BEYOND THE NUMBERS
A recent presidential proclamation will require certain people seeking to immigrate lawfully to the United States to prove they have health insurance, can quickly sign up for it, or can pay for any reasonably anticipated medical expenses. Like other Trump Administration policies, the proclamation — a form of Presidential action that’s akin to an Executive Order — will make it harder for people to immigrate to the United States unless they’re already wealthy. And while the Administration claims that its purpose is to reduce uncompensated care costs, the proclamation will likely reduce the number of people enrolled in comprehensive health coverage, which could increase uncompensated care.
The proclamation requires certain groups of immigrants — such as people applying to become lawful permanent residents — to meet its new health coverage mandate or be denied entry to the United States. But only some types of coverage count toward the mandate. Medicaid and subsidized coverage that individuals buy through the Affordable Care Act (ACA) marketplaces don’t. So-called “short-term” health plans do. These plans, which an earlier Trump Administration rule allowed to last up to one year, can exclude coverage of the ACA’s essential health benefits and can deny coverage to people with pre-existing health conditions.
The Administration says the new health insurance mandate will protect America’s health care system and taxpayers from the burdens of uncompensated care. But the policy could easily increase uncompensated care, for two reasons:
First, it steers potential immigrants away from comprehensive coverage through Medicaid or subsidized marketplace plans and toward short-term plans with large coverage gaps. As noted, short-term plans don’t have to cover the ACA’s essential health benefits, such as maternity and mental health care, substance use disorder treatment, and prescription drugs — and they often don’t. While the proclamation claims to distinguish between subsidized and unsubsidized coverage, almost no one gets health coverage without some form of subsidy: families with employer coverage, which counts toward the new mandate, get tax benefits averaging about $4,000 per year. Counting sub-standard plans as insurance while not counting subsidized ACA coverage will simply push some immigrants toward skimpier coverage.
Second, the new policy — which is slated to take effect just days after the ACA’s open enrollment period starts on November 1 — will add to the climate of fear and confusion that discourages immigrant families from enrolling in public coverage programs for which they’re eligible. Some people who aren’t subject to this assessment may nonetheless fear signing up for coverage that won’t meet this new mandate. For example, a family may not sign their children up for Medicaid because they fear it could leave a parent unable to immigrate to the United States. As a result, the proclamation — like other Trump Administration policies — will raise uninsured rates among lawfully present immigrants and potentially their U.S. citizen family members. That, in turn, will increase uncompensated care costs. exacerbating the very problem the proclamation purports to address.
The proclamation is only one of many Administration actions that will raise uncompensated care costs. For example, the Administration has:
- Refused to defend the ACA against a lawsuit by 18 Republican attorneys general asking the courts to invalidate the entire ACA. If successful, that would increase the demand for uncompensated care by $50 billion in 2019, according to Urban Institute estimates.
- Promoted scrapping the penalty for those who go without health coverage, lessening the incentive for healthy people to buy insurance and prompting some instead to incur uncompensated care when they get sick.
- Approved state Medicaid waiver requests that have created significant barriers to enrollment among eligible people, jeopardizing progress in reducing uncompensated care costs. States that have expanded Medicaid to low-income adults under the ACA have seen both larger coverage gains and larger drops in uncompensated care: a 47 percent decrease in uncompensated care costs on average compared to an 11 percent decrease in states that did not expand Medicaid.
- Sabotaged the ACA’s implementation in various ways, including by slashing outreach funding for marketplace enrollment and expanding the availability of skimpy plans. That sabotage has contributed heavily to 1.3 million fewer people having health coverage between 2016 and 2018. Data show a strong relationship between uninsured rate changes and changes in uncompensated care.
U.S citizens make up a large majority of all uninsured non-elderly people. Targeting new immigrants as drivers of uncompensated care obscures the fact that the vast majority of uncompensated care is incurred by uninsured U.S. citizens, whose ranks will rise due to Administration policy.