Additional Titles









Sustainable Medicine + Sustainable Development = Duty to Die

Illegal Aliens & EMTALA








PART 2 of 2


Dr. Madeleine Cosman, Ph.D., JD
August 27, 2005

I appeared with Lou Dobbs on CNN in July, 2005, to speak about America�s generous awards of expensive Medicaid benefits. Lou asked, �Is it true that only four states check for citizenship before awarding Medicaid?�

Yes. California escalated in one year from 450,000 Illegal Aliens on Medi-Cal in 2002 (California�s version of Medicaid) to 750,000 in 2003.

Poor American citizens get Medicaid. Illegal Aliens get Medicaid. While Medicare is meant for American elders over age 65, Medicaid is meant for America�s indigent at any age. Poor people, especially children, are offered excellent medical care that includes fulsome benefits that vary state to state. Beyond basic medical office and hospital care, some states provide dazzlingly generous additions, such as free prescription drugs, free long-term care, free nursing home care, free home repairs, free hairdressing, free gardening, and free pest control.

Before we get to those specific benefits, look at the groups who get them. America�s generosity as Hospital to the World[1] includes huge numbers of non-citizen �foreigners� who are welcome as Qualified Aliens. Comprehensive medical care extends to nine Qualified Alien groups:

1) aliens lawfully admitted who become legal permanent residents, called LPRs who have �Green Cards� for work, technically Immigration�s �I 551� status
2) refugees
3) aliens granted political asylum
4) Cubans and Haitians who entered America under the 1980 Refugee Education Assistance Act
5) aliens granted parole from prison for at least one year
6) aliens scheduled for deportation but whose deportation has been withheld
7) aliens granted �conditional entry�
8) battered alien women from any country who are welcomed under the Violence Against Women Act of 2000; and
9) victims of �severe forms of trafficking� who are brought to America and covered under the Trafficking Victims Protection Act of 2000.

Free emergency treatment is open to all: Qualified Aliens, Non-Qualified Aliens, and Illegal Aliens.

Amazingly, public health experts complain that there are �troubling disparities� between the medical care of citizens versus aliens. We are so generous in our provision of free medical care that we continued care for seven years even for Alien groups we booted out of Medicaid after the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) welfare reform law of 1996.

That law eliminated many abuses, and restricted welfare and public benefits for many aliens. Nevertheless, the law requires states to provide Medicaid to Qualified Aliens who otherwise meet state eligibility criteria. PRWORA law requires mandatory coverage for LPRs with 40 qualifying quarters of Social Security coverage; refugees for 7 years after their entry; asylees for 7 years after our granting of asylum; Cuban and Haitian entrants; victims of severe forms of trafficking; individuals whose deportation is withheld, for the first 7 years after the withholding; �Amerasian� immigrants for 7 years after their entry; and to honorably discharged US military veterans, and active duty military personnel, their spouses and dependent children (even though military personnel and families are covered under other specifically crafted military medical plans).


America�s graciousness panoply of medical services is available to all who enter her open Golden Door, with or without permission. The patient pays nothing. The state pays all costs but is reimbursed by the federal government for its statutory percentage.[3] All state Medicaid programs must offer:

  • Hospital inpatient services
  • Hospital outpatient services
  • Prenatal care
  • Vaccines for children
  • Physician services
  • Nursing facility services for persons age 21 or older
  • Family planning services and supplies
  • Rural health clinic services
  • Home health care for persons eligible for skilled nursing services
  • Laboratory and x-ray services
  • Pediatric and family nurse practitioner services
  • Nurse-midwife services
  • Health center (Federally Qualified Health Center) services, and ambulatory services of an FQHC (medicine comes to the patient)
  • Early and periodic screening, diagnostics, and treatment (EPSDT) services for children under age 21

The feds will match 34 optional state Medicaid services that include:

  • Diagnostic services
  • Clinic services
  • Intermediate-care facilities for the mentally retarded
  • Prescribed drugs and prosthetic devices
  • Optometrist services and eyeglasses
  • Nursing facility services for children under age 21
  • Transportation services
  • Rehabilitation and physical therapy services
  • Home and community-based care for chronic impairments

Are you shocked? Wait. Optional services are extremely varied and generous. Florida�s frail elderly and developmentally disabled young adults[4] in a Medicaid program called Consumer-Directed Care select from a range of services that Medicaid customarily provides. But ordinarily it assigns people as medical attendants and for medical services without the beneficiaries� choice. This Florida program for consumer-directed care instills responsibility in the beneficiaries by clever use of stratagems. Florida imprints the name of the Medicaid beneficiary as the hiring party on the checks, rather than State of Florida (with 50% help from the federal government) that actually pays the bills.

