Repeal, Replace and Leave Out Immigrants: The American Health Care Act’s Impact on Immigrants

By Wendy Parmet

Given the Trump Administration’s stance on immigration, it probably shouldn’t be surprising that the new health law it is touting, the American Health Care Act (AHCA), will likely have a devastating effect on immigrant and their families. Although not surprising, it should nevertheless be troubling.

Even under the ACA, noncitizen immigrants are far less likely than citizens to have health insurance. In part, this is because immigrants are poorer than the native-born population and are less likely to receive insurance through their workplace. It is also because, contrary to the contentions of its critics, the ACA does not provide any coverage to undocumented immigrants. Indeed, the Obama Administration refused to treat young immigrants who received work permits under the Deferred Action for Childhood Arrival (DACA) program as lawfully in the country and thus eligible to purchase insurance on the exchanges.  In addition, the ACA kept in place the 1996 Personal Responsibility and Work Opportunity Reconciliation Act‘s (PRWORA’s) tight restrictions on immigrants’ eligibility to Medicaid and CHIP. As a result, by 2015, 7 million of the 33 million Americans without insurance were noncitizen immigrants.

Yet although the ACA leaves many immigrants uninsured, it does provide relief to some lawful immigrants. First, it permits lawfully present immigrants who are ineligible for Medicaid to purchase insurance on the exchanges, even if their incomes are below the threshold required for citizens to participate on the exchanges. Second, because immigrants have lower wages than native born citizens, those who are not barred from Medicaid or CHIP due to PROWRA are more likely than native-born citizens to benefit from the ACA’s Medicaid expansion.  More generally, because of their lower wages, immigrants benefit disproportionately from the ACA’s progressivity.

The AHCA, in contrast, is regressive. Starting in 2020 it will deny states the funds they rely on to maintain the Medicaid expansion. It also would replace the ACA’s income-based support with tax credits that are based on age. As commentators have pointed out, this will make it very difficult for people with low incomes to afford insurance.

The AHCA’s impact on immigrants, however, is not due solely to its regressivity. Buried within the AHCA are provisions that specifically target immigrants. One limits eligibility for tax credits to non-citizens who are “qualified” within the meaning of PRWORA. Because PRWORA’s definition of “qualified” is narrower than the ACA’s definition of “lawfully present,” some immigrants who are able to buy insurance on the exchanges would now be barred. In addition, and perhaps most importantly, the AHCA allows states to bar payment of services rendered to non-citizens prior to the provision of evidence of citizenship or immigration status. This provision, which is similar to rules in effect prior to 2009, will likely make it difficult for many immigrants and even the new-born citizen children of immigrants to get needed care.

Of course, the AHCA is not the only potential policy change that will affect immigrants’ access to health care. At least anecdotally, it appears that the Administration’s more expanded approach to immigration enforcement is deterring many immigrants from seeking health care. A widely-circulated draft executive order that would have allowed legal immigrants who use health benefits to be considered a “public charge” and hence deportable has also raised great fear in the immigrant community.

Immigration critics argue that health benefits should be limited to citizens, as only they “deserve” taxpayer support. Even if one could forget the ethical and human rights problems with that argument, it foolishly ignores the public health ramifications. Like it or not, immigrants are members of our communities. They live and work amongst us. They share our germs. They use our health care facilities. Many work in those same facilities. The costs of their ill health will inevitably be borne by all of us, in emergency visits that we all end up having to pay for, illnesses that are transmitted, and work that is not done.  By injecting its anti-immigrant agenda into health policy, the Republican leadership and the Trump Administration are threatening the health of all Americans.