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Obama’s Executive Order, Its Impact on Health Care Costs, and the Constitutionality of Executive Orders

Pres. Barack Obama will address the nation tonight at 8 pm (Thursday, November, 20, 2014). He is expected to discuss his executive order that will delay deportations of up to 5 million migrants.

What does an executive order on immigration have to do with Medicaid? Well, you can bank on the fact that almost none of the 5 million people has private health care coverage….which means, there is a high likelihood that most, if not all, the people would qualify for Medicaid.

With the expansion of Medicaid in many states, adding another 5 million people to the Medicaid program would be drastic.  Think about it…in NC, approximately 1.8 million people rely on Medicaid as their insurance.  5 million additional Medicaid recipients would be like adding 3 more North Carolinas to the country.

So I looked into it…

The Kaiser Family Foundation website states that even immigrants who have been in America over 5 years are sometimes still barred from getting Medicaid and those people would remain uninsured.  The Kaiser website states that under current law “some lawfully present immigrants who are authorized to work in the United States cannot enroll in Medicaid, even if they have been in the country for five or more years.”

By law, only immigrants who have green cards are entitled to enroll in Medicaid or purchase subsidized health care coverage through the ACA. Usually those immigrants with green cards are on the course to become citizens.

Regardless of whether Obama’s executive order tonight will or will not allow the 5 million people Medicaid coverage (which it will not), the executive order absolutely will greatly increase health care costs

The truth is that, with or without Obama’s executive order, the government already funds some health care for undocumented immigrants. We have an “emergency Medicaid” program and it pays hospitals to provide emergency and maternity care to immigrants if: 1) he or she otherwise would be Medicaid eligible if they weren’t in the country illegally or 2) he or she are legally present in this country for less than 5 years.  (Which is the reason that ER wait times are so long…if you have no health insurance and you get sick, the ER is precisely where you go).

However, with the additional 5 million people living within the borders of USA, it is without question that the “emergency Medicaid” funds will sharply escalate as hospitals provide more emergency care. ER waits times will, inevitably, increase. Health care costs, in general, surge as the population increases.  And the addition of 5 million folks in America is not a “natural” increase in population.  It will be like we added additional states.  Overnight and with the stroke of a pen, our population will grow immensely.  I guess we will see whether we get “growing pains.”

An act of Congress will still be required before the undocumented immigrants impacted by the executive order would be allowed to participate in the Medicaid programs and the Children’s Health Insurance Program (CHIP) coverage.

As to the Constitutionality of executive orders…

Executive orders are not specifically mentioned in the Constitution.  Many people interpret the nonexistence of executive orders in the Constitution as barring executive orders.

Article I Section I of the Constitution clearly states that all legislative powers reside in Congress. However, an executive order is not legislation. Technically, an executive order is a policy or procedure issued by the President that is a regulation that applies only to employees of the executive branch of government.

Nonetheless, our country has a vast history of president’s issuing executive orders. Abraham Lincoln issued an executive order to engage military in the Civil War, Woodrow Wilson issued an executive order arming the military before we entered World War I, and Franklin Roosevelt approved Japanese internment camps during World War II with an executive order.

Regardless of your political affiliation, in my opinion, it is very interesting that Obama would initiate an executive order regarding immigration given his past statements over the years complaining about past presidents’ executive orders being unconstitutional.

In 2008 campaign speeches, Obama regularly emphasized the importance of civil liberties and the sanctity of the Constitution.

In fact, in speeches, Obama stated, “most of the problems that we have had in civil liberties were not done through the Patriot Act, they were done through executive order by George W. Bush. And that’s why the first thing I will do when I am president is to call in my attorney general and have he or she review every executive order to determine which of those have undermined civil liberties, which are unconstitutional, and I will reverse them with the stroke of a pen.”

Whether or not people believe that executive orders are constitutional, it is indisputable that presidents on both sides of the aisle have issued executive orders.

Reagan and Bush issued executive orders. Although there is an argument that those executive orders came on the heels of congressional bills, as adjustments. Neither Reagan nor Bush simply circumvented Congress.

Going back to tonight’s anticipated executive order allowing 5 million migrants to remain in America…

While the executive order will not allow the 5 million people immediate access to Medicaid and other subsidized health care, it will allow 5 million more uninsured people to exist in America, which will, undoubtedly, increase health care costs and ER visits. And, eventually, the additional 5 million people will be eligible for Medicaid, subsidized health care, and all other benefits of living in America.

