When Legislators Ignore the Real Problems, They Only Have Bad Choices

Whatever decision Minnesota legislators make to resolve the dispute over health care for undocumented immigrants, it will be wrong.

If Republicans prevail and most undocumented immigrants are denied enrollment in MinnesotaCare, they, like other uninsured people, will end up in expensive hospital emergency rooms for issues that could have been resolved earlier in a doctor’s office.  And if the Democrats are able to continue the program they created last session, several thousand new people are added to a system in which costs are unsustainable.

The issue is defined by how politicians view those who entered the country illegally. Democrats see them as victims, Republicans see them as villains. When Democrats ruled the legislative roost last session, they opened enrollment in MinnesotaCare to undocumented immigrants. In today’s closely divided legislature, Republicans are striking back, demanding that unauthorized residents of Minnesota be barred from the public health program.

Republicans like State Rep. Isaac Schultz, who represents central Minnesota, make the spurious claim that every undocumented immigrant enrolled in MinnesotaCare amounts to a $7,000 taxpayer subsidy. That’s the per capita cost for all MinnesotaCare enrollees. Of course, some cost more, some less, some very little.

Since enrollment in MinnesotaCare opened to undocumented immigrants in January, more than 17,000 people have signed up, nearly three times the initial projection. Filed claims, though, are lower than originally estimated. According to the Minnesota Department of Health, fewer than 4,000 claims were filed in the first three months of the year, costing $3.3 million. The state estimates that the program will cost $200 million over four years. Republicans say the price tag will be closer to $600 million.

Democrats argue people not price tags. The 81,000 undocumented immigrants in Minnesota are a diverse group; 47,000 are from Mexico and Central America, 12,000 are from Asia and 11,000 from Africa. Nearly 60% of the 81,000 have lived in the U.S. for more than 10 years, according to the Migration Policy Institute.

Those advocating for open enrollment in MinnesotaCare point out that Minnesota’s undocumented population pay substantial state and local taxes – an estimated $220 million annually, according to the Institute of Taxation and Economic Policy – and are ineligible for many public benefits.

The likely legislative compromise will allow children of undocumented immigrants to retain coverage through MinnesotaCare, but terminate the enrollment of adults at the end of this year. The deal offers political benefits to those who want to be tough on immigrants and to those who say that caring for children reflects the basic decency of most Minnesotans. An estimated 5,000 of Minnesota’s undocumented population are under age 16.

As a matter of policy, the compromise continues the bipartisan political malpractice when it comes to the health system. Nationally and in Minnesota, health programs are jiggled and juggled to fit political narratives, not the realities of a health system in which cost increases are unsustainable. A case in point is the terrible “Big Beautiful Bill” passed by the U.S. House of Representatives. While Republicans made sure the impact of cuts to health programs is minimized before the next federal elections, they impose new costs on state budgets that will require more immediate attention. Reform it isn’t.

When the cost of state health programs needed trimming, both parties join in false solutions. Among the most common fix is to reduce the government’s costs by shifting costs to others. Reimbursements to hospitals and providers, for example, long have been a favorite target for budget trims. Payments to dentists, to cite one example, were so low for years that many stopped providing care to patients enrolled in MinnesotaCare and other public health programs. While reimbursements for dentists have been increased a bit in recent years, routine dental care for low-income residents of rural Minnesota remains hard to find.

That is the shortsightedness of legislative proposals for MinnesotaCare. Barring enrollment in MinnesotaCare denies people access to preventive and routine care, not to health care. People who can’t afford a visit to a doctor or dentist for early care often wait until the need is great enough to send them to the emergency department, the most expensive health setting in the system. Once there, hospitals are obligated under federal law (ironically, a law signed by conservative icon President Ronald Reagan) to provide care regardless of the patient’s ability to pay.

Already, an estimated one-fourth of Minnesota hospitals are in financial distress. Add to that the likelihood of the higher costs tariffs will add to drugs and supplies and reductions in Medicaid, and hospitals will be forced to closed, leaving communities without a vital health resource and an economic anchor. On the other hand, expanding MinnesotaCare without meaningful cost controls puts a greater burden on health providers and ultimately on taxpayers.

What is needed  more than anything is to stop one-off health policies that punish or reward  narrow constituencies while ignoring the much larger issues. Stopgap solutions not only do  little to resolve the unsustainable cost of health care, they often exacerbate the problem. Health care is becoming the largest driver of public budgets at every level of government. For families, health care spending is more than rent and utilities combined.

Everyone’s expectations of health care will have to change. People have to take better care of themselves and accept more responsibility to be sharp-eyed consumers. Doctors and other care providers should be reimbursed for improving the health of people, relying on evidence-based procedures and coordinating care, especially for those with chronic conditions. Insurers will have to accept more risk for those with existing health problems, and they will be asked to invest more in prevention. Government will have to demand greater accountability of everyone.

Health access for undocumented immigrants is this year’s headline. The exploding cost of care for the elderly and disabled Minnesotans is right behind along with the growing financial impact the new generation of miracle drugs that will be far more expensive than anything we have seen. And on and on.

It is in the best interests of everyone for people to have access to affordable, quality care. But access isn’t free and the costs can’t be shifted away from consumers or taxpayers without consequences. Demonizing immigrants, pharmaceutical companies or anyone else won’t fix the problems and often make them worse.

The first and most urgent cure is for policymakers to heal themselves – start by being honest and transparent about health policy. It requires broad fixes, shared contributions and and long term solutions. Otherwise, all the choices are bad and worse.