Variations of this demonstration program, technically called Cash and Counseling, have proved highly successful in Florida, Alabama, and New Jersey.[5] The services these

Floridians on Medicaid obtain include:

  • Personal care, hairdressing, and grooming
  • Homemaking, cooking, and cleaning
  • Consumable medical and personal care supplies
  • Adaptive home improvements such as wheelchair ramps and grab bars
  • Home repairs and maintenance
  • Pest control and yard work


Where does Medicaid money come from? Signed into law in 1965 as Title XIX of the Social Security Act, Medicaid is jointly funded by federal and state governments. Joint funding is not 50-50, however. Some states get more than 75% paid by Washington.

Those states have financial incentives to generously offer more Medicaid services to more people. Federal money-matching rewards big spenders.

Federal matching money makes it hard for states to say �No� to supporting more Medicaid patients. The federal government pays from a minimum of 50% up to a maximum of 83% of each state�s Medicaid costs.[6] The average federal contribution is 57%.

States with lower per capita income get more government money, those with higher get less. This Federal Medical Assistance Percentage (FMAP) in 2000 paid 76.8% of all Medicaid in Mississippi, 70 % in the District of Columbia, and 59.8% in Alaska.[7] Alaska's FMAP increased markedly in 2005.[8] The federal government also reimburses states for Medicaid administration and for Indian Health Service facilities.

For 12 states, the feds pay hospitals for providing emergency services to Illegal Aliens.[9] But amounts are minuscule. In 2005, the state of California got $70,000,000 to help with pitiful shortfalls. California�s San Diego County was about $100,000,000 in the red and Los Angeles County about $140,000,000. Therefore the $70,000,000 was nice to see but it was only cosmetic not substantial help.

Medicaid provides medical care and health-associated services for America�s poor. While Medicare is open to all aged 65 and over and to the disabled of any age, Medicaid is a welfare program for the indigent. Medicaid began as the medical expansion of federal welfare programs providing cash income for the poor, the dependent children and their mothers, the disabled, and the aged.

Medicaid pays for more medical care for the poor than any other source. Its costs are higher than Medicare�s. In 1999, 41 million people received Medicaid. In 2003 Medicaid had 47 million people enrolled. In 2002 Medicaid paid out to providers $146.4 billion, paid premiums for HMOs and for poverty-stricken Medicare recipients of another $33.9 billion, paid hospitals taking a �disproportionate share� of indigent people $14.4 billion, and paid administrative costs of $10.6 billion.[10]

Total Medicaid expenditure in 2000, excluding administration, was $194.7 billion. Of this, the federal government paid $111.1 billion and the states paid $83.6 billion. Medicaid outlays for 2001 were $226 billion. For 2002 expenses topped $258 billion. Medicaid projections for 2006 are $334.9 billion plus another $4.3 billion for an expanded State Children's Health Insurance Program (SCHIP). Medicaid spending is predicted to reach $578 billion by 2012.[11]

Medicaid spending increased 10.6 % in 2001, and more than 13.3% in 2002. It is still higher in 2003 and 2004. However, these percentage increases do not tell the full story. Because federal and state governments jointly fund Medicaid, states must make painful decisions. They must choose between funding their Medicaid recipients or paying their firefighters, police, and road builders.

In 1992, Medicaid spending represented 17.8% of total state spending. For 2002, it was more than 20%. Projections to 2020 show a quadrupling of the spending for long-term care, which now accounts for about half the total Medicaid budget.[12]

Though there are national guidelines for Medicaid, each state establishes its own eligibility standards, determines benefit type, amount, duration, and scope, sets payment rates for physicians and hospitals, and administers its Medicaid program Medicaid welfare benefits vary wildly from state to state, some very generous in quality, quantity, and duration, others more restricted. A person eligible for services in one state may be ineligible in another.

