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Immigrants and Health Care: What’s Really at Stake?

New America Media, Commentary, Michael Fix Posted: Oct 09, 2009

Editor's Note: Health care reform and immigration are more linked than many imagine. Even legal permanent residents could find health care reform affecting them in ways they did not imagine. Michael Fix is Senior Vice President of the Migration Policy Institute and Co-Director of its National Center on Immigrant Integration Policy. MPI is an independent, non-partisan, non-profit think tank in Washington, D.C. dedicated to analysis of the movement of people worldwide. IMMIGRATION MATTERS regularly features the views of advocates and organizations working on issues related to immigration.

WASHINGTON D.C. — With the Senate on the verge of taking up what could be once-in-a-generation reform of America’s health care system, policymakers have a rare opportunity to reduce the ranks of the nation’s 46 million uninsured by expanding Medicaid, providing private insurance subsidies, and mandating employer coverage.

The scope and success of health care reform, however, will be directly affected by lawmakers’ decisions regarding the eligibility of legal immigrants for health benefits, and their approaches to screening out unauthorized immigrants.

There are proposals under consideration in Congress that would exclude many legal immigrants from core benefits and impose new verification requirements to keep unauthorized immigrants from accessing health care benefits. Though directed at immigrants, those proposals would have important spillover consequences for taxpayers and health care consumers, native-born and immigrant alike.

One key question is whether Congress will choose to keep restrictions from a 1996 welfare reform law that requires legal immigrants to wait five years after they get a green card before they become eligible for Medicaid and other public benefits such as food stamps. Extending the five-year waiting period for eligibility for private insurance subsidies or retaining it for Medicaid would affect more than 1 million of the nation’s 12 million legal permanent residents, we estimate in a report we released earlier this week.

Our report, Immigrants and Health Care Reform: What’s Really at Stake?, finds that despite high workforce participation rates many immigrants are uninsured. In fact, our analysis of U.S. Census Bureau figures suggests that 4.2 million legal immigrants and slightly more than half of the estimated 12 million unauthorized immigrants are uninsured.

Though Congress appears certain to impose a mandate requiring employers to provide health insurance coverage for their workers, it is likely that small firms (those with fewer than 25 workers, for example) would be exempted from such a mandate. That could have a significant effect on immigrants, who are more likely than native-born workers to be employed by small firms.

We found that 38 percent of legal immigrants work at small firms of 25 workers or less, compared to 28 percent of native-born workers. And just 32 percent of legal immigrant workers at these small firms have insurance, compared with 71 percent for U.S.-born workers.

How Congress shapes the health reform bill has major implications, of course, for individuals, health care providers, and insurers. States with large immigrant populations could see expanded use of emergency rooms and public clinics if health care reform results in legal immigrants (and the unauthorized as well) being dropped from employer-sponsored insurance.

Some other findings from our report:
• 38 percent of legal immigrant children and 31 percent of unauthorized immigrant children have employer-provided coverage, compared to 61 percent of U.S.-born children.
• Unauthorized immigrants represent 15 percent of the nation’s 46 million uninsured, while legal immigrants account for 9 percent.
• The share of legal immigrant adults who are uninsured ranges from 54 percent in Texas, 45 percent in Florida, and 42 percent in California to 28 percent in New York.
• 23 percent of the uninsured in California are legal immigrants, who account for more than 10 percent of the uninsured in Texas, New York, Florida, Illinois and New Jersey.

Leaving large numbers of legal immigrants out of health care reform would hurt efforts to achieve the top goal of the legislation, which is to extend coverage to the nation’s 46 million uninsured. And excluding recently arrived legal immigrants would be a departure from Congress’ recent actions, since lawmakers have restored to legal immigrants some of the public benefits that were cut under the 1996 welfare reform law.

As Congress drafts its health reform legislation, it is fairly simple to assume there would be substantial savings achieved by excluding many immigrants from subsidies and coverage. But those budget projections do not factor in the costs associated with leaving so many people uninsured. After all, denying coverage does not eliminate the need for health care, and uninsured immigrants will head to emergency rooms or may postpone necessary medical attention – ultimately shifting costs to taxpayers and other health care consumers.

You can read the full report at Migration Policy Institute.

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