Reform's Mixed Impact on Immigrants: The New Law's Implications Seem Clear, but the Indirect Effects Could Be Critical

Article excerpt

At first glance, the Affordable Care Act's implications for immigrants seem obvious. The legislation benefits legal immigrants and leaves out the undocumented. As of 2014, it provides legal immigrants with subsidies to purchase insurance, requiring them, like other Americans, to maintain coverage and offering them access to state insurance exchanges. But the law denies undocumented immigrants any subsidies or even the use of the exchanges to buy insurance with their own money.

The full story, though, is more complicated. The act leaves in place a five-year waiting period for legal immigrants to qualify for Medicaid and the Children's Health Insurance Program. As a result, though they will be able to use the exchanges to purchase subsidized coverage, many recently arrived legal immigrants with incomes below or near the poverty line are likely to remain uninsured for want of resources to pay their share of the costs.

Yet because the act provides substantially increased aid to community health centers, it may help many immigrants-both legal and undocumented--receive medical care even without insurance.

And because the law includes requirements for citizenship verification for anyone using the exchanges, it may also have unexpected, indirect effects on the administration of insurance for immigrants and non-immigrants alike.

The impact of these provisions will depend on how the federal and state governments implement the law. Language barriers are a major factor in immigrants' access to health coverage and health care. Depending on the level of community outreach, the legislation could affect Hispanic and other immigrants in significantly different ways.

ACCORDING TO A 2009 Kaiser Family Foundation report, one in four people without health insurance in the United States is an immigrant. Legal immigrants will therefore be among the major beneficiaries of the new subsidies to make insurance affordable. Anticipating those benefits as well as the increased aid for community health centers, Hispanic representatives in Congress voted overwhelmingly for the Affordable Care Act.

But immigrant-rights advocates are disappointed by the legislation's failure to eliminate the five-year waiting period for legal immigrants' eligibility for Medicaid and CHIP. In 2009, when Congress reauthorized CHIP, it gave states the option of covering pregnant women and children who, as recent immigrants, would otherwise be deemed ineligible. To date, only 18 states and the District of Columbia have taken up that option.

The new health-reform act will both raise and reduce coverage of undocumented immigrants beginning in 2014. Unlike legal immigrants, the undocumented will not be required to have insurance, nor will they qualify for premium tax credits or cost-sharing subsidies. Many American-born children of undocumented immigrants will undoubtedly pay a price for their parents' exclusion and fail to be enrolled. "Confusion around the new law is certainly going to prevent many of the 4 million citizen children of undocumented immigrants from receiving coverage for which they are eligible," says Jennifer Ng'andu, deputy director of the Health Policy Project at the National Council of La Raza.

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Some undocumented immigrants may receive health coverage because their employers decide to comply with the employer-responsibility provisions of the law. Because they work disproportionately for small businesses that are exempt from the law's requirements, however, the undocumented aren't likely to see substantial gains. In fact, when firms that have provided health insurance in the past begin purchasing it through the exchanges, their undocumented workers could lose coverage they previously had.

One benefit of the legislation for low-income immigrants is unambiguous. Currently, many undocumented as well as legal immigrants receive medical care from federally financed community health centers. …