ACA back in spotlight

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.”