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The US spends over $2 trillion a year on health care, but 46 million US residents lack coverage during a typical year. High and rising costs and lack of coverage are the major motivations for health care reform proposals that would shift doctors' payments away from the number of procedures performed and require insurers to cover all applicants. There is disagreement over whether to offer a public health care plan and whether to require employers to provide health insurance to their employees or pay a tax, the play-or-pay mandate.

An estimated 6.8 million of the uninsured are unauthorized foreigners. President Obama, in response to a question, said that unauthorized foreigners would not be covered under a universal health care plan. He said "I want a comprehensive immigration plan" that minimizes illegal migration, and added that one exception to no-care-for-the-unauthorized could be children.

When President Obama addressed Congress on September 9, 2009 and said that unauthorized foreigners would not have access to government-subsidized health care, Rep. Joe Wilson (R-SC) shouted "You lie!" Wilson was censored by the House of Representatives, but his outburst linked the health care and immigration reform debates and led to stronger provisions in Senate health care reform bills aimed at ensuring that unauthorized foreigners do not receive government-subsidized care or health insurance.

There are five major health care reform proposals. The House in July 2009 approved the 1,000-page America's Affordable Health Choices Act (HR 3200). It would create a public health care plan, provide subsidies for low-income individuals to help them obtain coverage, require everyone to have insurance and require employers to offer it, and make sweeping changes to Medicare. It carries a $1 trillion price tag over the next decade, and would cover 97 percent of Americans.

House Speaker Nancy Pelosi (D-CA) emphasized that unauthorized foreigners would not be covered by the House bill; one of the bill's sections is labeled "No Federal Payment for Undocumented Aliens." The Congressional Hispanic Caucus favors health care coverage only for "legal, law abiding" immigrants who pay their "fair share" for health care.

However, the House Ways and Means Committee defeated an amendment to the AAHCA that would have required health-care providers receiving federal funds to check on the legal status of non-emergency patients via the government's Income and Eligibility Verification System (IEVS) and the Systematic Alien Verification for Entitlements (SAVE) systems. Representatives in areas with recent influxes of unauthorized foreigners in the South and Midwest were most vocal in demanding that such foreigners not receive subsidized health care.

Since 2005, Medicaid, the federal low-income health program, has required applicants to verify their legal status; proposals to expand Medicaid retain current verification requirements. A 2007 study questioned the value of verification, noting that it increased administrative costs but detected few unauthorized foreigners (most presumably do not apply).

The Senate Health, Education, Labor and Pensions (HELP) and Finance Committees separately developed heath care reform bills expected to cost less than $1 trillion over a decade. Under the HELP bill, employers of more than 25 workers would have to offer health insurance or pay $750 per worker in a new payroll tax for the 26th and each other additional employee. Temporary and seasonal farm workers would not count toward the 25 employees that trigger the employer mandate.

The finance bill would require employers of at least 50 workers to provide health insurance or reimburse the government up to $400 per employee for any subsidies their employees receive to obtain health insurance. Individuals would be required to have health insurance or face fines, but unauthorized foreigners could not buy subsidized health insurance and legal immigrants would have to wait five years for subsidized coverage.

Massachusetts enacted a health care law in 2006 that required all citizens to have health insurance, including immigrants; the state provided subsidies for low-income residents to obtain at least the state's Commonwealth Care insurance. In July 2009, however, some 30,000 legal immigrants who have been in the US less than five years were removed from the rolls in a bid to save $130 million.

The share of health care costs in the compensation of a median-wage full-time US worker more than doubled between 1980 and 2007, from 4.6 to 10 percent. Western Growers Association said that 10 percent of US field workers are covered by health insurance, and that the employer cost of health insurance is 13 to 15 percent of farm worker earnings.

There were an estimated 100,000 vacant jobs for Registered Nurses (RNs) in July 2009. The $787 billion ARRA economic stimulus bill included $500 million to address shortages of health workers in the US, including $100 million to promote nursing and increase capacity at US nurse-training schools. A sixth of the 2.5 million RNs, some 400,000, were born abroad, including 40,000 who entered the US in the previous five years. There are 500,000 US residents with RN credentials who are not employed as RNs.

Births. The number of births fell from 4.3 million in 2007 to 4.2 million in 2008, or from about 11,820 births a day in 2007 to 11,635 a day in 2008. The number of deaths rose slightly, from 2.4 to 2.5 million, so natural increase fell from 1.9 million in 2007 to 1.8 million in 2008. In most years, births peak in the summer months and are lower during the winter months.

California had 552,600 births in 2008, down 14,000 from 566,400 in 2007. The number of marriages rose to 246,800 in 2008 from 225,900 in 2007.

Kobach. University of Missouri law professor Kris Kobach often defends cities that enact ordinances fining landlords who rent to unauthorized foreigners or employers who hire them. Kobach, who says that Congress has abdicated its responsibility to deal with illegal migration, argues that states and cities have a constitutional right to enforce immigration laws using tools at their disposal. Kobach helped Arizona to defend a statute that cancels the business licenses of employers who repeatedly hire illegal immigrants.

Kobach worked at the Department of Justice after the September 11, 2001 terrorist attacks. He says the fact that several hijackers were stopped by traffic police who had no information about their immigration status motivated his interest in local immigration enforcement.

Julia Preston, "Health Care Debate Revives Immigration Battle," New York Times, September 6, 2009. Antonio Olivo, "Debate heats up on healthcare for illegal immigrants," Los Angeles Times, August 11, 2009. Julia Preston, "Lawyer Leads an Immigration Fight," New York Times, July 21, 2009. Moira Herbst, "More Foreign Nurses Needed?" Business Week, July 21, 2009.