On November 7, the House of Representatives passed H.R. 3962, the Affordable Health Care for America Act, a bill that in part creates health insurance subsidies for people with low incomes. Congress was strongly lobbied
to delay access to these subsidies for Lawful Permanent Residents (LPRs), or “green card” holders, by imposing a five-year waiting period. Ultimately, however, the final version of the bill passed without as much as an amendment offered to impose a waiting period of any duration on LPRs. This may be a sign that the tide is shifting on the broader issue of immigration, as Republican leadership decided at the last minute not to force a vote on an immigration provision within the bill
, as reported by Jennifer Bendery of RollCall. She suggests that by not pressing the immigration issue in the House the GOP was placating Hispanic Republicans. It is also likely that Republicans concluded it was in their political interest to focus instead on splitting the House Democrats on the issue of federal subsidies for health care programs that cover abortion with the so-called Stupak-Pitt Amendment. That amendment, which became part of the final bill in the House, has since undeniably become the most controversial aspect of the House bill for the Democratic majority
The National Counsel of La Raza (“La Raza
”), the leading national Latino civil rights and advocacy organization in the United States, applauded the bill's passage, but argued that it did not go far enough.
La Raza calls for the removal of the five-year waiting periods currently in place for LPRs seeking Medicaid, Medicare and the Children’s Health Insurance Program (CHIP). The Affordable Health Care for America Act specifically leaves these five-year waiting periods in place, even as it does not impose a similar waiting period for the new insurance subsidies.
The Federation for American Immigration Reform (FAIR
), a non-profit organization advocating for restrictions on immigration, both lawful and unlawful, argues that not including the five-year waiting period will be problematic.
To persuade law makers that LPRs should not have access to health insurance subsidies “the day they get their green cards,” FAIR produced a cost analysis report
in which they estimated the cost of providing insurance subsidies to recent LPRs to be in the billions of dollars.
However, a report entitled "Immigrants and Health Care Reform: What’s Really at Stake?
” by the Migration Policy Institute
notes that any apparent savings from excluding the recent LPRs from applying for insurance subsidies would be offset by cost shifts in other areas. For instance, individuals without health insurance will continue to use the health care system at emergency rooms and community clinics. When Massachusetts decided to save $130 million by removing recent LPRs from its insurance subsidy program, its state hospitals ended up having to budget an extra $87 million for non-urgent emergency care to account for the resulting influx of uninsured patients at their emergency rooms. Further calculations would be necessary to assess the impact on the public health by leaving LPRs without access to subsidized health insurance coverage.
A similar exclusion of recent LPRs from insurance subsidies at the national level would disproportionally affect hospitals in states with the highest LPR populations, according to the Migration Policy Institute report. Taxpayers and those paying insurance premiums in California, New York, Texas and Florida would end up footing the bill if there was a five-year waiting period for LPRs to access the insurance subsidies.
Another point of contention within the House debate (and presumably in the upcoming Senate debates) is the citizenship verification requirement. What should a U.S. citizen applying for these insurance affordability credits be required to present in order to prove his or her eligibility? In a country without a national ID card, the answer is far from simple. The verification process for those claiming to be U.S. citizens is established by Section 341(b)(4)(C) in the House bill. It requires the applicant to provide his or her name and a matching social security number, which are then checked against records at the Social Security Administration. FAIR argues
that this process is insufficient, and that it will lead to illegal aliens fraudulently claiming citizenship in order to apply for the insurance subsidies.
On the other side of the issue, Janet Murguía and Ralph Neas
(of La Raza and the National Coalition on Health Care, respectively), argue that such “complex layers of citizenship verification” cause excessive delays in obtaining medical treatment, have failed to identify a significant amount of fraudulent claims and are expensive to administer.
Last month officials in L.A. county, required by a 2005 law to verify the citizenship of recipients of subsidized state health care pursuant to the Deficit Reduction Act, complained that virtually no illegal immigrants were found to be attempting to cheat the system. When a $28 million retroactive review of 100,000 records was conducted in Los Angeles County, it found less than 1% lacked proper documents, though most eventually produced them. “Verification of Illegal Immigrants Is Scrutinzed Amid Health Care Debate: L.A. County officials Question Cost-Effectiveness of Rules Aimed at Screening Those Trying to Get Public Health Services
, Los Angeles Times, October 6, 2009.
A Congressional Oversight Committee study concluded that nine states had spent nearly $17 million dollars and caught only eight undocumented persons attempting to gain benefits using false documentation. The Congressional Budget Office found that in 44 states where the new rules were implemented a decline in the demand for Medicaid was noted; advocates believe that most of this decline is due to U.S. citizens who do not possess a driver’s license, passport, or birth certificate. A review of 240,000 records in El Monte, California found only two suspicious documents, both proved to be legitimate.
The Affordable Health Care for America Act now faces its next challenge in the Senate. With an election year looming, the health care debate is expected to continue to be highly polarized as incumbents facing re-election on both sides play to their bases. A recent Pew Research Center poll
found that only 52 percent of registered voters want to see their own members of the House of Representatives reelected next November, which may make Democrats particularly nervous about losing their majority control. This number comes close to the all time lows that were seen prior to the 1994 election when Republicans overtook the Democratic Congress, and the 2006 election when Democrats reclaimed the two chambers after 12 years in the minority. Because Republican sentiment has become increasingly hostile to health care reform, specifically provisions covering immigrants (as illustrated in Rep. Joe Wilson’s now infamous cry
) Democrats could be pushed to cave to Republican demands. (Photo: House Speaker Nancy Pelosi on November 7, 2009 announcing the passage of The Affordable Health Care for America Act, by Luke Sharrett for The New York Times)