Im­mi­gra­tion safety net

Over­haul not likely to im­prove health­care ac­cess

Modern Healthcare - - LATE NEWS - Joe Carl­son

If leg­is­la­tion to over­haul the U.S. im­mi­gra­tion sys­tem ever be­comes law, it’s still likely to leave mil­lions of cit­i­zens-to-be re­ly­ing on safety net health­care providers for years to come. The Se­nate passed a bi­par­ti­san im­mi­gra­tion over­haul bill in June that would give cur­rently un­doc­u­mented im­mi­grants some ac­cess to health in­sur­ance cov­er­age dur­ing a long nat­u­ral­iza­tion process. But House Speaker John Boehner (R-Ohio) has vowed to pre­vent a vote on com­pre­hen­sive im­mi­gra­tion re­form, de­spite re­ports that as many as 50 House Repub­li­cans would sup­port some ver­sion of the Se­nate leg­is­la­tion.

A new anal­y­sis of the Se­nate bill’s ef­fect on health­care found that the mil­lions of un­doc­u­mented im­mi­grants who would start on the path to cit­i­zen­ship are likely to con­tinue re­ly­ing on pub­lic hos­pi­tals, free emer­gency care and fed­er­ally qual­i­fied health cen­ters and clin­ics. The anal­y­sis was done by Ge­orge Wash­ing­ton Univer­sity health pol­icy pro­fes­sor Leighton Ku.

The con­tin­u­ing lack of a pay­ment source for th­ese tran­si­tional U.S. res­i­dents likely will squeeze safety net providers, who al­ready are fac­ing de­creased fed­eral pay­ments un­der the Medi­care dis­pro­por­tion­ate-share pay­ment pro­gram for serv­ing low-in­come and unin­sured pa­tients un­der the health­care re­form law. Com­mu­nity health cen­ters in many ar­eas of the coun­try say they’re al­ready over­whelmed by de­mand for their ser­vices.

Roughly 11 mil­lion un­doc­u­mented im­mi­grants live in the U.S. to­day, and un­der the Se­nate’s Bor­der Se­cu­rity, Eco­nomic Op­por­tu­nity and Im­mi­gra­tion Mod­ern­iza­tion Act, they would be able to ap­ply for a sta­tus known as RPI, or “reg­is­tered pro­vi­sional im­mi­grant.”

Un­der the bill, th­ese pro­vi­sional res­i­dents would be able to use their own money to buy cov­er­age through the state health in­sur­ance ex­changes es­tab­lished un­der the health­care re­form law dur­ing the 10-year wait­ing pe­riod be­tween be­com­ing an RPI res­i­dent and a nat­u­ral­ized cit­i­zen.

Chris­tine Har­ley, a Wash­ing­ton pol­icy an­a­lyst for the As­so­ci­a­tion of Asian Pa­cific Com­mu­nity Health Or­ga­ni­za­tions, said that would be a wel­come change from the rules laid out in the Pa­tient Pro­tec­tion and Af­ford­able Care Act, which bars un­doc­u­mented im­mi­grants from buy­ing cov­er­age on the ex­changes with their own money. That pro­vi­sion was in­cluded by con­gres- sional Demo­cratic lead­ers to de­fend the leg­is­la­tion from Repub­li­can charges that it would pro­vide free care for peo­ple in the coun­try il­le­gally.

But crit­ics have cited what they con­sider two ma­jor short­com­ings in the Se­nate bill that are likely to leave im­mi­grants with­out in­sur­ance cov­er­age, and there­fore re­liant on the health­care safety net that serves low-in­come and unin­sured peo­ple.

First, RPI res­i­dents would not be el­i­gi­ble for the fed­eral sub­si­dies that are avail­able to lower-in­come res­i­dents who pur­chase in­sur­ance cov­er­age on an ex­change. “This would let a small num­ber pur­chase in­sur­ance, al­though most would be un­able to af­ford it with­out sub­si­dies,” Ku wrote.

His study, which was partly funded by the Com­mon­wealth Fund, notes that RPI res­i­dents are much more likely than cur­rently un­doc­u­mented im­mi­grants to get jobs that of­fer health cov­er­age, based on the ex­pe­ri­ence of im­mi­gra­tion re­form in 1986. That could make sub­si­dies un­nec­es­sary for at least some of the newly le­gal­ized im­mi­grants.

A sec­ond flaw of the Se­nate bill cited by crit­ics con­cerns Med­i­caid, which the ACA re­lies on to ex­pand cov­er­age to the unin­sured. The Se­nate im­mi­gra­tion bill says Med­i­caid will not be avail­able to RPI res­i­dents un­til five years af­ter they re­ceive full-cit­i­zen sta­tus. Since the “path to cit­i­zen­ship” is a 10-year process, that means RPI res­i­dents will have to wait at least 15 years be­fore be­com­ing el­i­gi­ble for Med­i­caid.

Har­ley said it’s hard to un­der­stand that lim­i­ta­tion, given that RPI res­i­dents will be pay­ing state and fed­eral taxes dur­ing the process of at­tain­ing le­gal res­i­dency. “Once you are here and pay­ing taxes, there shouldn’t be those re­stric­tions,” she said. “And we know that im­mi­grants con­trib­ute more to th­ese pro­grams than they take from them.”

But some House Repub­li­cans have de­manded that un­doc­u­mented im­mi­grants be re­quired to buy health in­sur­ance on their own to qual­ify for le­gal sta­tus so tax­pay­ers don’t have to pick up their health­care costs. Mean­while, Sen. Bar­bara Boxer (D-Calif.) has pro­posed that the fed­eral govern­ment dis­trib­ute at least $250 mil­lion to state and lo­cal gov­ern­ments to help them cover the costs of pro­vid­ing care to im­mi­grants not cov­ered by the ACA.


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