Provider Shortage for Medicaid Recipients

By Roberta Capp, Published: June 13

Roberta Capp is a Robert Wood Johnson clinical scholar fellow at Yale University, where she practices emergency medicine and is researching health care delivery for patients with Medicaid and Medicare insurance.

The debate over “Obamacare” has focused largely on the number of uninsured Americans and how the regulations will be implemented. Not enough attention is being paid to the difficulties our health-care system imposes on those with Medicaid insurance, which is being extended to millions who lack coverage.

Frequently, people blame patients for using emergency departments “inappropriately.” But some Medicaid patients do everything they can to see a doctor, to no avail, and must resort to emergency department visits. My own experience has been instructive.

One Monday a few months ago, the waiting room of the emergency department (ED) where I work had 30 patients, some of whom had waited 12 hours to be seen. My first patient was a woman with chest pain. She has Medicaid insurance. Her medical problems include diabetes, previous heart attacks, asthma and acid reflux. I ordered an electrocardiogram and saw from her file that she had been evaluated in the ED for chest pain 14 times in the past year and hospitalized on seven of those occasions. After reading her previous diagnostic tests and treatments, I was confident that her chest pain was not caused by a heart or lung problem. I was also curious about how her care was being coordinated.

The first time this woman had chest pain, she said, she called our hospital’s primary-care clinic, where she had seen a different doctor at each previous appointment. After holding for more than 30 minutes, she hung up and went to the emergency department. That visit resulted in a hospital admission for a heart stress test, the results of which were normal. But this woman continued to experience pain. She later saw a doctor at our primary-care clinic who prescribed an acid-reflux medication and told her to return to the ED if she had more pain.

This woman prefers to see a ­primary-care doctor, she told me, which is why she would call the clinic when she had pain. But often she was either unable to get an appointment right away or couldn’t get a person on the phone. When she did reach someone, once she said “chest pain,” she was almost always told to call 911 immediately and go to the ED.

The patient’s records showed that in the past year she had had two cardiac stress tests, one coronary catheterization procedure and two CT scans of her chest, all of which were normal. Simply put, she received the best care possible — and doctors assessing her were reassured that she did not have heart disease or a clot in her lungs. But she also underwent duplicate testing, which increased her costs without providing additional benefits, exposed her to more radiation and raised the potential for false-positive test results.

When this patient was able to get an appointment quickly, she then had to arrange transportation. Medicaid will pay for taxi service, she told me, but she has to call at least three days ahead to schedule the ride. Ultimately, she told me, she has concluded that “the only way to see a doctor soon enough is to call an ambulance” and go to the ED.

She cried as she told me her story. A primary-care doctor had recommended that she see a gastroenterologist for her chest pain, as it might be coming from her stomach, but the next available appointment was two months later. She hoped to see one in the emergency department, she told me, because she could no longer deal with her pain.

In our hospital, about one in 10 patients with Medicaid is a frequent visitor to the emergency department because many physicians don’t accept that insurance. Trying to understand the inability of patients with insurance to see primary-care providers, I called three local clinics, pretending to be a patient with Medicaid, and tried to make an appointment. The soonest I could see a primary-care doctor was two months. Primary-care physicians who accept Medicaid insurance are overwhelmed with patients, many of whom have social challenges in addition to health issues. Some are their family’s sole caretaker; many are dealing with housing or transportation issues or food insecurity. These complexities often go unaddressed by health-care providers.

The experience of many such Medicaid patients who struggle to see primary-care doctors inspired me to partner this spring with Project Access New Haven, a nonprofit in Connecticut that provides services to frequent ED users who have Medicaid. Patients work with a “navigator” dedicated to helping them maneuver through our complex health system. The patient and navigator work as a team to figure out transportation and housing problems, get food vouchers, make immediate appointments with primary-care doctors or address other issues that can improve patients’ health.

If all states implement the Affordable Care Act, 18 million more people will be enrolled in Medicaid by the end of 2016. Even if some states opt out, the program is poised for a huge expansion. But having insurance does not guarantee access to health care. Policymakers need to explore and reduce the barriers Medicaid patients face as millions join an already overburdened system.