The loss of Medicaid coverage does not leave immigrants completely unprotected; they remain eligible for emergency medical services under Medicaid.(3) To understand more about emergency benefits, we examined data about the undocumented aliens who were eligible only for emergency coverage. After standardizing for differences in caseload composition, the overall average cost per capita for an undocumented alien was almost exactly the same as for an average beneficiary, 103 percent of the average cost. However, the per person costs were 60 percent of the average in California and 223 percent of the average in the rest of the nation.
A likely reason for these peculiar findings was the limited access of undocumented aliens to emergency Medicaid coverage in most of the nation. Official estimates of the number of undocumented aliens suggest that undocumented aliens in most of the nation were far less likely to enroll in Medicaid than in California (based on Immigration and Naturalization Service 1997). There might have been greater access in California because: (1) undocumented aliens in California could enroll in Medicaid at the welfare office, but received Medicaid cards indicating they had limited benefits; in most other states, undocumented aliens were enrolled only after they had an emergency and (2) the immigrant and health care provider communities may have been more aware of benefits in California. The post-emergency system of enrollment used elsewhere meant that few undocumented aliens were ever granted access to Medicaid. An uninsured alien might have avoided medical care as long as possible, thinking there was no way to pay. Even if the alien received care at an emergency room, the hospital might not bother to enroll the person in Medicaid unless there was a high medical bill. Thus, most states had a pattern in which very few undocumented aliens were ever enrolled in Medicaid and those admitted were quite ill and had very high expenditures.
Another complication regarding emergency care is that most state Medicaid programs are shifting to managed care. There will be tensions between emergency services, which are almost inherently fee-for-service, and the expansions of managed care. Immigrants trying to get access to emergency care under Medicaid may encounter additional problems because of these changes in the health care delivery system.