As Congress debates comprehensive immigration reform, members of both parties have insisted on barring undocumented immigrants who achieve provisional legal status from receiving Medicaid coverage or Obamacare subsidies (a provision that was already part of the health law). But preventing these immigrants from gaining basic health benefits is actually a fiscally irresponsible model that will only raise health care spending and contribute to a sicker U.S. population.

The common argument against providing health care to undocumented immigrants is that, since they’ve broken the law, they should be punished. A part of that punishment involves denying them health care services through public entitlement programs or federal subsidies that are dependent on Americans’ tax dollars. “We must value the contribution of immigrants to our country. In doing so, we must protect our borders, we must protect our workers, and we must protect the taxpayer,” said House Minority Leader Nancy Pelosi (D-CA) on Thursday.

But the taxpayer already foots the bill for undocumented immigrants’ care — just in an incredibly inefficient and half-baked way. Under the auspices of the Reagan-era Emergency Medical Treatment and Active Labor Act (EMTALA), hospital emergency rooms can’t turn away patients based on their citizenship or insurance status. That doesn’t mean that their care magically becomes free — undocumented men and women who use the emergency room are still slapped with a hefty hospital bill.

However, if they are unable to pay that bill — which is fairly likely considering that they probably don’t have any insurance — then a combination of the federal government, state governments, hospitals, and other American consumers of U.S. health care are forced to absorb the cost. In turn, that raises prices for medical services, since hospitals want to recoup some of their losses. Some studies have estimated the price of subsidizing undocumented immigrants’ health care at about $10.7 billion per year.

The federal government has long been aware of this problem. In fact, soon after EMTALA’s passage, lawmakers authorized a special Medicaid fund that mostly goes towards subsidizing emergency treatments for undocumented immigrants. The program costs about $2 billion per year, and most of that money is used on delivering babies for pregnant, undocumented women who go to the emergency room.

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Gov. Jan Brewer (R-AZ) has a message for her party: expand Medicaid — or else.

The combative GOP governor is sticking by a threat she made to veto all legislation until lawmakers resolve the 2014 state budget and pass Obamacare’s Medicaid expansion. On Thursday, Brewer proved that wasn’t just talk, vetoing five bills sent to her desk in quick succession.

“I warned that I would not sign additional measures into law until we see resolution of the two most pressing issues facing us: adoption of a fiscal 2014 state budget and plan for Medicaid,” wrote Brewer in her veto message. “It is disappointing I must demonstrate the moratorium was not an idle threat.”

Arizona officials only have five weeks before reaching the constitutional deadline for passing a budget. Last Thursday, six Republican state senators joined a unified Democratic caucus to pass a Medicaid expansion bill — but efforts have been gummed up in the state House since then.

Brewer isn’t letting the issue slide. She has been touring the Grand Canyon State to shore up support for the expansion and put pressure on reticent lawmakers in her own party.

Some Republicans opposed to the expansion have warned of dire political consequences for lawmakers who buck the traditional conservative opposition to Medicaid. In a letter to Republican legislators, the chairman of the Maricopa County Republican Committee wrote of the state senators who voted for expansion, “Their egregious actions will have serious consequences. Their political careers are all but over and their days numbered.” He referred to Brewer as a “rogue governor” in the same statement.

But Brewer appears to be sticking by her convictions. At the beginning of the year, she became the third Republican governor to embrace expansion, asserting that it would provide health coverage to 50,000 low-income Arizonans. While promoting the expansion in March, Brewer attested to the dire consequences of failing to expand Medicaid. “The human cost of this tragedy can’t be calculated,” said Brewer, flanked by public health officials, doctors, and advocates for the poor. “Remember, there is no Plan B.”

The Kaiser Family Foundation (KFF) estimates that expanding Medicaid would cut Arizona’s uninsurance rate by nearly a third.

On Thursday, California officials revealed insurance companies’ opening bids for the state’s Obamacare marketplace in 2014. The numbers are great for consumers — and terrible for right-wing fear mongering over the health law.

Covered California, the agency tasked with constructing and maintaining the Golden State’s insurance marketplace, announced in a press release that rates submitted by 13 insurers for the 2014 individual marketplace were far lower than initially expected, ranging from a stunning 29 percent below the current average premium for small business health plans to only two percent above them.

For Californians who will gain coverage in the marketplace, that means affordable health plans with a minimum base of ten “essential health benefits,” including prescription drug services, mental health care, and maternity services. And the announced rates are even better for consumers considering that they don’t take Obamacare’s federal insurance subsidies into account. Depending on income, the average middle-aged Californian would pay anywhere from $40 to $300 per month for a mid-level “Silver” health plan on the marketplace. Younger, healthier Americans looking to buy bare-bones “Bronze” health plans would end up paying less than $170 per month — or even nothing at all — if they make less money and receive federal Obamacare subsidies.

