CASE 41: PRENATAL CARE FOR ILLEGAL IMMIGRANTS Early in the legislative session, State Representative Randy Richards held a press conference to discuss his proposed bill that would prevent state agencies and other health care providers from offering prenatal care to illegal immigrants and billing the cost to Medicaid. According to Representative Richards, "Providing prenatal care to illegal immigrants and then billing that cost to Medicaid is committing fraud. We must not blur the lines between personhood and citizenship in this state. It is my belief that providing any such benefits to illegal immigrants is serious violation of federal law." After his brief remarks, Representative Richards opened the floor for questions. Ed Stevens with the Times Daily asked, "Mr. Representative, isn't it true that the children of the mother are United States citizens if born here, regardless of the immigration status of the mother?" "That is true, Ed; however, the care is being provided to the mother herself, and there is no guarantee that the child will in fact be born here, so he or she may or may not ultimately become an American citizen. Besides, that's not the point. These people are here illegally, and to continue to provide services to them just encourages them to break the law. We must break this cycle of encouraging lawlessness!" "But, Representative Richards, can't we assume that a significant number of these women will ultimately give birth to children here who will be U.S. citizens?" asked Gina Harper from Channel 5 News. "Again, that is not the point. If they are ultimately born here, then the child is as an American entitled to benefits; however, many of us believe that the law needs to be changed so that you have to be born to at least one American parent in order to get citizenship." With that reply, he ended the press conference. After the Richards press conference, a number of reporters started contacting Mike Foley, the executive director of the state's Health Care Authority. The Health Care Authority is the state agency charged with administering the federal Medicaid program in the state. As a result of the number of calls, Mike reluctantly agreed to hold a brief press conference on the issue the day after the Richards press conference. At 3:30 p.m., Mike met with reporters in the Authority's large conference room. Mike began by saying, "I don't have any opening remarks regarding Representative Richards's proposed legislation, but I will be happy to answer anyone's questions concerning the current program and how we administer it in the state today." "Mr. Foley, in your opinion is it Medicaid fraud for the state to pay for prenatal care for illegal immigrants?" asked June Adkins from Channel 9 Action News. "No, in fact, the President and Centers for Medicare and Medicaid Services have both issued interpretations of Title XIX of the Social Security Act that say that we should offer prenatal care under the program regardless of a woman's citizenship or immigration status," replied Mike. Gina Harper from Channel 5 News then asked, "Well, then where is Representative Richards getting his information that it's committing fraud?" "I can't answer that, Gina. You would have to ask Representative Richards about that. Perhaps he knows something I don't, but prior to this conference I went back and reviewed both the President's and CMS' interpretations of the statute." "If you don't mind, Mr. Foley, what is your personal opinion on providing prenatal care to illegal immigrants?" asked Ed Stevens. "Well, Ed, the cost of providing really good prenatal care for any woman who qualifies for Medicaid is less than $1,000.00. Studies show that good prenatal care decreases the risk that a child will be born with a serious medical condition. Any child born with a serious medical condition will cost well over $130,000 to treat. As you know, any child born here gets United State citizenship and would surely qualify for Medicaid if his or her parents cannot afford to pay, regardless of the parents' citizenship or immigration status. It would seem to me that it just makes good economic sense to provide these people with the proper care. As the old adage goes, 'An ounce of prevention is worth a pound of cure,'" replied Mike. "Do you agree with Representative Richards that by providing services for illegal immigrants we are encouraging them to come here and break the law?" Stevens asked. "You know, Ed, that is really beyond the scope of this conference. It really doesn't matter how I feel about Representative Richards's personal beliefs regarding immigration. It's simply my job to administer the program according to federal and state statutes and regulations. At this time, the state has simply mandated that the agency administer the program according to federal regulations and guidelines." After Mike's press conference, Representative Richards went ballistic. He issued a statement on his official letterhead that read in part, "Mr. Foley was completely out of line. He had no business commenting on legislation that I am sponsoring. It's Mr. Foley's job to administer the program and if the legislature wants to implement restrictions on who qualifies for the program, then that is the purview of the legislature. I have sent a demand to Mr. Foley's boss, the state's Secretary of Health and Human Services, demanding that Mr. Foley retract his statements and issue an apology or be forced to resign as executive director of the Health Care Authority." Mike, who was covered under the state's merit protection plan, refused to retract his statements or issue an apology. According to Mike, "I did nothing wrong. The press asked for information on the plan, and I provided it. I did not state my personal beliefs and try to pass them off as the state's official stance on this issue. I simply commented about the current state of the program and cited statistics regarding prenatal care and the cost of caring for a child that is an American citizen should he suffer due to a lack of good prenatal care." In response to Mike's lack of an apology, Representative Richards introduced a bill to remove the executive director's merit protection status and make the position a governor's appointment with Senate confirmation.

DISCUSSION QUESTIONS 1. In holding his own press conference, did Mike act unethically? To what extent should public employees refrain from publicly contradicting elected officials? Should the First Amendment protect such employees who speak out against elected officials, or should the official (in his or her official capacity) refrain from making such remarks? Would it matter if the official made the remarks to a reporter while off the clock and not at his official state office? 2. Can you cite an ethical theory that would support Representative Richards's position? How does this theory support his position? What ethical theory can be used to oppose the representative's position and why? 3. To what extent should elected officials be allowed to revise a state's merit protection policy to exempt personnel from its coverage? If the legislature agreed that the position was one that should be exempt from coverage, should such exemption apply to the office's current incumbent, or should the current employee be covered by the original terms of his or her employment? 4. Both Representative Richards and Mike Foley are state officials wrestling with what is essentially a federal responsibility. In terms of immigration policy, what could elected leaders and public administrators at the federal level do to relieve the burdens of their counterparts at state and local levels? Speculate on why this is not happening