In the shifting goalposts of United States law since World War II, Hispanic immigrants have gone from being legal seasonal laborers to undocumented laborers considered illegal, and finally to being considered a threat to national security worthy of deportation.

While many immigrants in the region fill a need — picking apples and cherries and other fruits in Washington’s orchards — they also present a public policy problem.

Medical oaths and government mandates to provide health care to everyone are complicated by the country’s hodgepodge immigration policy that makes the presence of many immigrants illegal. Immigrants without papers are generally not eligible for government health care, including under the recent health care reform. And although it may be possible for them to buy health coverage, the jobs undocumented immigrants take rarely lend themselves to the paychecks necessary to buy private insurance. Nonetheless, hospitals are required by federal law to provide emergency care for people in need.

Cassie Sauer, spokeswoman for the Washington State Hospital Association, says that’s a good thing, because a community is healthier when everyone has access to health care.

“We believe it is in all our best interests [for undocumented immigrants to] get care,” Sauer says.

But who picks up the tab? A few programs created by the Washington Legislature work to provide government funding to pay hospitals for such care.

One is the Alien Emergency Medical Program, which allows hospitals to be reimbursed when an undocumented immigrant enters an emergency room for life-, limb- or organ-threatening problems.

“The clinician has to establish that indeed it was an emergency,” says Gail Kreiger, section chief of Health Care Benefits and Utilization Management for the state’s Health Care Authority (HCA). The eligibilities only last for the period of time when the immigrant was in the hospital, Kreiger adds.

Immigrants must apply after such an emergency to have their issues considered under the program. But Kreiger says hospitals have an incentive to help with this.

“Hospitals can facilitate it, because they of course want to be paid,” she says.

While the numbers are still being tallied, about $44 million in state money is estimated to have been spent on undocumented immigrants in 2012 through this program.

The program also allows immigrants to get cancer care or dialysis that has been predefined by a doctor. In those cases, according to Kreiger, the coverage period starts the day you enter dialysis or cancer treatment (surgery, chemotherapy or radiation), ends at your last session and covers strictly those procedures. In 2010, about 270 undocumented immigrants around the state received this sort of care, according to the HCA.

A second program, the Children’s Health Program, covers minors and currently has about 20,500 kids enrolled, according to Jim Stevenson, communications director for the HCA. In fiscal year 2013, it will cost the state approximately $26.4 million.

“Children are our healthiest caseload and much of that care translates as preventive, which should avoid longer-term expensive care,” Stevenson says.

A third program deals with the discrepancy between an undocumented immigrant mother and her child being born on American soil. That makes the infant a U.S. citizen and, by that logic, Washington state provides prenatal care to pregnant women.

That program has an enrollment of 23,155 people and in 2013 cost around $90.5 million, according to Stevenson.

Sauer, the WSHA spokeswoman, says she can’t quantify how much so-called charity care results from undocumented immigrants. But with the passage of the Affordable Care Act, Sauer says undocumented immigrants will become the biggest bloc of people without access to health care.

Stevenson, communications director of the state Health Care Authority, points out that the amount spent on medical coverage in Washington is far larger than the bills racked up by immigrants without papers.

The three programs — emergency care, children’s health insurance and prenatal care for mothers-to-be — fold into a budget that Stevenson says approaches $5 billion each year on medical assistance and Medicaid. So the three that offer help for undocumented immigrants represent about 3.2 percent of that segment of health care spending.

But if you add the Medicaid money that goes for long-term care disability and behavioral health care (about $3.2 billion) and the approximately $2 billion spent on purchasing health care for Washington state employees, government spending on undocumented immigrants is closer to 1.5 percent.

When it comes to public services, undocumented immigrants actually do pay into some systems, systems from which they will never benefit. Every worker who gets a job with a false Social Security number (a common way for undocumented immigrants to get jobs) winds up paying into Medicare and Social Security, programs that he or she won’t ever be able to use. In that sense, immigrants help subsidize entitlement programs for citizens.

Those numbers aren’t small, either. Just in 2010, it’s thought that as much as $2 billion for Medicare and as much as $8.7 billion for Social Security came from undocumented immigrants, according to a study published by

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