That stands in stark contrast to heated GOP rhetoric and outlandish insurance company predictions about Obamacare. Last week, the Republican-led House of Representative voted to repeal the Affordable Care Act for the 37th time. During a House Energy and Commerce Committee hearing on Obamacare “rate shock” last week, House Republicans predicted hikes as high as 66 percent for Californians’ premiums based on internal documents from 17 major U.S. insurance companies.

Such claims may make for good politicking — but as the California numbers underscore, they aren’t actually reflected in reality. During last week’s House hearing, Topher Spiro, Vice President for Health Policy at the Center for American Progress (CAP), warned against making hysterical claims about health insurance rates under Obamacare. He noted that independent analyses have shown that an influx of Americans into the insurance pool and marketplaces designed to foster competition would actually end up lowering Americans’ premiums, especially in high-population states like California.
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Obamacare critics have been pointing to several companies’ claims that the law is forcing them to cut their part-time workers’ hours as proof that the health law is bad for businesses and employees. But a new report finds that employers were cutting health benefits and workers’ hours long before Obamacare was even an idea.

According to data compiled by the Employee Benefit Research Institute (EBRI), large employers have increasingly been turning to part-time workers for their labor. Between 2007 and 2011, the percentage of workers employed in part-time jobs increased from 16.7 percent to 22.2 percent of the work force. That means that workers’ hours have also been declining, since using more part-time workers lets companies scale back on how many hours those employees can work.

But these companies’ cuts haven’t been limited to workers’ hours — they’ve been cutting back on part-time employees’ health benefits, too. During the same four year period, part-time workers experienced a 15.7 percent decline in the likelihood of having health coverage through their jobs:

As the graph demonstrates, that trend existed even before the recession, and has only gotten worse since then.

Cost-cutting at the expense of employees’ benefits and wages certainly isn’t new behavior for large companies. Even employers with full time workers have been shifting the cost of medical care onto their employees through the increasing use of high-deductible and bare bones health plans — something that industry experts expect to continue. Over the last decade, average annual health insurance premiums rose by approximately 97 percent — but workers’ contributions to those premiums increased by an outsized 102 percent in the same time span.

This reflects the dangers of a health care system in which employers are the major providers of Americans’ health coverage. Recent history suggests that companies would have continued slashing workers’ benefits and hours anyway — Obamacare has just given them a convenient excuse.

The debate over Medicaid expansion has devolved into a GOP platform for grandstanding about the health reform law and the Obama administration. But an NPR article from Tuesday shines a light on what, exactly, most Republican governors’ refusal to expand Medicaid will mean for real Americans by examining poor communities in a state headed by one of Obamacare’s most ardent critics: Gov. Rick Perry (R-TX).

The piece centers on particularly destitute populations in southern Texas, where some uninsured residents are so poor, sick, and unable to cope with their medical bills that they resort to desperate measures such as crossing the border into Mexico for medications and even sharing their insulin shots:

[M]any of those who live here [in Brownsville] — including poor Latino immigrants, both legal and undocumented — suffer from diabetes and lack of insurance. Some of those uninsured diabetics, including American citizens and others living here legally, used to go across the border to Matamoros, Mexico for insulin. But now with the fear of brutal drug violence and tougher border restrictions, families share their insulin shots rather than risking the crossings.

A community health worker in Brownsville noted that “many of those who used to cross the border would qualify for Medicaid under the expansion offered by the health care law.”

This inequity is further exacerbated when dealing with a more serious or life-threatening chronic condition. One official at Brownsville’s local health clinic described how difficult it is to provide specialty care services to the poor and uninsured, emphasizing that Medicaid coverage would make it far easier to convince physicians to take on patients:

“Once you diagnose a cancer, then what?” said Dr. Henry Imperial, the clinic’s medical director. “How are you going to give me chemotherapy or surgery or radiation therapy? It goes out of our hands.”

Those complications can make for some intense arm-twisting among Brownsville’s medical ranks. Imperial said he often plies fellow doctors in town with beer to see his uninsured patients. “When they see me approaching them, they start running away,” he joked before turning somber. “It’s just tough. I could not do an appendectomy. I cannot operate on gall bladders. I need a surgeon.”

Most specialists, including surgeons, in Brownsville, accept Medicaid, said Imperial. “It does pay for services that otherwise the patient does not receive.”

GOP leaders like Perry and even some of the more serious conservative academic critics of Obamacare’s Medicaid expansion regularly cite the program’s low reimbursement rates as a reason for dismissing it. Perry has denounced expansion as doubling down on a “broken system,” since doctors won’t want anything to do with Medicaid to begin with.

