PHOENIX – Two sweeping policy changes that could transform how people live in the United States have been championed by President Barack Obama: Affordable health care for all and a path to citizenship for the 11 million immigrants illegally in the country.
But many immigrants will have to wait more than a decade to qualify for health care benefits under the proposed immigration overhaul being debated by Congress, ensuring a huge swath of people will remain uninsured as the centerpiece of Obama's health care law launches next year.
Lawmakers pushing the immigration bill said adding more recipients to an already costly benefit would make it unaffordable.
Health care analysts and immigration proponents argue that denying coverage will saddle local governments with the burden of uninsured immigrants. They also fear a crisis down the road as immigrants become eligible for coverage, but are older, sicker and require more expensive care.
Those placed on provisional status would become the nation's second-largest population of uninsured, or about 25 percent, according to a 2012 study by the Urban Institute.
"All health research shows that the older you get, the sicker you become, so these people will be sicker and will be more expensive on the system," said Matthew O'Brien, who runs a health clinic for immigrants in Philadelphia and researches health trends at Temple University.
The Affordable Care Act will make health insurance accessible for millions of uninsured people starting in January through taxpayer-subsidized private policies for middle-class families and expanded access to Medicaid, the program for low-income people funded by federal and state dollars.
The proposed immigration overhaul explicitly states immigrants cannot receive Medicaid or buy coverage in new health care exchanges for more than a decade after they qualify for legal status, and only after certain financial and security requirements have been met.
Immigrants with provisional status may obtain insurance through employers once they have legal status to work, but many are unskilled and undereducated, and tend to work low-wage jobs at small businesses that don't have to provide the benefit under the health care law.
Immigrants illegally in the country also can access community health centers, but the officials who run those clinics said they are overwhelmed by the demand.
"We can't help everybody," said Bethy Mathis, executive director of Wesley Community Center in Phoenix. The clinic serves 7,000 patients a year who seek everything from vaccinations and relief from minor medical problems to care for long-term health conditions such as diabetes.
Debate over whether immigrants illegally in the country should be eligible for federal benefits nearly sank Obama's health care reform before it was passed by Congress in 2010. For lawmakers pushing immigration reform, there was no question that immigrants would continue to be excluded.
"That's one of the privileges of citizenship," said Republican Sen. John McCain, one of the so-called Gang of Eight pushing the immigration bill, during a conference call with reporters. "That's just what it is. I don't know why we would want to provide Obamacare to someone who is not a citizen of this country."
The issue has received more attention in recent weeks. Some House Republicans have threatened to kill the immigration bill unless immigrants are required to pay for all their health care costs even after they receive green cards or become citizens. Democratic Sen. Barbara Boxer, meanwhile, said she wants the government to distribute at least $250 million to state and local governments because they are the ones who will feel the financial pain of immigrants being left out of the health care law.
Pregnant women, children, seniors and the disabled are eligible for emergency Medicaid services regardless of their immigration status.
The politics behind the bill offer little solace to immigrant families struggling with growing medical bills.
Isabel Castillo came to the U.S. illegally with her parents when she was a child. She's now 28 and has not gone for an annual physical exam since 2007. Every pain triggers debate over whether it's worth a medical visit or not.
"You are like, 'God, should I go, should I wait? The bill is going to be so high,'" Castillo said. "You just wait until you can't tolerate the pain anymore and then you go to the emergency room."
Immigrants who are U.S. citizens are also affected by the limits on health care access if they provide for family members here illegally.
High school student Jacqueline Garcia of Phoenix works two jobs to support her 13-year-old brother and 52-year-old grandmother, who has severe diabetes. The woman's mobility is limited, her vision and memory are fading and she sometimes suffers from seizures. The children were born in the United States and are being raised by the grandmother, who does not have lawful status and as a result does not qualify for Medicaid.
"Every time she gets sick, I have to take her to the doctor. It's really expensive," Garcia said. "What if my grandmother doesn't make it for the 10 years? I mean, I am always going to be struggling. That's too long."
Opponents said they understand the concerns of immigrants not getting health care, but it becomes an issue of the added expense.
"We aren't saying people shouldn't get health care. The question is who is going to pay for it?" said Ira Mehlman, spokesman for the Federation for American Immigration Reform, a national group that opposes the immigration overhaul. "They would all be on Medicaid or heavily subsidized in some other way."
Critics of the decision said immigrants are eager to pay for affordable health care insurance and already support federal benefits by paying sales and income taxes. They note that adults unable to overcome health emergencies are less likely to contribute to the workforce and society.
"The risk of them being uninsured if they are in the country illegally is the same risk of anyone else in the country not being insured," said Stephen Zuckerman, a health economist for the Urban Institute. "It's always more expensive to treat people at a more advanced stage of disease."
In North Carolina, Jessica Sanchez-Rodriguez said she has undergone a series of surgeries and medicines to treat her spina bifida, a developmental congenital disorder, and an ailment that leads to brain swelling. Her parents brought her illegally from Mexico when she was 11 months old. As a minor, she received subsidized medical care, but she was cut off when she turned 18 in February.
Her family is trying to raise money for a $55,000 surgery to connect a catheter to her bladder.
"It's terrible," Sanchez-Rodriguez said. "I have to go to school with these pains."
Based on reporting by The Associated Press.