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Health Care and Immigration: Uncomfortable Bedfellows

The Congressional Hispanic Caucus was emphatic that illegal immigrants should be included when the landmark health care bill was being negotiated in 2009. But the White House and Democratic leaders said it was not the right time and health care would be taken care of when immigration was overhauled.

Now, as both chambers get serious about approving legislation that could enable about 11 million illegal immigrants to become citizens, Hispanic lawmakers are again being told that now is not the time. Barring a dramatic change of course, neither the bipartisan Senate bill nor a bipartisan House measure that’s now being crafted would help millions of uninsured, illegal immigrants get health insurance.

Any debate on health and immigration brings together one of the most polarizing laws in the country’s history — the Affordable Care Act (PL 111-148, PL 111-152) — with the equally emotional and divisive issue of immigration. It’s a toxic combination.

“Even when we are not discussing immigrants, Republicans and Democrats do not see eye to eye on who should have access to health care and under what circumstances,” said Rep. Luis V. Gutierrez, the Illinois Democrat who planned to retire but stayed in Congress to push for an immigration overhaul. Gutierrez, who has led the Congressional Hispanic Caucus’ immigration efforts, does not appear prepared to risk the effort with a wholesale debate over immigration and health care.

“The partisan politics of health care almost fatally infected the bipartisan policy cooperation on immigration,” he said in an email. So the bipartisan House group, of which he is a member, has decided to follow the Senate’s lead.

Under the Senate bill (S 744), illegal immigrants could buy insurance in the new health care marketplaces. But unlike American citizens and legal permanent residents, those with “registered provisional immigrant” status would not be eligible for the law’s federal tax credits to help them afford insurance on the exchanges. And these provisional immigrants would not be subject to the law’s mandate to have health insurance.

Gutierrez knows there is more to this debate. “The reality is that on a five-, 10- or 15-year path to citizenship, someone — or someone in your family — is likely to get sick or injured,’’ he said. “The question is whether Congress makes getting sick or injured and incurring health care costs a condition for staying in the country legally, and I think we should not.”

What Gutierrez was referring to is a position that led one Republican in the House bipartisan group negotiating an immigration package — Rep. Raúl R. Labrador of Idaho — to bolt. Labrador is a vehement opponent of the health care overhaul. He believes health care is everyone’s personal responsibility, and that should include, an aide to the congressman said, paying all of their medical bills. If they don’t, Labrador believes they should be asked to leave the country, the aide added.

It shouldn’t come as a surprise that lawmakers are not eager to mix health care and immigration. President Barack Obama delivered that message in his 2009 State of the Union address, in which he promised that no illegal immigrant would be covered by a health overhaul. The health care law made good on that pledge. And in June 2012, when he issued an executive order that young people who were brought here illegally as children and have gone on to college or the military would not face deportation, Obama decided that those so-called DREAMers — named for the legislation that would have legalized them — would not be covered by the health care law.

In his executive order and speech, Obama “created a marker on this issue,” said Clarissa Martinez-De-Castro, director of civic engagement and immigration at the National Council of La Raza. Even advocates such as Martinez-De-Castro see the peril in insisting that the immigration overhaul include health benefits for this group.

“There is a danger that taking on this debate in the context of immigration endangers the prospects for immigration reform,” she said in an interview. But, she added, by not helping these illegal immigrants get health benefits, lawmakers would be “adding a burden to that population” that the country will have to come to grips with in the future.

The Senate proposal does take one baby step toward providing a pathway to health insurance for this population by allowing them to buy insurance on the exchanges. But a report from the nonpartisan Migration Policy Institute shows that without access to subsidies, the vast majority of illegal immigrants likely would not be able to afford to buy insurance from the exchanges.

The report says 7 million, or 71 percent, of illegal immigrants are uninsured. And 84 percent of them, it says, have incomes below 400 percent of the poverty line, which would allow them to qualify for federal subsidies. Without such assistance, said Migration Policy Institute Senior Vice President Michael Fix, these immigrants are unlikely to be able to afford coverage.

Martinez-De-Castro said the irony of making it virtually impossible for these provisional immigrants to be part of the health exchanges is that it would undermine the economics of how those marketplaces are supposed to work. This population is disproportionately young, she explained. “Look at the math. You want more people who are young and healthy to create an overall pool to take care of those who are not,” she said.

There’s another financial aspect of this debate that works against those who want health benefits for this population. Given the current budget climate, lawmakers supporting this effort know it must be budget-neutral to succeed. Allowing these immigrants to get the health law subsidies would add to the cost of the immigration overhaul.

Sen. Marco Rubio, one of the “gang of eight” that drafted the Senate bill, said in a recent video post to constituents that it isn’t “fair” to allow people who have violated U.S. law by being here illegally to benefit from a government subsidy. Beyond that, “the last thing we want to do is legalize 11 million people and have a significant percentage of them dependent on government. It’s not that we’re not compassionate. It’s that we cannot afford it; it isn’t responsible,” the Florida Republican said

The inability of these unauthorized residents to get insurance goes beyond their being barred from the subsidies. Under current law, legal permanent residents have to wait five years after they get a green card before they can enroll in Medicaid or the Children’s Health Insurance Program. Under the Senate bill, those restrictions remain. And given the timetable for people to complete all the steps necessary for them to go from undocumented to being fully legal, it would likely be at least a decade before most of these newly legalized immigrants could gain access those programs.

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