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How Health Reform Excludes Unauthorized Immigrants – And Why That Needs to Change

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Northeastern University

The Affordable Care Act of 2010 was passed to extend health insurance coverage to an estimated 32 million previously-uninsured people living in the United States, in order to bring them more fully into the health care system. But one major group of residents was excluded completely from this landmark reform, because the legislation prohibits unauthorized immigrant adults from purchasing subsidized private insurance plans on the state health exchanges or gaining insurance through the expansion of Medicaid coverage to near-poor people. In fact, the 2010 health reform law also restricts help to some authorized immigrants, because laws previously on the books require all immigrants to have established five years of legal permanent residency in the United States before they become eligible for federal benefits.

Health reform’s restrictions on noncitizens, especially the unauthorized, underscore tensions between health and immigration realities. Ironically, a reform intended to make health insurance more of a universal right in the United States may also have the effect of further marginalizing unauthorized immigrants, stigmatizing them as “undeserving” of basic coverage now closer to becoming a right for everyone else.

Health Coverage Provided – and Denied – to Unauthorized Immigrants

Despite the restrictions they face under the Affordable Care Act, unauthorized immigrants can still continue to receive care in safety-net hospitals, clinics, and federally-qualified community health centers that attend to medically underserved populations in urban and rural areas. As in the past, such facilities will still provide certain emergency, preventative, and primary health care services to low-income patients regardless of their citizenship status or ability to pay.

In fact, the Affordable Care Act boosts funding for qualified community health centers by some $11 billion over the next five years. This will benefit unauthorized immigrants who are lucky enough to live in areas served by such centers – if they can make their way through the maze of bureaucratic forms, eligibility requirements, and waiting lines. But not all unauthorized immigrants are so lucky about where they live. And national reform is also leading to new demands on health centers and their staffs, as they provide new services to millions of Americans newly eligible for Medicaid coverage.

What is more, as health reform is fully implemented, decreases are happening in federal “Disproportionate Share” funding to safety-net hospitals that provide emergency care for Medicaid and uninsured patients. Those who drafted the 2010 legislation assumed that such payments would no longer be needed once many more Americans became insured. But a side-effect may be to make it harder for unauthorized immigrants to get access to emergency care or specialty care. Even the most committed of safety-net hospitals will have fewer resources to serve the uninsured, and the problem is most acute in Republican-led states that are, so far, refusing to accept the expansion of Medicaid to their own near-poor citizens.

Corrective Steps in Massachusetts, Vermont, and San Francisco

Although the overall picture for unauthorized immigrants is bleak, some states and cities have chosen to take a more inclusive approach to health care.

  • In 2006, Massachusetts created the Health Safety Net as part of comprehensive health reforms that were sponsored by Republican Governor Mitt Romney and later served as a model for the Affordable Care Act. Primarily funded through a pool of funds from hospitals, this program provides primary health services to all low-income state residents regardless of citizenship status, if they do not qualify for other public insurance. 

  • Vermont’s 2011 reforms use state funds to insure unauthorized immigrant residents.

  • In 2007, Healthy San Francisco was enacted to provide primary medical care to all otherwise uninsured needy city residents between ages 18 and 65. Recently, a Democratic state senator proposed that California pay for the unauthorized to get Medicaid coverage or gain access to the state-run health insurance exchange. 

Our own research shows that unauthorized immigrants in Massachusetts and San Francisco now enjoy access to basic health care services, albeit only limited services delivered though specified safety-net institutions. Because Massachusetts and San Francisco have actively decided to treat unauthorized immigrants as real residents, they provide better options for unauthorized residents than the rest of the country, even if coverage and access remain limited compared to the public and private options available to citizens and legal immigrants.

The Way Forward

For the sake of economic efficiency and public health, all Americans have a stake in making basic health care available to every resident. But in the absence of reforms like those in Massachusetts, Vermont, and San Francisco, millions of unauthorized immigrants living and working and raising families in communities across America face the threat of greater marginalization in the reformed system. Their access to health care will likely diminish, leading to deteriorations in wellbeing and growing disparities along lines of race, ethnicity, and legal status. Ironically, lines between vulnerable citizens and non-citizens may remain blurred for a time in states that are refusing to expand Medicaid and fully implement Affordable Care reforms for their own lower-income citizens. But divisions will grow as health reform is fully enacted.

In our view, the day will come when Affordable Care’s exclusion of unauthorized and newly legalized immigrants will have to change. To prevent the further marginalization and stigmatization of already vulnerable people, America will need to enact comprehensive immigration reform accompanied either by enlargements of rights to basic health care under national law or the spread across the entire country of creative state and local solutions like those adopted in Massachusetts and San Francisco. When it comes to health care, treating unauthorized immigrants like the real residents they already are is simple common sense.

Read more in Helen B. Marrow and Tiffany D. Joseph, “Excluded and Frozen Out: Unauthorized Immigrants’ (Non) Access to Care after Health Care and Immigration Reforms,” Journal of Ethnic and Migration Studies (forthcoming).