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Think Tank

How Might Immigration Reform Influence Health Care Reform?

After decades of debate and legal challenges, national health care reform moves onward. Next up: immigration reform.

The two are linked.

Immigrants — both those who are documented and those who are not — are less likely to have health insurance than their U.S.-born counterparts. Almost half the documented immigrants in the U.S. do not have health coverage, according to 2011 Employee Benefit Research Institute statistics.

In California, which has one of the country’s largest immigrant populations, immigration policies influence health care policies. Some contend that health care policies influence immigration.

We asked policymakers, immigration experts and consumer advocates how immigration reform might influence health care reform in California.

We got responses from:

Immigration Reform a Chance To Fix Mistakes in Health Reform

I am greatly encouraged by the fact that our elected officials and President Obama are making a commitment to reform our national immigration policies. It’s promising to know that both have also made it a priority to try to find a pathway for immigrants currently in this country to become citizens. This is long overdue and will make America’s immigration policy more in line with the principles of equality and opportunity upon which our nation was founded.

In his first term, the president led the nation by moving forward his vision for health care reform with the idea of providing access and coverage for all Americans. It is a tremendous victory that the ACA is now the law of the land, but for many, this victory was lessened by the sad reality that undocumented persons were left out. California is home to an estimated 2.6 million undocumented individuals. Research shows that 73% of the uninsured undocumented population would qualify for our expanded Medi-Cal coverage based on their income — but they will not be allowed to join, nor will they be allowed to participate in the exchange.

This wasn’t the only disappointing policy at the intersection of health care and immigration. Last year, Obama called for deferred (deportation) action for undocumented youth who were brought to the U.S. as children by their parents — an important first step. Sadly, they were subsequently carved out of health coverage under the ACA — unlike other deferred action individuals who will have coverage. Like health care reform, this policy of exclusion is short-sighted and creates an inequitable health care system.

It is disheartening that neither proposed plan addresses these issues and that both continue to uphold our nation’s current barriers to health care access. Any comprehensive immigration reform must include provisions extending health care coverage to individuals who are now unfairly denied solely due to immigration status. 

The health of immigrants impacts us all. While there are ways to obtain care through our safety net, many do not seek care for fear of deportation or other reprisals. These families work and live in our communities. Their children are part of our community. We will never have true health care reform or comprehensive immigration reform until all individuals have access to affordable health care coverage.

Immigration Policy Is Health Policy

California’s implementation of the landmark health reform law, the Patient Protection and Affordable Care Act, is an historic opportunity to improve the health of communities of color in our state. Unfortunately, the ACA does not provide affordable coverage for everyone. If we look at those who are left out, it is easy to see that our health and immigration policies are working counter to each other. In order to truly achieve lasting progress in the fight against health disparities, we need to pursue comprehensive immigration reform.

The ACA will have a tremendous impact on communities of color in California. CPEHN’s recently released fact sheets, “Achieving Equity by Building a Bridge from Eligible to Enrolled” and “Medi-Cal Expansion: What’s at Stake for Communities of Color,” explain how communities of color comprise the majority (roughly two-thirds) of the 2.7 million people who will be eligible for federal tax credits to buy affordable health insurance through Covered California (California’s health insurance exchange) and 67% of the 1.42 million adults who will be newly eligible for Medi-Cal. A significant portion of the newly eligible for each program will speak English less than very well (40% in Covered California and 35% in Medi-Cal).

While these important reforms are much needed, immigration status will unfortunately prevent hundreds of thousands from accessing preventive care and other vital health care services in our state. A recent report from the UCLA Center for Health Policy Research and the UC-Berkeley Labor Center shows that 2.3 million Californians with incomes below 200% of the federal poverty level still will be uninsured after the ACA is fully implemented, and of these, 790,000 — including children and working families — will be ineligible for coverage because of their immigration status. As a result, we will need to make sure our safety net programs are adequately funded and have the capacity to continue to provide care to the remaining uninsured.

With immigration status so inextricably connected to eligibility for Medi-Cal and Covered California, we must fix our immigration system so that everyone can get the care they need. As major contributors to our workforce, economic engine and cultural diversity, immigrants need a clear and fast path to citizenship, which includes access to affordable health care so they can stay healthy and help California prosper.