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Rep. Michele Bachmann (R-MN) this week said that prayers to God will ensure Obamacare’s repeal, after 37 House of Representatives attempts to do so.

“I think the President will ultimately be forced to repudiate his own signature piece of legislation because the American people will demand it,” she told an evangelical radio host Tuesday. “And I think before his second term is over, we’re going to see a miracle before our eyes, I believe God is going to answer our prayers and we’ll be freed from the yoke of Obamacare.”

She added, “I believe that’s going to happen and we saw step one last week with the repeal of Obamacare in the House. We have two more steps. We serve a mighty God and I believe it can happen.”

But this was not really “step one” for the House. At this point, House Republicans have devoted 43 out of 281 days in session to symbolic votes against Obamacare. In the last Congress, they devoted 15 percent of their time, or $50 million dollars, to a signed law that is already largely being carried out. Even top Republican leaders and Republican governors have admitted they lost their battle against Obamacare, though they vow to continue to hold symbolic votes on the matter.

Meanwhile, Bachmann has also accused Obamacare of “literally” killing people and tied it to news that the IRS was inappropriately targeting conservative groups.

(HT: Raw Story)

As the political fight over Obamacare continues, Republican legislators in highly uninsured states have turned their back on Medicaid expansion — despite the fact that expanding the public insurance program could extend coverage to millions of their constituents. Of course, even if stringently anti-Obamacare politicians refuse to cooperate with health reform, the law will still take effect. But that doesn’t necessarily mean those red states won’t feel the impact of refusing to add more residents to their Medicaid rolls.

Health care outcomes already vary widely across states. Unfortunately, health policy does too. The states that are already among the nation’s healthiest are the ones taking steps to ensure their low-income residents will have the insurance coverage they need — while the unhealthier, more highly uninsured GOP-led states are refusing to do the same. As an analysis from the Los Angeles Times points out, the health care reform law can’t change the fact that the stubborn lawmakers resisting Medicaid expansion are likely going to deepen the health disparities that already exist across the country:

With nearly every GOP-leaning state on track to reject an expansion of the government health plan for the poor, the healthcare law’s goal of guaranteed insurance will become a reality next year mostly in traditionally liberal and moderate states. These states already have higher rates of health coverage.

Residents of these states — concentrated in the Northeast, upper Midwest and West Coast — also have better access to doctors and are less likely to die from preventable illnesses.

Colon cancer deaths in states opposing Medicaid expansion, for example, are an average of 16% higher than in pro-expansion states, according to a Los Angeles Times analysis of state health data.

Deaths from breast cancer are 8% higher on average in anti-expansion states. And adults under 65 are 40% more likely on average to have lost six or more teeth from decay, infection or gum disease.

An earlier analysis found that the governors for the most unsinsured cities in the United States have been resistant to expanding Medicaid. And even after some of those governors started to come around — most notably, Florida’s Rick Scott — the Republicans in the state legislature have continued to block the initiative. Opposition persists despite the fact that the poor Americans in the South, who are already being forced to delay their medical care because they can’t afford it, stand to gain the most from Medicaid expansion.

This isn’t the only example of health disparities becoming sharply divided by region. Abortion access, another area of health policy that’s largely been left up to states’ interpretation, also varies widely from California to Mississippi to North Dakota to New York. “It shouldn’t be that simply because you live in Mississippi that you don’t have the same health care that you can get if you lived in California,” one abortion doctor who travels to practice at Mississippi’s last remaining abortion clinic recently pointed out. Nonetheless, that’s the growing reality for the entire health care sector.

Over ten percent of all doctors and nurses on the government’s Medicare and Medicaid blacklist end up on it because they defaulted on government-backed student loans. Medical workers on the blacklist are barred from treating Medicare and Medicaid patients or receiving federal reimbursements for a predesignated time period.

According to a Modern Healthcare analysis of federal records, more than 5,400 of the 51,729 people on the government health entitlement blacklist were placed on it after failing to pay an HHS-backed medical student loan. Given a still-shaky economy, some in the health care sector expect that trend to continue:

[Government data] show that one of the most common reasons for getting barred is failure to repay HHS-backed student loans: 5,417 people are currently kicked out of Medicare for that.

The number of annual exclusions related to student loans has grown steadily in the past decade, peaking at 517 in 2011 before declining again. “That is tied to the economy, and I would expect that to continue to rise,” [said Lynn Gordon, a Chicago-area hospital group partner].

The increasing frequency of default-related blacklisting could prove problematic as the Obama Administration tries to entice more medical students to become primary care and family doctors. Primary care providers and nurse practitioners will be crucial to effective Obamacare implementation, since the health law is expected to drive up demand for medical services as millions of previously uninsured Americans gain coverage.

