bcalvan@sacbee.com

On national television, President Barack Obama contended this week that his plan to overhaul the country's health care system wouldn't spend a single federal dime on undocumented immigrants.

As he spoke, a Republican congressman called the president a liar - once again bringing the incendiary issue of illegal immigration to the forefront of the national debate on health care.

While some say undocumented immigrants are scapegoats in an already heated debate, others say they are part of a bigger problem about how to handle a national health care crisis to control medical costs.

In a climate of economic trouble and rising insurance premiums, the cost of providing care to illegal immigrants has become a focus of public concern, putting pressure on politicians at all levels of government.

Sacramento and Yolo counties recently said they would begin requiring proof of citizenship before providing treatment at county clinics.

Few dispute that undocumented immigrants pose some financial drain on the nation's health care system, but some experts say the extent of that cost has been wildly exaggerated.

At the same time, health officials worry that denying health care to undocumented immigrants could have costly consequences to public health, particularly in controlling communicable diseases, such as tuberculosis and H1N1 flu.

"Some people are placing the blame for the financial problems that hospitals are having solely on undocumented immigrants. While it is a component of the challenges we have, it is not the sole reason and not the biggest reason," said Jan Emerson, a spokeswoman for the California Hospital Association.

Still, she said, "We know it's a hot-button issue."

In fact, the biggest source of uncompensated care - $7.7 billion - is attributable to federal underpayment for services provided to Medicare and Medi-Cal patients.

Of the $11.3 billion in uncompensated care California hospitals reported last year, about $1.5 billion was attributed to undocumented immigrants.

But it's all a "guesstimate," Emerson conceded. No one can be sure how many of the state's more than 6 million uninsured residents are undocumented immigrants, but one estimate puts it as high as 20 percent of all Californians without health insurance.

The lack of firm numbers makes the combined topics of health care and illegal immigration ripe for political clashes.

This was clearly evident Wednesday when Rep. Joe Wilson, R-South Carolina, interrupted Obama with a shout still thundering across the nation: "You lie!"

Obama was responding to claims that health care legislation drafted by Democrats would insure undocumented immigrants. "This, too, is false," the president said. "The reforms I'm proposing would not apply to those who are here illegally."

Wilson later apologized for his outburst but stood by his assertion that undocumented immigrants would benefit from health care legislation.

In town halls across the nation this summer, some congressional Republicans, including Rep. Dan Lungren, R-Gold River, have claimed illegal immigrants would receive health care services despite assertions to the contrary.

While some critics acknowledge that language in the legislation would bar illegal immigrants from receiving subsidies, they say it may allow them to buy low-cost health insurance from a proposed health insurance exchange, a new marketplace that could include a government-run insurance plan. Undocumented immigrants are not currently prohibited from obtaining private insurance.

Nor does federal law prohibit them from getting health care. Indeed, federal law prohibits hospitals from denying treatment to anyone with urgent need. Hospitals also are barred from asking patients about financial or citizenship status before providing emergency care.

A coalition representing hospitals in states with large populations of illegal immigrants, including California, succeeded in getting a total of $1 billion in federal funding as part of a four-year program that ended last fall to reimburse hospitals, doctors and ambulance companies providing care to undocumented immigrants.

California was awarded $72 million annually, the most of any state, but not all the money was used. "The program had mixed results. Some hospitals thought it was more costly and more work to submit claims," Emerson said.

The majority of those who seek emergency care at hospitals have insurance.

"It's not people gaming the system," such as undocumented immigrants, said Shana Alex Lavarreda, director of health insurance studies at the UCLA Center for Health Policy Research. "Right now, it's the counties that have to deal with undocumented immigrants.

The federal health care reform package won't change that," she said. With money tight, however, counties are increasingly reluctant to provide such services at their clinics.

This summer, the Sacramento County Board of Supervisors voted to require the medically indigent to prove legal status before treatment at county clinics. Yolo County passed a similar measure.

In Sacramento County, 4,000 of the 52,600 people eligible for indigent medical care are believed to be undocumented immigrants. Cutting services to that population is expected to save the county $2.4 million, according to a staff report presented to the board in June.

"I think it's a mistake, because it's much more costly in the final analysis for the community," said Supervisor Roger Dickinson, who opposed the restriction. "I think it's a mistake because it puts the community at greater risk of communicable diseases."

Health officials, who would rather skirt the politics associated with providing health care services to undocumented populations, contend that denying care to undocumented immigrants could prove costly to public health.

Public health officials say their job is to guard against threats to public health - not to serve as a law enforcement arm of the Border Patrol. "There are conditions and diseases that imperil the entire health of the community," said Dr. Glennah Trochet, Sacramento County's public health officer. "When (treatment) decisions are being made...those issues should be taken into account."

Call The Bee's Bobby Caina Calvan, (916) 321-1067.