Enacting health reform without comprehensive immigration reform will create an unsustainable paradox where efforts to expand coverage may actually increase the persistent health disparities communities of color face. To reaffirm the successes we’ve had in health policy, we must reform our immigration laws now.

Second-Class Citizenship Is Un-American

As a national organization advancing the rights of low-income immigrants based in California, the National Immigration Law Center has a vested interest in ensuring we complete the unfinished business of health care reform as we now take up immigration reform. However, the politics of immigration reform, the lingering defiance of the Affordable Care Act by opponents, and the heartburn created by the fiscal cliff/budget deficit debacle have created a perfect storm for a completely irrational discussion about how best to ensure that all of us can equally participate and contribute to this country we love.

It’s clear the November 2012 election and changing demographics in all the states have propelled Congress and the president to not only take up, but to compete with each other about who is most committed to immigration reform.  It’s in their political interest to pass immigration reform now.  If so, what’s in it for us?  We all should be demanding Washington do better than what is just politically feasible; we must ensure our leaders live up to our values of fairness, equality, and ensuring all of us at least have a fair shot to fulfill our dreams. If not, we risk more than just losing votes.

Citizens and lawfully present non-citizens residing in the U.S. will shortly have new opportunities to buy affordable health insurance under the ACA.  However, the eligibility rules for immigrants for health care coverage remain complex, confusing, and exclusionary. 

Fortunately, California has been a leader and model in the nation for implementing the ACA as well as its recognition and investment in our vibrant immigrant communities. Our embrace of immigrants is what makes California strong, unique, and a magical place. As a result, Californians have a great deal at stake and much to gain by ensuring immigration reform provides a roadmap to first class citizenship with modern and humane immigration policies so that our family, friends and neighbors can fully participate and contribute to our communities. Immigrants and non-immigrants alike need to make sure our leaders understand the true costs and human impact of our exclusionary policies and how all of us are directly affected.

Immigration reform must not continue to exclude immigrants from affordable health care options. What is really needed to create the political courage and to hold our leaders accountable is for a chorus of voices to remind them that to get sick is human and that second-class citizenship is un-American.

Congress Should Create Inclusive Culture of Coverage

I am frequently asked what my ethnic background is. My parents are Juan Roberto and Millicent, though Robert and Millie will suffice. My father emigrated from Nicaragua in 1945, and my mother’s lineage has had some residency in the U.S for hundreds of years. Likely my great-grandfather didn’t know that his mostly-German, partly-Dutch granddaughter would one day marry a Nicaraguan immigrant, nor that he would have half-Korean great-great-grandchildren, with name or lineage related to his that would be of the great American melting pot that is California.

Californians are complex; many of us are descendants of immigrants. Our state has a larger-than-average number of newcomers who come to the state because they recognize it as a place that promotes opportunity. Yet the dreams immigrants have here are hindered by protectionist policies meant to reduce some health or welfare spending, which is an empirically nominal amount for what immigrants contribute.

Even lawfully residing immigrants still have trouble obtaining affordable insurance. Many immigrants work in lower-wage jobs that don’t provide health care. And though many are within the income allowance for Medi-Cal, highly restrictive national immigration and public benefits policies have kept them from getting the care they need. The 1996 Personal Responsibility and Work Opportunity Act (PRWORA), sealed by former President Clinton and House Speaker Newt Gingrich (R-Ga.), excludes legal immigrants from most public benefits programs, including Medicaid, their first five years in the country.

The immigrant exclusions of PRWORA have been harmful to hard-working, lawfully residing immigrants. Despite that, California’s then-Gov. Pete Wilson (R) approved inclusionary state policies that have helped to create a more level playing field in recognizing economic and social contributions. And now, 17 years later, in the context of a landmark bipartisan immigration reform agreement, Washington, D.C., must have a frank and open discussion on what cranks the national economy. Exclusionary policies that leave some wage earners out in the cold will always leave local governments holding the bag and potential revenue creators leery of entering the marketplace that does not honor their contribution. Congress should use this opportunity of bipartisanship as a chance to integrate those who will become lawful permanent residents into a culture of coverage, to create a healthier population nationally and cut out the bureaucratic red tape that is wasted in holding immigrants back from fully participating in the American dream.

