Immigration Provisions Loom Over Efforts To Merge Reform Bills

Immigration and health care reform. Individually, the issues elicit strong opinions, but taken together the result is even more potent:  Rep. Joe Wilson (R-S.C.) was moved to call out, “You lie!” when President Obama told a joint session of Congress reform proposals would not expand coverage to undocumented immigrants, and rumors to the contrary helped motivate tens of thousands of people nationwide to join so-called tea parties protesting Democratic lawmakers’ health care overhaul plans.  

And now Senate and House leaders will have to iron out their differences on the subject because the two chambers’ respective health care reform bills take significantly different approaches to health insurance coverage for immigrants.

The House bill (HR 3962) would open up proposed health insurance exchanges to immigrants but would provide federal subsidies only to people whose U.S. citizenship could be verified.

By comparison, the Senate bill (HR 3590) would limit access to plans offered through the health insurance exchanges to people whose U.S. citizenship could be verified. President Obama supports the Senate’s tighter citizenship requirements for plans offered through the exchanges.

How these differences are resolved will have huge implications for states with large immigrant populations, especially California. The 2000 census found that 26.2% of California residents were born outside of the U.S., compared with 11.1% of U.S. residents overall.

Moreover, the prospect of tighter eligibility rules governing access to the health insurance exchanges could diminish the impact of health care coverage expansion efforts in California.  Of the more than 5.3 million California residents who were uninsured at some point in 2007, researchers from the UCLA Center for Health Policy Research concluded that 20% were not U.S. citizens and did not have a green card, meaning more than one million people living in California could be barred from buying coverage through an insurance exchange. 

According to the Congressional Budget Office, the Senate’s approach would leave about 23 million people uninsured, one-third of whom would be undocumented immigrants. 

By comparison, CBO’s analysis of the House bill projects that it would leave 18 million people uninsured, again with undocumented immigrants accounting for about one-third of that number.

That difference is big enough to have notable implications for California, especially given the state’s budget deficit and the prospect of picking up the tab for a major Medicaid expansion in the not-so-distant future. 

More news on efforts to work out the differences between the Senate and House reform bills appears below.

What’s in the Bills

• A provision in the Senate health reform bill (HR 3590) would single out the construction industry from insurance exemptions afforded to small businesses, the New York Times reports. Under the Senate bill, all businesses with fewer than 50 workers would be exempt from financial penalties levied on employers that fail to provide coverage to their employees. However, under a provision added late in the legislative process, construction companies with five or more workers would have to provide health coverage or pay an excise tax of $750 per worker. It was added after lobbying efforts by labor unions representing construction workers (Pear, New York Times, 1/4).
• On Dec. 27, House Majority Whip James Clyburn (D-S.C.) and Democratic Congressional Campaign Committee Chair Rep. Chris Van Hollen (D-Md.) said that final health reform legislation might not include a public health insurance plan option but that the bill still could attract adequate support from congressional Democrats for final passage, The Hill‘s “Blog Briefing Room” reports. The Senate bill, which the chamber passed on Christmas Eve, does not include a public option. The House bill (HR 3962) does (Fabian, “Blog Briefing Room,” The Hill, 12/27/09).
• The Community Living Assistance Services and Supports Act, which would fund long-term care for the elderly and disabled, is poised to make it into the final health care reform bill, even though the majority of the Senate opposes it, the Los Angeles Times reports. An amendment to delete it from the Senate reform bill garnered 51 votes but failed to meet the threshold of 60 votes needed to strip it from the legislation. Despite opposition from key Democratic moderates, it survived Senate negotiations because no individual senator insisted on its removal as a condition for his or her support of the legislation (Oliphant, Los Angeles Times, 12/31/09).
• Nine senators have asked Senate Majority Leader Harry Reid (D-Nev.) to include a provision in final health reform legislation that would ban drug patent settlements, in which a brand-name drugmaker pays a generic drugmaker to keep less costly generics off the market, Reuters reports. The provision is included in the House reform bill but not the Senate version (Reuters, 12/30/09).
• House Democrats Bart Stupak (Mich.) and Diana DeGette (Colo.) have said that disputes over abortion language in a final reform bill could result in a number of lawmakers changing their vote on the legislation, CQ Today reports. Stupak, who introduced an amendment to the House bill that would prohibit insurance plans participating in the exchange that receive federal funds from offering abortion coverage except in cases of rape, incest or to save the life of the woman, said he expects 10 to 12 other Democrats to vote against final health reform legislation if language regarding abortion coverage under federally subsidized insurance plans from the Senate bill is included. Meanwhile, DeGette, co-chair of the Congressional Pro-Choice Caucus, said 42 House members have pledged to vote against any legislation that “goes against current law.” Neither Stupak nor DeGette would release the names of House Democrats who have threatened to vote against final legislation because of abortion coverage (Stern, CQ Today, 12/31/09).

Nebraska Deal Sparks Outcry

• On Dec. 30, 13 Republican state attorneys general sent a letter to House Speaker Nancy Pelosi (D-Calif.) and Senate Majority Leader Harry Reid (D-Nev.) demanding that a deal to pay the cost of Medicaid expansion in Nebraska included in the Senate’s reform legislation (HR 3590) be rescinded or they would file suit, The Hill‘s “Blog Briefing Room” reports (Fabian, “Blog Briefing Room,” The Hill, 12/30/09). The provision was inserted in the bill to secure the support of Sen. Ben Nelson (D-Neb.) (Kinnard, AP/San Francisco Chronicle, 12/31/09).
• On the same day, Nelson defended his vote for the Senate health bill in a 30-second television advertisement broadcast during the Holiday Bowl football game, which featured the University of Nebraska, the New York Times reports (Davey, New York Times, 12/31/09).

Shaping the Debate

• The health insurance industry, which would be affected more by health reform legislation than any other sector of the health care system, is preparing for changes to its business practices and profitability as a result of the legislation, the Wall Street Journal reports (Johnson, Wall Street Journal, 12/26/09). According to the AP/Washington Times, the Senate’s health care bill (HR 3590) would be more favorable to the insurance industry than the House bill (HR 3962) because it lacks a public option, which the industry opposes (AP/Washington Times, 12/26/09). The Senate bill also would mandate that individuals purchase insurance and strengthen penalties for those who do not, likely resulting in an influx of new customers (Wall Street Journal, 12/26/09).
• Large health care interests have begun lobbying on the state level in an attempt to influence the outcome of the current debate over health reform, the New York Times reports. According to a study by the National Institute on Money in State Politics, health care providers contributed about $102 million to state political campaigns across the U.S. during the 2008 election, surpassing the $89 million spent on the federal level and contributed by the same donors. Similarly, the drug industry spent more than $20 million in state political contributions in 2008 (Kirkpatrick, New York Times, 12/29/09).
• In an effort to thwart the inclusion of any limits on medical malpractice lawsuits in health reform legislation, an association of trial lawyers is funding an advertising campaign highlighting the number of annual deaths caused by medical errors, the New York Times reports. The American Association for Justice — formerly known as the Association of Trial Lawyers of America — began the print, radio and online campaign in September (Olson, New York Times, 12/29/09).
• The Progressive Change Campaign Committee is launching phone and advertising campaigns urging voters to ask Sens. Bernie Sanders (I-Vt.) and Russ Feingold (D-Wis.) to vote against any health reform legislation that does not include a public option, The Hill‘s “Blog Briefing Room” reports. In addition, the group is planning to deliver petitions to Sens. Sherrod Brown (D-Ohio) and Al Franken (D-Minn.) (Zimmermann, “Blog Briefing Room,” The Hill, 12/30/09).