In early March, Verónica del Cid Gaitán noticed a rash on her arms and suspected she’d had an allergic reaction. She’d been avoiding medical care — she didn’t have health insurance and couldn’t afford a large bill — but management at the restaurant where she worked insisted she get the rash checked out before returning. So, Gaitán “fearfully” went to the emergency room at Greater Baltimore Medical Center — her first time accessing health care since she arrived in the U.S from Guatemala last year.
Doctors discovered a mass in her colon when they ordered an ultrasound of her digestive system to see what she might have consumed that caused the rash. Gaitán spent a total of five days in the hospital undergoing further testing and having surgery to remove the mass.
Now, she’s left wondering how she’ll make ends meet if she’s billed for the hospitalization, and she must pay out-of-pocket for her follow-up appointments and medication.
Gaitán is one of the estimated 275,000 undocumented immigrants residing in Maryland who could have benefitted from a bill that would have allowed them to purchase health insurance on the Maryland Health Benefit Exchange. The bill failed in the legislative session that concluded this month.
The legislature did pass another bill authorizing the health exchange and Department of Health to study ways to extend Medicaid coverage to undocumented immigrants. The agencies will present their findings prior to next year’s legislative session.
Granting access to the health exchange or Medicaid benefits would provide the state’s first legal paths for undocumented people to obtain comprehensive health insurance. They are currently prohibited from purchasing health insurance on the exchange by provisions in the Affordable Care Act, and also barred from public health insurance benefits via Medicare and Medicaid.
These changes to the law would make a “night and day difference” for a community that “currently has no way of accessing insurance, even if they can [afford to] buy it,” said Ninfa Amador, a research and policy analyst at CASA, a regional immigrant advocacy organization and supporter of the two bills. Seven activists from the group were arrested at the statehouse on April 7, after several days protesting the apparent likelihood that the health exchange bill would die in the Senate finance committee.
State Del. Bonnie Cullison, who sponsored both bills, said the legislation strategically targeted “two different populations” of undocumented immigrants — those with the means to purchase health insurance, and those with incomes low enough to qualify for Medicaid.
“What is important to remember is most of these folks are working in Maryland, and paying taxes in Maryland, and contributing to our economy in Maryland. So to shut them out of our health benefit exchange is unreasonable, and in my book, inequitable,” said Cullison, a Democrat from Montgomery County.
The tax contributions of undocumented immigrants help sustain Medicare and Medicaid — programs for which they themselves do not qualify. According to research conducted by New American Economy, an immigration research and advocacy organization, undocumented people in the U.S. paid $20.1 billion in federal taxes and $11.8 billion in state and local taxes in 2018.
Forging a path forward
About 6% of Marylanders were uninsured in 2019, or 357,000 people, according to an analysis by the health exchange. That percentage has not budged in recent years, despite the state’s best efforts to whittle down the number of people without health insurance. About 30% of the state’s uninsured population is believed to be undocumented.
Hispanic people are the largest uninsured racial or ethnic group in the state with 10% uninsured — four times the rate of white people.
Although undocumented immigrants may be able to purchase health plans from private insurers, those marketed to people without Social Security numbers typically aren’t compliant with the Affordable Care Act — meaning they do not cover preventive care or they have exorbitant deductibles. Private health plans are also prohibitively expensive for the vast majority of people, undocumented or not. Cathryn Paul, public policy director at CASA, said none of the organization’s undocumented members in Maryland are insured under plans they purchased in the private market.
Undocumented immigrants often turn to hospital emergency departments to access needed care, because they’re prohibited from turning patients away under federal law. Lack of health insurance means undocumented people often go without preventive care, leaving chronic or potentially life-threatening health conditions undiagnosed and untreated. This also drives them to the ER, often for avoidable reasons, and at greater cost to the patient as well as the system.
“The ways that they’re getting care now are not sustainable,” Amador said.
Maryland hospitals report providing $120-$150 million in uncompensated care to undocumented immigrants annually, Cullison said. The Maryland Hospital Association expressed its support of the failed health exchange bill.
Low-income undocumented immigrants qualify for a Medicaid program that covers only emergency care, and are sometimes enrolled when they visit the emergency department. Although this relieves hospitals of some of the financial burden that uncompensated care creates, that cost is transferred to federal and state governments, and, by extension, taxpayers.
Allowing undocumented immigrants to purchase health insurance on the exchange would help the state economically, Cullison said. And giving them access to full Medicaid benefits means that they could prevent and treat health problems in a much more cost-effective manner — before they become full-blown, expensive emergencies that can cause disability and even death, she said.
Still, many undocumented people are young and generally healthy, Cullison said, so adding them to the exchange would help stabilize and lower premiums overall by balancing out the “pool” of people buying insurance.
“It’s a win-win,” Amador said.
When purchasing health insurance on the exchange, undocumented immigrants would not be able to access the income-based federal subsidies available to citizens and immigrants with legal status — such as permanent residents — that help cover premiums and cost-sharing. But a similar state subsidy could potentially be introduced if some version of the bill were to pass in future, Cullison said.