Medicaid costs have risen meteorically for two reasons. More and more people have qualified for care. The care they receive has become more expensive.

Stratospheric costs also are results of our nation�s medical successes. Scientific achievements in neonatology, for instance, enable very premature infants to survive despite extremely low birth weights. Thanks to advancements in trauma care, horrendously injured people survive, requiring rehabilitation or custodial care.

Improved elder care results in very old people with multiple fatal afflictions nevertheless enduring, but requiring long-term acute care, palliative care, or custodial care.


States get carrots and states get sticks. They are offered copious money and prodigious, expensive responsibilities. For instance, states are encouraged to select among 34 �optional� services whose costs the federal government will match. The states must then provide those services to all 9 groups of Qualified Aliens, Green Card holders, immigrants, ayslees, and others. States must provide �optional� Medicaid coverage to all Qualified Aliens or to none of them at all. States cannot discriminate among Alien groups or sub-groups of people it cares to help. States cannot extend �optional� medical care only to some Qualified Aliens.

Furthermore, once a state commits to help one group, it may be trapped into providing Medicaid to others or lose federal money for all groups. Federal legislation rewards big spenders by encouraging states to offer more Medicaid services to more people, yet requires that states provide mandatory Medicaid for categorically needy groups. If these categorically needy are not provided for, the federal government will refuse to pay its percentage of the bill.

Note the use of medical language for labeling groups for medical care: categorically needy, categorically related, and Medically Needy. The categorically needy group per federal law requires every state to fund the medical care of people eligible for Transitional Aid to Families with Dependent Children (TAFDC); children under age 6 from low-income families (at or below 133 % of the federal poverty level); pregnant women at or below 133 % of the federal poverty level; Federal Supplemental Security Income (SSI) recipients; adoption or foster care assistance recipients; particular �protected groups�; children under age 19 in families with incomes at or below the federal poverty level; certain Medicare beneficiaries.

When medical language changes, Medicaid benefits change or disappear. States have the choice to provide or not to provide coverage for categorically related groups. They differ from categorically needy groups. The categorically related include various infants, children, institutionalized people, state SSI recipients (as distinct from the federal SSI people who by mandate get medical coverage), certain aged, blind, and disabled people, and a huge category called Medically Needy people.

Almost every state has Medically Needy. Florida, for instance, offers Medicaid to 27,000 in that class. Most are critically ill and require expensive care.

What does Medically Needy mean? A story by Tallahassee Bureau Chief John Kennedy of The Orlando Sentinel, entitled Medically Needy Receive Last-Minute Reprieve (May 1, 2003) reported on the Florida Legislature�s midnight agreement to a bill to prevent cuts to the Medically Needy program. The projected cuts were intended to require Medicaid recipients to pay for some of their own care from their monthly stipends. An example is 31-year-old Shauna Anderson of Altamonte Springs, living with her third kidney transplant. Her monthly prescription costs of $3,200, or $38,400 per year, are paid by Florida, but half that money is reimbursed to the state by the federal government.

Federal tax monies also paid half of each of the three kidney transplants that generally average about $100,000 each. If the Florida law had passed, Shauna Anderson�s $700 a month in cash Social Security benefits would have been reduced to $450 monthly with the remainder applied to her care.[13]

States have increased eligibility to include many people otherwise considered too rich for an entitlement. Some states enroll in Medicaid people with incomes three times the federal poverty level (FPL). In Missouri Medicaid�s Managed Care Plus, a family can join Medicaid if making less than 300 percent of the FPL, or $55,200 per year for a family of four. In Vermont, children qualify for Medicaid if family income is below 225 percent of the FPL. Uninsured adults qualify if their income is no more than 185 percent of poverty.[14]


Under Medicaid and the pernicious philosophy of medicalizing, words are stunningly abused. All words, all things, all people are equal. A vulnerable victim is a vulnerable victim, and a vulnerable victim demands medical attention and medical money. Look at the title: State Children�s Health Insurance Program (SCHIP). Originally it was created to help children who �fall between the cracks� because their families don�t have private insurance but have incomes too high for Medicaid. States such as Colorado, Illinois, Maryland, New Jersey, Rhode Island, and Wisconsin extend coverage to the children�s parents. Arizona uses unspent SCHIP funds to cover uninsured low-income adults without children.[15]

Many assume that women on welfare with numerous children are the major Medicaid drain. That is both true and not true. Welfare mothers and their children are the most numerous beneficiaries. But their cost is far less as a group than other groups to which some of the mothers and some children belong. For example, Illegal Alien children have inordinately high incidences of disabling �mental diseases� that include behavioral �disabilities� such as Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder.

