This week, the working group in the House of Representatives that has spent the last four years hammering out a deal on comprehensive immigration reform threatened to call it quits. The issue? What to do about health care for the 11 million immigrants who came to the country illegally.
Republicans in the group wanted immigrants to be completely barred from any government health care benefit, federal, local or otherwise. They also floated the idea of requiring immigrants to purchase their own private health care or be required to leave the country. But sources close to the negotiations said Democratic leadership worried the threat of deportation was simply too cruel considering the high price of private insurance.
"The 11 million shouldn't be eligible for health care subsidies," says Rep. Raul Labrador, R-Idaho, a member of the working group. "They shouldn't be eligible for any subsidies at all. That was the agreement that they had before I was even a member of the group."
Under the House bill, immigrants would not be eligible for the roughly $3,000 in tax subsidies available to Americans looking to purchase health care through the Affordable Care Act's exchanges.
But keeping the country's immigrants from health care won't necessarily keep the medical costs from accruing. While some immigrants will get health care through their employer, others will either have to buy private insurance or be forced to pay exorbitant medical bills on their own.
"The House group is 90 percent down the road [of] an agreement that recognizes that 11 million people aren't leaving our country," say a House aide familiar with negotiations. "In the next 10 to 15 years, some of them are going to get sick or get in car accidents...we have to figure out something to do that doesn't create a barrier for those people to get care."
Even conservative pundits recognize that there is still a cost to keeping the 11 million who will come out of the shadows uninsured.
"They still show up in the emergency rooms and the hospitals have to pay for them," says Tevi Troy, a senior fellow at the Hudson Institute and former deputy secretary of the U.S. Department of Health and Human Services.
The Center for American Progress, a progressive think tank, has estimated that keeping immigrants ineligible for the Affordable Care At would undermine the law's primary intention – to lower costs by requiring everyone to be insured.
"Failing to extend this goal of inclusion to the millions of unauthorized immigrants living here will undoubtedly compromise the system's ability to lower cost," Marshall Fitz, a the Director of Immigration Policy at CAP, wrote in analysis of how immigration reform and health care intersect.
The question of whether to give health care subsidies that are available under the Affordable Care Act to immigrants who come out of the shadows has long been fraught with peril.
"During the Affordable Health Care debate, they would say that is too controversial, we cannot deal with it because it will kill the bill. Now we are getting the exact same argument but in the opposite direction," says Shawn Gremminger, a lobbyist who represents low-income health care providers. "Republicans don't support money to go to care for undocumented populations. Democrats, who fundamentally agree, are just too scared to try and include something. They think it will bring down the bill."
During the health care debate in 2009, architects of the legislation ultimately decided not to cover immigrants who came here illegally, fearing it would sink the effort entirely.
Under the Affordable Care Act, immigrants who entered the country illegally are not eligible for subsidies and are not even allowed to purchase health care through the exchanges if they have the means to do so.
Even with that explicit language, doubt still circulated among GOP members in Congress that immigrants who broke the law were being rewarded with benefits. It was that question that led Rep. Joe Wilson, R-S.C., to scream at President Barack Obama "You Lie" during a formal address to Congress when the president stated that his bill would not allow anyone who entered the country unlawfully the chance to get health insurance under exchanges.