419 includes provisions establishing a tax abatement program for health care companies expanding or moving into Nevada.

He also pushed back on the notion that the issue was isolated to his district.

“Undocumented immigrants live throughout this state,” he added. “The issue could be exacerbated more in the urban areas but all of us suffer from this. They’re your constituents as well, and I think in general we want to make sure they’re covered because that’s the right thing to do.”

Doñate’s Senate District 10 is 17.6% uninsured while Titus’s Senate District 17 is 8.4% uninsured, according to reports compiled by the Legislative Counsel Bureau. Nevada’s statewide uninsured rate is 11.3%. Those reports do not include demographic data regarding immigration status.

State Sen. Jeff Stone (R-Henderson) also pushed back against the HOPE Act, saying he’d received emails from people saying they don’t want to subsidize health care for people who are here illegally.

“I don’t want to make this a partisan event but we’ve had the greatest influx of undocumented immigrants in this country in the past three years,” he said, adding that the federal government, not the state, should foot the bill.

“You can have open border policies. That’s fine. But President Biden, send us a check.”

The Nevada Republican Party is also opposed to the bill. Jim DeGraffenreid, the party’s Republican National Committeeman, spoke in opposition on behalf the group: “We should not discuss a single penny of taxpayer [money] going to aliens until every last homeless veteran is sheltered, every American citizen in foster care has found their forever home with a loving family and every Nevadan lives in a neighborhood free of crime.”

Titus and Stone both noted having additional questions about the fiscal impact of SB 419, but Tuesday’s hearing was limited to policy discussions. If the bill progresses, it will be referred to a fiscal committee for discussions on the cost.

Doñate has estimated using data from Nevada Medicaid and the Guinn Center that covering 94,500 additional people with Medicaid would cost approximately $78.5 million annually.

While conservatives voiced disapproval of the proposal, others expressed enthusiasm for the bill. Many shared stories of insurance gaps leading to delays in seeking out health care for themselves or their family members.

“No one should be worried about having access to chemo, access to a checkup or access to being healthy,” said Jose Macias, a community organizer. “Life is not about blue or red. It is about human rights.”

Rico Ocampo, who was invited to speak as part of the bill presentation, recalled watching his big brother being rushed to the emergency room in 2006 with severe abdominal pain. What doctors first suspected was kidney stones turned out to be stage-4 pancreatic cancer. Juan Carlos, whose mixed-status family called him Carlitos, was just 17 years old.

“When the doctors told Carlitos about his diagnosis, he looked at my parents immediately and yelled out loud, ‘no me quiero morir; no me quiero morir,’ which translates to ‘I don’t want to die; I don’t want to die,” said Ocampo. “It was a moment that will forever haunt me.”

By the time Carlitos died, his medical bills totaled more than $300,000. When the family couldn’t pay, says Ocampo, University Medical Center put a lien on their home and took their home.

“We were stripped of our dignity,” he added, “forced to bear the burden of Carlitos’ illness and death on our own. Undocumented people are humans, and we deserve access to health care just like everyone else.”