ACA back in spot­light

Im­mi­gra­tion re­form brings de­bate on cov­er­age

Modern Healthcare - - COVER STORY - Jes­sica Zig­mond

Whether to in­clude any type of fed­eral as­sis­tance for health­care cov­er­age for a newly le­gal class of im­mi­grants could turn into a thorny is­sue this year as law­mak­ers at­tempt to over­haul the na­tion’s im­mi­gra­tion poli­cies.

Health­care ex­perts on Capi­tol Hill said they were not sur­prised that the pro­pos­als— one from Pres­i­dent Barack Obama and the other from a bi­par­ti­san group of eight sen­a­tors—did not of­fer fed­eral help in some form to the coun­try’s ap­prox­i­mately 11 mil­lion il­le­gal im­mi­grants.

That’s pri­mar­ily be­cause law­mak­ers al­ready ad­dressed the is­sue in the run-up to the Pa­tient Pro­tec­tion and Af­ford­able Care Act, which made it clear that pro­vi­sions in the 2010 law would not ap­ply to any­one not “law­fully present” in the coun­try. It’s also be­cause Congress and the Obama ad­min­is­tra­tion are gear­ing up for a se­ries of bud­get bat­tles, mak­ing it dif­fi­cult for any law­maker to sug­gest poli­cies that would add to the na­tion’s large fed­eral deficit.

Still, mem­bers of Congress and pol­icy ex­perts sug­gested health­care cov­er­age pro­vi­sions for this pop­u­la­tion will sur­face in the im­mi­gra­tion re­form de­bate.

The pres­i­dent’s four-part plan cre­ates a “pro­vi­sional le­gal sta­tus” where un­doc­u­mented im­mi­grants must reg­is­ter, sub­mit bio­met­ric data, pass crim­i­nal back­ground and na­tional se­cu­rity checks, and pay fees and penal­ties be­fore they’re el­i­gi­ble. The pro­posal also says un­doc­u­mented im­mi­grants must pay taxes, and clearly in­di­cates that those un­der the pro­vi­sional le­gal sta­tus are not el­i­gi­ble for wel­fare or other fed­eral ben­e­fits, in­clud­ing sub­si­dies or tax cred­its un­der the Af­ford­able Care Act.

Un­der the 2010 law, tax cred­its are avail­able to those ci­ti­zens and le­gal im­mi­grants with in­comes be­tween 100% and 400% of the fed­eral poverty level to help buy cov­er­age through the state in­surance ex­changes, or “mar­ket­places,” as HHS now refers to them.

“Cer­tainly no one is go­ing to come out on record un­til the whole bud­get and se­ques­tra­tion thing plays out,” said Matthew Buettgens, a se­nior re­search an­a­lyst at the Ur­ban In­sti­tute, a lib­eral Washington think tank. Buettgens also said he doesn’t think it’s likely there will be at­tempts to ex­tend ben­e­fits through Med­i­caid, given that would add to both state and fed­eral bud­gets at a time when states are still de­cid­ing whether they will ex­pand their pro­grams. And, even then, the 1996 wel­fare-re­form law im­poses a five-year wait­ing pe­riod for im­mi­grants to be el­i­gi­ble for Med­i­caid. “Ex­tend­ing sub­sidy el­i­gi­bil­ity would be more likely some­thing to be pro­posed,” Buettgens con­tin­ued. “But that would raise fed­eral spend­ing.”

Sen. Marco Ru­bio (R-Fla.), who un­veiled the Se­nate pro­posal with seven of his col­leagues, un­der­scored that mes­sage when he com­mented on the pres­i­dent’s plan last week.

“I was en­cour­aged by the pres­i­dent’s ex­plicit state­ment that peo­ple with tem­po­rary le­gal sta­tus won’t be el­i­gi­ble for Oba­macare,” Ru­bio, the son of Cuban im­mi­grants, said in a state­ment. “If in fact they were, the po­ten­tial cost of re­form would blow open an­other big, gap­ing hole in our fed­eral bud­get and make the bill un­ten­able.”

It’s the term “le­gal”—used both in Ru­bio’s state­ment and the pres­i­dent’s plan—that is at the heart of the de­bate over whether to pro­vide fed­eral help for im­mi­grants to ac­cess health­care cov­er­age. The con­tro­ver­sial 2010 law ex­tends ben­e­fits to those liv­ing in the coun­try legally, but the plan mapped out by the pres­i­dent cre­ates this “pro­vi­sional le­gal sta­tus,” which Sara Rosenbaum, pro­fes­sor of health law and pol­icy at Ge­orge Washington Univer­sity, says places them in a limbo stage.

“I think they should be rec­og­nized as a le­gal group,” Rosenbaum said. “Th­ese peo­ple are on a path­way to full le­gal sta­tus, and, as such, their health and wel­fare is im­por­tant,” she con­tin­ued. “This is a group that pays a lot of taxes, so it’s not as if they don’t pro­duce rev­enues for the coun­try.”

That ar­gu­ment is likely to play out on Capi­tol Hill this year, as im­mi­gra­tion-re­form cham­pi­ons such as Rep. Luis Gutierrez (D-Ill.) will ad­vo­cate for im­mi­grants who are liv­ing in the coun­try legally to ben­e­fit from the health­care re­form law.

“Many will have an op­por­tu­nity to get health in­surance through their em­ploy­ers, but the con­gress­man feels we would be shoot­ing our­selves in the foot if we ex­cluded le­gal im­mi­grant fam­i­lies from the Af­ford­able Care Act for a sig­nif­i­cant length of time,” Dou­glas Rivlin, a spokesman for Gutierrez, said in an e-mail while House mem­bers were in re­cess last week. “He plans to work with those craft­ing im­mi­gra­tion mea­sures to ad­dress this.”


Sen. Marco Ru­bio (R-Fla.) an­nounces at a news con­fer­ence that sen­a­tors have reached agree­ment on prin­ci­ples of leg­is­la­tion to rewrite the na­tion’s im­mi­gra­tion laws.

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