CRS Says 'Vexing' Questions on Immigration Loom in Health Care Bills

Congressional Quarterly Homeland Security
November 4, 2009
By Jane Norman, CQ HealthBeat Associate Editor

A new report by the Congressional Research Service says that "vexing" questions might be raised for lawmakers if illegal immigrants are barred from a new health insurance system, including whether they could be denied needed medical care.

The Nov. 2 report comes as the House moves toward a floor vote on Democrats' health care overhaul bill (HR 3962) amid a discussion of remaining issues such as illegal immigration and how it is handled in the legislation. The merged health care bills in the Senate are awaiting a Congressional Budget Office score before floor action.

The report raises the prospect that illegal immigrants could find a new spotlight on their legal status if everyone else is required to hold health care insurance but they are not. "Will health care providers be less likely to provide medical treatment to uninsured people whom they presume are likely to be unauthorized aliens?" asks the CRS.

Only in the Senate Finance Committee bill (S 1796) are illegal immigrants specifically exempted from the personal mandate to have health insurance coverage, the report says. Only in the Finance bill are they expressly barred from taking part in the health insurance exchanges that will serve as insurance marketplaces.

The House bill and a bill approved by the Senate Health, Education, Labor and Pensions Committee (S 1679) would allow illegal immigrants to take part in the exchanges if they use their own money to purchase health insurance.

But in all three bills, illegal immigrants would be ineligible for the federal subsidies that will help low- and moderate-income people pay for their insurance, says the CRS report.

Legal permanent citizens are treated much the same as U.S. citizens in all three bills. They are required to purchase health insurance, are eligible to buy it through the exchange, and are eligible for premium and cost-sharing subsidies if they meet the other requirements, such as income levels.

The provisions on immigrants, though, raise potentially troublesome questions for lawmakers, the report says, including:

- If illegal immigrants are exempted from the insurance mandate, would they be able to underbid U.S. citizens in the labor market, particularly among private contractors and the self-employed?

- Will U.S. citizen children in a mixed-status immigrant family be less likely to benefit from the federal health care subsidy if a parent who is an illegal immigrant is ineligible?

- Should U.S. citizens who sponsor new legal permanent residents be required to assume some responsibility for their health insurance costs?

- Should the current five-year ban on federal means-tested benefits for legal permanent residents also apply to the premium subsidies?

CRS estimates, based on census data, that at the beginning of 2009 there were 36.8 million foreign-born residents, including 21.3 million non-citizens, making up 7.1 percent of the total U.S. population.

Many are poor. CRS says that 23.4 percent of non-citizens are below the federal poverty threshold, while close to 28 percent fall between 100 percent and 199 percent of that threshold.

The census doesn't ask about immigration status, but CRS says the Pew Hispanic Center put the number of illegal immigrants at 11.9 million in 2008. Among them, an estimated 59 percent of adults and 45 percent of children with illegal immigrant parents lacked health insurance in 2007.

The CRS report notes that verification procedures for immigrants vary among the Finance bill, the House bill and the HELP bill.

In the HELP bill, the secretary of Health and Human Services would be required to verify an individual's eligibility to enroll. In the Finance bill, three identity documents would need to be verified by the Social Security Administration and the Department of Homeland Security.

The House bill would require the new health choices commissioner to verify citizenship and immigration status.

None of the bills would alter laws on immigrants' eligibility for Medicaid or the Children's Health Insurance Program.

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