by Tim Rutten

January 9, 2010

Whatever their final shape, the healthcare reforms being negotiated by Democratic members of the House and Senate represent the most consequential piece of social legislation Congress has considered in half a century.

Californians, however, have a bigger stake in the outcome than other Americans -- and residents of Los Angeles County perhaps the biggest stake of all. In fact, if the final bill most closely resembles the one passed by the Senate, the county will be left far worse off than it is today.

The problem stems from the Senate bill's treatment of immigrants.

Both the House and Senate bills propose establishing insurance exchanges and giving low-income people subsidies to purchase coverage.

The Senate, however, would limit participation in the exchanges to U.S. citizens. The House would allow legal immigrants who aren't citizens to buy through the exchange, but would deny them federal subsidies. Neither version makes any provision for undocumented immigrants.

According to the Congressional Budget Office, the Senate's approach will leave 23 million American residents without health insurance, and about 7 million of those people will be undocumented. The House version allows 18 million people to go without coverage, of which roughly 6 million will be undocumented immigrants.

Because nearly 30% of all Californians -- as opposed to just 11.1% of all U.S. residents -- were born in another country, the statewide implications become a little clearer. Moreover, a UCLA study found that 20% of the 5.3 million Californians without health insurance in 2007 were not U.S. citizens. In other words, if something close to the Senate version of reform passes, at least 1 million residents of this state will be denied coverage. (The recent economic collapse and the consequent double-digit unemployment doubtless have pushed these numbers up.)

Narrow the focus to L.A. County and the picture becomes much bleaker. This county has more uninsured residents than any other local government in the country -- somewhere around 3 million, according to the best local estimates. Supervisor Zev Yaroslavsky, who has long been deeply immersed in the healthcare issue, likes to point out that "if Los Angeles County's uninsured were their own county, they'd be the third-largest county in the United States."

It's a safe bet that the majority of those people are immigrants, because health officials say that 40% of all the patients treated at county hospitals are undocumented. In recognition of that fact and of the hospitals' legal and ethical responsibilities to treat the uninsured ill and injured -- regardless of their immigration status -- Washington currently subsidizes their care at facilities, like L.A. County's, with "disproportionate" numbers of such patients.

As the result of efforts by Rep. Henry Waxman (D-Beverly Hills), the House reform bill reduces those federal payments only modestly, while the Senate version deeply cuts them. If the bill that ultimately emerges from the negotiations follows the Senate's prescription, L.A. County's millions of uninsured immigrants -- whatever their legal status -- will be denied the ability to obtain health insurance and the county will be on the hook for their hospital bills.

From this vantage point, that's not much of a reform.

Waxman, who is one of the House negotiators, is said to be working hard to protect those hospitals that could be hurt by the Senate approach. It seems increasingly likely, though, that the compromise bill is going to leave the county's health system worse off than it is today -- the House version marginally so; the Senate approach disastrously.

More farsighted participants in this process already are arguing that to make a real difference -- particularly in California -- these changes in the healthcare system need to be followed by comprehensive immigration reform that includes a path to citizenship for the nation's 12 million undocumented residents, something else President Obama has promised. The United States Conference of Catholic Bishops made that point in a news conference this week.

Another UCLA study released this week examined the aftermath of Ronald Reagan's 1986 amnesty for some 3 million undocumented immigrants and found that the benefits to the economy were striking. Using that as a benchmark, the researchers concluded that if the currently undocumented population was allowed to regularize its status, it would add $1.5 trillion to our gross domestic product over the next decade.

Thus, immigration reform would go a long way toward paying for healthcare reform -- if we can summon the political will to accomplish both.