Illegal Alien children are among the 500,000 �mentally disabled� youngsters on Medicaid obtaining government provided Ritalin and other psychotropic drugs. America also pays Social Security Disability Income to these children, therefore providing financial incentives to bad, bizarre behavior. On the street this is called �crazy money.�

Disabled children on Medicaid rarely are cured. Their families benefit from extra money from their kids� �disabilities,� the schools benefit, and the kids themselves get extra practical benefits (such as bicycles), plus monetary and personal distinction.

My truck mechanic employs an Illegal Alien who has five children. Two are said to be autistic, two have Attention Deficit Disorder, and one has Oppositional Defiant Disorder. All five take Ritalin and other drugs. The autistic children have had �Shadows� that disappeared last year because our state governor forbade them. Shadows are individual medical attendants who work one on one with each child and cost about $30,000 per child per year. The Illegal Alien assistant-mechanic and his wife dine out each Thursday evening thanks to government-supplied respite care baby sitters.

Four distinct programs within Medicaid have different effects on the budget:[16]

  • the disabled younger than age 65 is the fastest growing group, accounting for a very large share of spending relative to the number of beneficiaries
  • the low-income elderly receiving Long-Term Care (LTC) in nursing homes cost the program the most, about $27,000 per person annually (2003 figures)
  • the dual eligibles (for both Medicaid and Medicare) do not receive LTC but obtain subsidized Medicare services in deductibles, coinsurance, and �Part B� premiums, and get outpatient drugs free in many states
  • Mothers on welfare and their kids are the most numerous beneficiaries (three-quarters of the total) but cost the least (one-fourth the total). In 2002, average Medicaid cost (federal plus state) for acute care for kids was about $800.

The 2003 Medicaid budget of $280 billion required federal spending of $158.7 billion plus state spending of $121.2 billion. LTC recipients constituted less than 5% of recipients, yet spent almost 18%, $47 billion of the total budget.

The remaining $230 billion was paid to cover acute care of about 39 million people, coming to about $5,900 per year per recipient, adult and child. But if each child consumed only about $800, then the amount spent per adult was astronomical, about $11,000 per adult on Medicaid.

Medicaid drug benefits totaled 11% of Medicaid spending in 2000. Medicaid beneficiaries, either elderly or disabled, accounted for almost 80 percent of those drug expenditures.


States have incentives to squander Medicaid money. To save is costly. For Mississippi or D.C., for instance, whose match percentage tops 70%, the matching money is 3:1. To spend one state Medicaid dollar generates three more from the feds. To save one state Medicaid dollar costs them three dollars of federal money.[17]

Everyone who qualifies as eligible is entitled to Medicaid benefits. Medicalization of select social problems as diseases -- where alcoholism is defined as a disease, addiction is defined as a disease, and obesity is defined as a disease -- vastly expands the Medicaid patient population.

Now Illegal Aliens also are medicalized. Like other social hazards that if not controlled will destroy our nation, Illegal Aliens perversely use language and structures of medicine for generating care, compassion, and cash.

We must close our Golden Door. Intentionally, volitionally, and rationally we must invite in only those we select. Only then will we restore American medicine to its excellence, integrity, and affordability for its citizens and for those to whom we willingly provide charity.

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Now America�s Medicaid is coerced altruism. Those who demand American self-sacrifice ravenously take while those who pay taxes often have less comprehensive care than Medicaid beneficiaries, including Illegal Aliens. Hospital to the World cannot stand with a perpetually open Golden Door. The Illegal Alien is presented as a vulnerable victim who merits our compassion and our medicine. His illegal act of border-crossing is medicalized into: �I am sick. Help me!� We must muster the courage to say �No!�

