Could Medicaid Expansion Debate Turn Into An Immigration Issue?
By Julie Appleby and Patricia
Borns
Feb 26, 2014 - Kaiser Health News
This story was produced in partnership with the Miami Herald
Florida lawmakers backing expansion of the statefs Medicaid program plan to
mount a new argument this legislative session: That voting against extending the
program would deprive low-income U.S. citizens of access to insurance thatfs
available to some legal immigrants.
At issue is a little-noticed provision of the federal health law that allows
some low-income immigrants who are living here legally to qualify for subsidies
to help them buy private insurance through online marketplaces.
Poor U.S. citizens arenft eligible for those subsidies because the law
provided for an expansion of Medicaid to help them get coverage.
But a U.S. Supreme court ruling made this provision voluntary, and Florida
was among two dozen states that opted out, leaving
an estimated 760,000 state residents ineligible for either subsidies or
Medicaid.
gIt doesnft matter where you are on the immigration issue c Itfs a fairness
issue,h said Republican state Sen. Rene Garcia of Hialeah, who has introduced a
bill in the session that begins March 4 to accept billions in federal dollars to
extend coverage to hundreds of thousands of Floridians.
But in a state with a large foreign-born population, the immigration issue
injects a political wild card into a debate that has largely revolved around
ideological differences. Critics of the health law argue the federal government
canft be counted on to continue paying for expanded benefits. Proponents say it
would be foolish to walk away from billions of federal dollars that would extend
coverage to hundreds of thousands of poor Floridians and reduce uncompensated
care costs for health care providers.
In Arizona, concerns about the political fallout of the immigration issue
were said to have helped persuade Republican Gov. Jan Brewer, an ardent foe of
the health law, to expand Medicaid eligibility last year. Brewerfs budget
advisers said that without expanding the program, gonly legal immigrants, but
not citizens [below the federal poverty line] would be eligible for subsidies,h
according to documents obtained by the Associated Press.
But in Florida, proponents see an uphill battle. Last year, the
Republican-controlled state Senate and Gov. Rick Scott, a Republican, blessed a
similar expansion bill, but the House, also controlled by Republicans, refused
to go along.
gI donft think [this] will change the landscape,h said Thomas W. Arnold, the
statefs former Medicaid director, who is now a lobbyist for the health care
industry.
To be clear, the health law provision does not apply to immigrants in the
country illegally, who
are barred from Medicaid, subsidies or even from purchasing private coverage at
full cost through new online marketplaces.
But the lawfs framers sought
an option for legal immigrants, many of whom are barred from enrolling in
Medicaid for five years. If those immigrants are in the five-year waiting
period and earn less than the federal poverty level -- $11,400 for an individual
or $19,530 for a family of three – they can qualify for a subsidy to help them
buy private insurance. To get this help, they cannot be offered
affordable health insurance through their jobs.
In addition, those earning between 100 percent and 400 percent of the poverty
level – up to about $46,000 for an individual or $78,120 for a family of three –
are eligible for the same subsidies as U.S. citizens.
The provision for poor, legal immigrants has received little
publicity to date, in part because even advocates of Medicaid expansion prefer
to talk about its financial and health benefits, rather than raise an issue that
might spark backlash against immigrants.
"The optics of it are difficult," said Jennifer Ngfandu, until recently the
director of health and civil rights at the National Council of La Raza, an
Hispanic advocacy group. "It makes it look like legal immigrants are getting
better treatment than U.S. citizens, but this was born out of Congress being
punitive to immigrants c [wanting] to maintain the restrictions that prevent
low-income immigrants from Medicaid.h
Opponents of expansion, too, could find the discussion politically
difficult.
gItfs hard to see there would be any traction for anyone on this issue,h said
Joseph Antos of the conservative American Enterprise Institute. gTherefs a
lot of sensitivity, not just about immigration, but there is also an element of
racial issues and discrimination. No one wants to be in the position of saying
something discriminatory to anybody.h
eVery Few Are Awaref
Currently, Florida does not offer Medicaid to adults without dependent
children, no matter how low their income. For parents, the income cutoff is 38
percent of the federal poverty level, or $7,421 for a family of three.
Children in families earning more would qualify under more generous rules for
kids.
But in participating states, the health law expands the program to cover
everyone up to 138 percent of the federal poverty level, about $15,900 for an
individual, including adults without children.
The federal government pays 100 percent of the cost of newly eligible
enrollees for the first three years, and scales back over time to 90 percent.
Expanding the program could bring Florida about $66 billion in federal dollars
over the next decade, according to a 2013 report from the Urban Institute. It
would cost the state about $5 billion over that same period.
Garciafs legislation, which has a House companion sponsored by state Rep.
Amanda Hickman Murphy, a Democrat, calls for using federal dollars to buy
private insurance policies for those newly eligible for Medicaid.
Under the proposal, the state would use federal dollars to allow Medicaid
enrollees to buy private insurance policies. Arkansas
and Iowa have adopted similar programs and several other states have shown
interest.
But despite support from Scott and the state Senate last year, Florida
House members preferred a much smaller expansion that would have used state
dollars only.
Republican House Speaker Will Weatherfordfs opposition to Garcia and Murphyfs
bill remains unchanged, spokesman Ryan Duffy said in an email. He did not
respond to questions about the differing access to subsidies for U.S. citizens
versus legal immigrants.
Garcia said he plans to publicize how rejecting the expansion creates a
disparity between some citizens and legal immigrants.
gVery few are aware of that component of the law,h he said. gWhen they
realize it is there, it may change some mindsets,h he said.
Immigrants May Still Have Trouble Getting Coverage
Despite their inclusion in the health law, getting insurance is proving
difficult even for legal immigrants who qualify for a subsidy.
For one thing, they still must pay about 2 percent of their household income
toward the premium, which could be a stretch for some families.
gI donft go to the doctor regularly, why am I going to pay for a service I
donft use?h asked Fila Granados, an immigrant in this country legally who works
at Plants in Design nursery in Homestead.
And simply finding out about the option may be difficult since few insurance
brokers and counselors are familiar with the provision.
At a recent enrollment event in Florida City, a community with many Haitian
and Hispanic immigrants, many of the trained counselors were unaware that some
immigrants could qualify for subsidies.
gI didnft know about the rule,h said Kristia Stewart, a case manager of
Community Health of South Florida (CHI), who is in charge of outreach and
enrollment. Greg Jenkins, a navigator with the Epilepsy Foundation of Florida,
which assists people with health plan enrollments in 35 Florida counties, also
knew nothing about it.
Technical issues with healthcare.gov have also hampered efforts.
gIf you are in a non-expansion state, it will say you are not eligible for
Medicaid or the subsidies,h said Shelby Gonzales, senior policy analyst at the
Center for Budget and Policy Priorities.
She and others said the Department of Health and Human Services is working to
resolve the problem. In the meantime, advocates suggest that legal immigrants in
the waiting period consider filing an appeal if they are below poverty and have
been rejected for subsidies.
Daniela Hernandez contributed to this report.