Similarly, if undocumented people were to qualify for Medicaid, the cost would need to be shouldered entirely by the state since federal funds can’t be used to cover those who lack legal status. Under normal circumstances, the federal government picks up a large portion of states’ Medicaid tabs.
Implementation of the health exchange program as envisioned in the failed bill would cost the state $550,000 in the first year and $250,000 in each year thereafter, according to a 2021 health exchange report. If state subsidies were added, net first-year costs would be $90 million, increasing to $145 million the following year and $165 million the year after, with costs stabilizing into more modest annual increases after that. Subsidy price tags would presumably be at least partially offset by decreased use of emergency medical services.
With subsidies, undocumented immigrants would pay an average annual cost of $3,600 in the first year and 3% to 5% more each year thereafter, according to the health exchange.
A long journey
Gaitán hasn’t been able to work since she was hospitalized and doesn’t know if she’ll still have a job once recovered. After more than a month since the surgery, her incision remains taped and she moves slowly and tentatively around the small two-bedroom apartment she shares with her husband and four other renters.
The mass removed from her colon was fortunately not cancerous, but Gaitán appeared so worried about cancer when talking to her doctors that one of them asked her why. She explained that her mother and most women on the maternal side of her family had died from breast cancer. Her 25-year-old niece is currently undergoing chemotherapy for breast cancer in Guatemala while awaiting a double mastectomy.
Forty-year-old Gaitán has never had a mammogram, and though her doctor urged her to get one, she has no way to pay for it. While she does have emergency Medicaid coverage, it is unclear whether she will be billed for the hospitalization following her emergency room visit. She had her first follow-up visit last week, and has another scheduled in mid-June. She will need to pay for these out-of-pocket.
At her follow-up appointment, Gaitán’s surgeon prescribed a medication for pain and inflammation that she discovered cost $250 at the pharmacy, so she didn’t pick it up.
Gaitán’s surgeon told her to be extra cautious during her recovery, “since I can’t see her often” due to finances, she said in Spanish. GBMC and other health systems are required to offer financial assistance programs that reduce or eliminate the cost of care for low-income individuals, but Gaitán said no one has informed her of such a program, not even the social worker who visited her home after she was discharged.
GBMC spokesperson Krystina Wales declined to comment on Gaitán’s case, citing patient privacy regulations. She said information on financial assistance is offered to patients in both Spanish and English, during registration and discharge, and can also be found on the GBMC website or on posters in the emergency department.
“We encourage our patients to ask questions and seek assistance as needed,” Wales said.
Gaitán can’t work at least until her next follow-up visit in two months, pending the surgeon giving her the green light to lift over 10 pounds. Her husband, Reinaldo Reyes Pérez, works as a dishwasher at the same restaurant and recently had his hours cut. He is diabetic, but does not see a doctor, instead self-managing his insulin dosing. Much of the income left over after bills are paid goes to purchasing insulin — which they get from a friend — and making sure they have the food needed to avoid diabetic crisis. The couple also sends money to their youngest daughter, currently studying medicine at a university in Guatemala.
They crossed the Mexican border in July of last year, spending eight days in the desert before arriving in the Phoenix area and continuing on to Maryland. They left Guatemala in search of better economic opportunity, Gaitán said. The couple still owes $20,000 to the “coyote” who helped them cross.
Given their financial precarity, having health insurance would be “quite a blessing,” Gaitán said in Spanish. She worries about how they will get by — let alone pay for health care — without her income.
An uncertain future
The health exchange bill passed the House but died in the Senate finance committee after its chair, Melony Griffith, a Democrat from Prince George’s County, expressed reservations. Griffith said she wants to wait until the report on Medicaid coverage for the undocumented, authorized by the bill that did pass, is produced in advance of next session so that it can be compared side-by-side with the 2021 health exchange report, which also looks at costs and feasibility of a Medicaid expansion.
Griffith said her decision not to move the bill forward was a “very thoughtful one,” to wait until “we have the comparative data in front of us” and all options for extending health coverage can be reviewed. She said the state may need to make some tough decisions on what to invest in — Medicaid or health exchange subsidies. Although the failed version of the health exchange bill did not include subsidies, this issue will need to be addressed at some point, she said, because “if we are not subsidizing it [costs], then the most vulnerable wouldn’t have access” to the exchange.
Meanwhile, “we’ve lost time,” Cullison said, with passage of another bill now delayed by a year. It’s not a short process to obtain a federal waiver exempting Maryland from federal rules prohibiting undocumented immigrants to buy insurance on the exchange, she said. The legislature is investigating other ways to initiate the process that would not involve passage of a bill, she said, but no one is certain whether that’s possible.
Regardless, expanding access to health insurance for undocumented immigrants would go a long way in fulfilling Maryland’s commitment to health care equity, she said: “This is just another piece of that.”
This article has been updated to reflect that there is no federal law prohibiting undocumented immigrants from purchasing private health insurance.