Back to Part -----> 1 of 2


1, See Madeleine Pelner Cosman Hospital to the World Welcomes Illegal Aliens,
2, See Madeleine Pelner Cosman, Who Owns Your Body?: Doctors and Patients Behind Bars (Praeger Publishers, 2005).
3, Cato Institute in Washington D.C. is hosting a major conference on Medicaid in 2005 to examine the program's costs and future.
4, See James Frogue The Future of Medicaid: Consumer-Directed Care Heritage Foundation, Backgrounder #1618 (January 10, 2003).
5, Kevin J. Mahoney, "Quality Because of Choice, Not in Spite of It," Advances, Robert Wood Johnson Foundation, Issue 3, 2002; Foster et al., Cash and Counseling: Consumers' Early Experiences in Florida, p. 1.; Centers for Medicare and Medicaid Services, Cash and Counseling, Demonstration and Evaluation Program, pp. 4 and 12. Centers for Medicare and Medicaid Services, Cash and Counseling, Demonstration and Evaluation Program, and Leslie Foster et al., Cash and Counseling: Consumers' Early Experiences in Florida, Interim Memo, Mathematica Policy Research Inc., Princeton, New Jersey, April 2002, p. 1.
6, Centers for Medicare and Medicaid Services, Medicaid: A Brief Summary.
7, Centers for Medicare and Medicaid Services, Medicaid: A Brief Summary.
8, Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000 (Public Law 106-554)
9, Centers for Medicare and Medicaid Services, Medicaid: A Brief Summary.
10, A summary of Medicaid services is available through the Centers for Medicare and Medicaid Services. See Medicaid: A Brief Summary. For lists of mandatory and optional services, see the Centers for Medicare and Medicaid Services Web site at
11, Congressional Budget Office, Current Budget Projections, at. National Association of State Budget Officers and National Governors' Association, Medicaid and Other State Healthcare Issues: The Current Situation, May 2002, p. 1, at [Read] See [Read]
The Federal 57% is assumed the average through 2012. National Association of State Budget Officers and National Governors' Association, Medicaid and Other State Healthcare Issues: The Current Situation, p. 1. National Association of State Budget Officers, "Medicaid to Stress State Budgets Severely into Fiscal 2003," March 15, 2002, at
12, See James Frogue The Future of Medicaid: Consumer-Directed Care Heritage Foundation, Backgrounder #1618 (January 10, 2003)
13, John Kennedy can be reached at 850-222-5564 or
14, Joe Moser, Welfare Reform to Medicaid Reform Heartland Institute April 1, 2003
15, Joe Moser, Welfare Reform to Medicaid Reform Heartland Institute April 1, 2003
16, I am grateful to conversations and calculations on Medicaid Spending on October 2, 2003 with Tom Miller, recently Director of Health Policy at Cato Institute in Washington, D.C., now with the Senate, who can be reached at; Greg Scandlen, Director, Consumer Health Care Coalition, accessible through e-mail HealthBenefitsReform and Gerry Smedinghoff, CPA, available at
17, See James Frogue The Future of Medicaid: Consumer-Directed Care Heritage Foundation, Backgrounder #1618 (January 10, 2003)

� 2005 Madeleine Cosman - All Rights Reserved

E-Mails are used strictly for NWVs alerts, not for sale

Dr. Cosman is a medical lawyer located in California. Her forthcoming book in 2005 is Who Owns Your Body?: Doctors and Patients Behind Bars. She lectures worldwide on medical law and medical policy, has testified before Congress on medical law issues, and has spoken in Washington for Cato Institute and Galen Institute. She wrote the ABCs of the Clinton Medical World for Congress in 1993. A Director of California Rifle and Pistol Association, she writes "Guns and Medicine" for Firing Line. One of her 15 published books was nominated for the Pulitzer Prize, National Book Award, and was a Book of the Month Club Dividend Selection.

Madeleine promotes free-market, patient-centered medicine, and Health Savings Accounts.

Her J.D. is from New York's Cardozo School of Law, Ph.D. from Columbia University, M.A. from Hunter College, and B.A. from Barnard College. She is a member of the New York State Bar, New Jersey Bar, American Bar Association's Health Law Section, and American Inns of Court. Madeleine is Professor Emerita of City College of City University of New York and a Life Fellow of the New York Academy of Medicine.











Promoters of open borders and elevating the status of Illegal Aliens brilliantly use Americans� medical compassion against ourselves. If it bleeds, it leads.