Immigration safety net

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 congressional 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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