Delivering on Promise of Health Care Reform for Immigrants

The forward momentum of immigration reform has raised the hopes and spirits of millions of people in our country. However, as the blueprints for legislation emerge, beginning with the principles set forth by the bi-partisan “Gang of Eight” Senators and President Obama, the danger looms large that lawmakers will repeat some of the terrible mistakes of the past. One notable mistake was the institution of what’s called the “five-year bar”, created under the Personal Responsibility and Work Opportunity Act (PRWORA), passed in 1996, which prevents recent lawful immigrants from having access to federal benefits.

In the health care context, this has meant the denial of Medicaid to recent lawful permanent residents (those with “green cards”) until they have been in the country for five years. As we all know, ongoing preventive medical care, the type offered to low-income residents through the Medicaid program, helps to track and treat illness before it leads to costly emergency room visits.

Still, over the last few days some critics are already poisoning the debate by alleging that our national debt will soar if unauthorized immigrants are made lawfully present and able to access health benefits. Despite what critics may say, the truth is that ensuring immigrants have full access to health care programs and services actually brings down the cost of health care for all of us while also benefiting public health and California’s economy.

A recent report from the Immigration Policy Center showed that California’s undocumented immigrants pay $2.7 billion in sales, income and property taxes. Our state’s immigrants make up a third of the workforce, and California needs the future revenue that immigrant workers provide. From agriculture and domestic work to textile production and construction; California’s immigrant workers keep our state economy running. Ensuring that anyone who earns lawful status has access to health care will surely help us maintain a strong workforce for the future.

With 2.6 million out of 11 million of our nation’s undocumented immigrants living here in California, our state has a colossal stake in the fight for a roadmap to citizenship that does not restrict benefits to any new lawfully present population under immigration reform. Otherwise, there could be a hefty shift of responsibility from the federal government to California’s state and local governments, and we certainly would be disproportionately impacted compared to other states.

Health Care Reform Success Depends on Immigration Reform

Health care reform and immigration policy reform seem separate, but, in fact, success in achieving the long-term goals of health care reform cannot be achieved without comprehensive immigration reform.

First, one of the key shortcomings of the Affordable Care Act is its exclusion of millions of both legal and undocumented immigrants from its expansions of health insurance coverage. The ACA continues the five-year ineligibility of legal permanent residents for Medicaid originally enacted in 1996.  And while the Obama administration is granting temporary legal status to undocumented youth through the Deferred Action for Childhood Arrivals program, it made these hundreds of thousands of youth ineligible for Medicaid. It will take comprehensive immigration policy reform to restore eligibility for Medicaid for all legal immigrants.

Second, health insurance exchanges must verify the citizenship and immigration status of all applicants. If the exchanges rely on the same Department of Homeland Security verification system currently available to employers, there will be many wrongful denials of coverage due to the notoriously erroneous DHS database. Improving the accuracy of the immigration status verification system can only be addressed through comprehensive immigration reform. 

Third, there is continuing misinformation in immigrant communities that using health care can jeopardize one’s future immigration status under the “public charge” exclusion in immigration law. California’s immigrants are particularly vulnerable to this myth, resulting in the chronic under-enrollment of eligible immigrants in Medi-Cal. A definitive clarification that receiving health insurance or health care services is irrelevant to the public charge exclusion can only be enacted by Congress as part of immigration legislation.

Fourth, health care providers left to care for the uninsured will face heightened political scrutiny as publicly funded organizations who serve immigrants, including undocumented immigrants. In the rhetoric of immigration policy debates, the distinctions between legal and undocumented immigrants are easily obfuscated. Safety-net providers such as community health centers and public hospitals will easily become vulnerable to anti-immigrant-motivated budget cuts.

Finally, health care reform cannot succeed without continued reliance on international medical graduates to provide primary care, especially in underserved areas. Immigration policy fairness should include more pathways for international graduates (and their families) to remain in the U.S. and become permanent members of our health workforce and society. A parallel pathway would be supporting immigrant youth in pursuing health careers since many come from the same underserved communities.