But the ballooning cost of a medical education could end up being a major barrier to the Administration’s recruitment efforts. According to the Association of American Medical Colleges’ (AAMC) 2012 report on medical school debt, “86 percent of medical school graduates had education debt, with a median amount of $162,000″ in 2011 — a number that has been rising steadily over the years:

AAMC estimates that a borrower with the median $162,000 debt “would have monthly payments ranging from $1,500 to $2,100 after residency.”

That disproportionately affects the very primary care doctors that are integral to health care reform and the U.S. medical system at large. In a 2012 report, consulting firm Merritt Hawkins & Associates found that family practitioners, pediatricians, and psychiatrists are the lowest-paid physician groups in the U.S. with a base pay of $189,000.

While that’s still a lavish salary compared to average U.S. compensation, it pales in comparison to specialist pay — and as the entitlement blacklist numbers underscore, that contributes to a system in which care providers are banned from treating certain patients for purely financial, rather than medical or criminal, reasons.

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One congressman is so vehemently opposed to Obamacare that he’s willing to sacrifice his own health insurance in order to make a point.

Rep. Mark Amodei (R-NV), who entered Congress in 2011, was asked last week prior to the House’s vote to repeal Obamacare whether he would be giving up his own government-sponsored health insurance. “Happy to,” Amodei replied.

QUESTIONER: Will you give up your own congressional health care after voting to repeal tomorrow?

AMODEI: Happy to. Have a nice day.

Watch it:

The Federal Employees Health Benefit Program (FEHBP), which covers all federal workers, is similar in many ways to Obamacare. For example, both provide tax-payer subsidized coverage and allow enrollees to choose private insurance plans from a highly-regulated market.

ThinkProgress reached out to Amodei’s office to see whether he has dropped his government insurance plan yet, but they have yet to respond.

Unless the Nevada congressmen is fortunate enough to attain insurance elsewhere, whether though a spouse or a private insurance plan, Amodei’s decision to give up FEHBP is financially ill advised. Giving up health insurance means he’s more likely to forgo preventive care and would have to pay large medical bills out of pocket or, if he can’t afford them, pass those bills onto taxpayers.

Still, giving up government health insurance was briefly in vogue among Tea Party Republicans on Capitol Hill. At least half a dozen GOP congressmen personally gave up government-sponsored health care in 2011 after running on a repeal-Obamacare platform.

There’s new evidence to suggest that Obamacare is impacting the health industry for the better by successfully encouraging a greater emphasis on primary care. Ensuring that Americans are receiving regular preventative care is an important tenant of the health law, since it can ultimately help lower costs by preventing people from delaying medical treatment until they’re already very sick.

For the first time ever, Americans are now spending more money on primary care physicians than they are on specialists, according to a new survey by the physician recruiting firm Merritt Hawkins. In what Merrit Hawkins’ president referred to as a “seismic shift” in medicine, primary care doctors are now the greatest source of revenue for the hospitals where they work:

For the first time, primary care physicians are driving more revenue on a per-doctor basis to hospitals than are specialists, according to a survey of hospital chief financial officers by physician recruiting firm Merritt Hawkins. It’s expected that this result is not a fluke, but a reflection of the growing emphasis on primary care by hospitals and the health care system in general. [...]

Merritt Hawkins said there were major shifts in the health care system from 2010 to 2013 that put pressure on all physicians, particularly specialists. One major factor is the 2010 Affordable Care Act, which has several pieces that put more onus on primary care to cut overall costs and keep patients healthy, especially those with chronic conditions or who otherwise would delay care until they are seriously ill. The rise in primary care contributions came as overall per-physician revenue for hospitals fell — from more than $1.5 million in 2010 to more than $1.4 million in 2013. It’s the lowest median in the 11 years Merritt Hawkins has conducted the survey.

As more than 25 million previously uninsured Americans gain coverage under Obamacare, the trend toward primary care is expected to continue. Those people likely avoided expensive medical treatment while they didn’t have insurance, but they’ll have the opportunity to seek regular check-ups once they become covered in 2014. In order to tackle the influx of Americans who will require primary care services, there will be opportunities for nurse practitioners to expand their role as health care providers.

As state and federal officials work toward the full implementation of Obamacare, politicians on both sides of the aisle have blasted the ongoing effort as a “train wreck.” But there’s mounting evidence to suggest those concerns are overblown. Although there’s still more work to be done to prepare for the state-level insurance marketplaces that will open to the public in 2014, much of the health reform law is already in effect — and it’s already having a demonstrable impact on the United States’ health industry. In addition to the shift to primary care, Obamacare has also already ensured that health care will be cheaper for many Americans by forcing private insurers to lower their premiums.