Reform Update: Immigration bill no help for uninsured on path to citizenship

House Speaker John Boehner (R-Ohio) is vowing to prevent a vote on immigration reform even though the latest reports from Capitol Hill suggest as many as 40 or 50 Republicans are willing to back some version of the legislation that passed the Senate last June.

But even if that bill were to come to a vote in the House, a new analysis of the legislation suggests that even if millions of undocumented immigrants start on the path to citizenship, they're likely to continue relying on safety-net healthcare programs for many years to come.

One of the overarching goals in the Patient Protection and Affordable Care Act was to reduce the 50 million Americans who lack access to healthcare coverage, thereby reducing the need for a safety net healthcare system. But the new class of immigrants who would be created under the bill passed by the Senate is likely to continue finding many barriers to accessing healthcare and insurance coverage.

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.”

These provisional residents would be able to purchase 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.

That's a welcome change from the rules laid out in the Patient Protection and Affordable Care Act, which expressly barred any illegal immigrant from using an exchange, even if she paid with her own money, according to Christine Harley, a Washington policy analyst for the Association of Asian Pacific Community Health Organizations.

But critics have noted several shortcomings in the Senate bill that are likely to leave immigrants without insurance coverage, and therefore reliant on the public hospitals, free emergency care, and community-based clinics and health centers that serve vulnerable populations today.

Although RPI residents would be able to use the insurance exchanges, for example, they 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,” George Washington University Professor Leighton Ku wrote this week in a study of the healthcare implications of the Senate bill (PDF).

Ku's study, which was partly funded by the Commonwealth Fund, does note that RPI residents are much more likely to get jobs that offer insurance coverage, based on the experience of immigration reform in 1986. That could make subsidies unnecessary for at least some of the new immigrants.

A second short-coming of the Senate bill cited by critics concerns Medicaid, which, along with the exchanges, was supposed to be a major tool in the 2010 healthcare reform law to reduce the nation's legion of 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 effectively means RPI residents will need to wait at least 15 years before becoming eligible for the expanded Medicaid coverage.

Harley said it was 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. And we know that immigrants contribute more to these programs than they take from them,” Harley said.

It remains to be seen whether the bipartisan Senate bill, which passed on a 68-32 vote June 27, will ever become law.

Boehner said in a July 27 interview on Face the Nation that “the House does not like the Senate bill. It's one big, massive bill that in my opinion doesn't have enough serious triggers to protect our border.” He said the house would debate a series of bills to address immigration.

While the Obama administration is preparing to award $54 million to fund organizations to act as “navigators” to counsel consumers on how to use the health-insurance exchanges, concerns are growing about an additional layer of regulation imposed by some states that could limit the navigators' usefulness.

A report published today by the Washington-based Center for Public Integrity says 16 states have passed laws requiring additional regulation of the navigators beyond what the federal government is rolling out. The laws were promoted by insurance agents and brokers as necessary to rein in uninformed navigators. Critics say the agents fear losing work to the navigators. The newly enacted state rules are designed to stop navigators from doing their jobs, which cannot involve recommending specific plans.

Republican Texas Gov. Rick Perry has been a virulent opponent of healthcare reform and has refused to set up a state-based exchange to help residents obtain coverage. But about 130 local political and civic group leaders in Dallas met at Parkland Memorial Hospital yesterday to begin laying the groundwork for a campaign to reach out to the more than half million or 26% of Dallas County residents who are uninsured, according to the Dallas Morning-News.

Dallas County Judge Clay Jenkins told the audience the county had to pay $562 million in unreimbursed care costs in fiscal 2012, which would be picked up in large part by the federal government if it could get more of the uninsured covered under reform. “We need to roll up our sleeves,” said Monica Alonzo, Dallas deputy mayor pro tem.

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