Vice President for Health Policy
Senators Orrin Hatch and Marco Rubio have proposed amendments to the bipartisan immigration reform bill now before the Senate that go well beyond the tight benefit restrictions already in the bill, as a recent Center analysis explained. One amendment would leave many workers who gain legal status without health insurance for at least 15 years. As a result, these workers would likely go without needed medical care, leaving many of them and their families less productive and in poorer health. Under current law, undocumented workers are ineligible for nearly all forms of public benefits including Medicaid, the Children’s Health Insurance Program (CHIP), and the subsidies that will be available to purchase coverage in the new health insurance exchanges (also known as marketplaces). In addition, most legal immigrants are not eligible for Medicaid and CHIP for their first five years in the country, though they will be eligible for subsidies to help them pay the cost of exchange coverage. Under the bipartisan immigration bill, undocumented immigrants who convert to legal status will be ineligible for Medicaid as well as subsidies to help them purchase exchange coverage for the entire ten-year period that they are in Registered Provisional Immigrant (RPI) status. (States could opt to cover some children and pregnant women through Medicaid and CHIP, according to the Congressional Budget Office.) That means that a large share of these immigrants will likely go without health coverage for a decade. Then, when they become lawful permanent residents (LPR status), they will generally remain ineligible for Medicaid for an additional five years. The Hatch-Rubio amendment would bar those who convert from RPI to LPR status (and agricultural workers who convert from Blue Card to LPR status) from the exchange subsidies, as well, for an additional five years (or until they become citizens, if sooner). Because most would already be ineligible for Medicaid for those five years, the amendment would leave many of these immigrants uninsured and without access to care for at least 15 years — and potentially longer, depending on how long it takes them to become lawful permanent residents. Many of these uninsured immigrants, like other people without health insurance, would likely go without needed preventive care like immunizations and medical services such as prescription drugs to manage chronic conditions. They would be more likely to end up in poorer health, develop serious illnesses including infectious diseases affecting the overall health of the community, and require costly care such as hospital admissions to treat preventable but serious conditions. That would likely increase uncompensated care costs, worsen the health of immigrants and their families, and make them less productive workers. The alternative course — allowing RPI immigrants who gain LPR status to participate in subsidized exchange coverage, as the Senate bill now does — could bolster the long-term viability of the new health insurance exchanges. Those immigrants who are granted LPR status after 10 years or more and then get help to purchase coverage in the new health insurance exchanges will tend to be somewhat younger and healthier than other people in the exchanges. Adding these immigrants to the insurance risk pool would thus help reduce the risk of adverse selection and better ensure stability and affordability for exchange premiums. That should also keep down the average federal cost of providing exchange subsidies. By barring immigrants gaining LPR status from receiving subsidies to purchase exchange coverage for another five years, the Hatch-Rubio amendment would instead worsen the exchanges’ risk pool and thereby raise to higher levels the premium charges for everyone else who buys coverage through the exchanges.