If you need yet another reason to conclude that the Senate Republicans’ proposed health care bill – the so-called Better Care Reconciliation Act (BCRA)– is designed more to appease different parts of the Republican base than improve the health care financing system, look no further than page 2 of the draft. There hiding in plain sight are provisions barring certain classes of documented immigrants from participating in health insurance exchanges. To understand why the bill includes these provisions, and why they make no sense from a health policy perspective, a bit of history is helpful.
As Patricia Illingworth and I document in our recent book, The Health of Newcomers: Immigration, Health Policy, and the Case for Global Solidarity, anti-immigrant sentiment has long distorted health policy. That was the case during the summer of 2009, when opponents of what became the ACA rallied in town hall meetings charging that President Obama wanted to provide coverage to undocumented immigrants. When Obama pledged to a joint session of Congress that undocumented immigrants would not be covered by his plan, Rep. Joe Wilson of South Carolina shouted out “You lie.”
The ACA in fact does not cover undocumented immigrants, including those who are permitted to stay under the deferred action for childhood arrivals program (DACA). But it does permit all lawfully present immigrants to purchase insurance on the exchanges. Some of these immigrants, including international students and others with short-term visas, are not “qualified” to receive most federally-funded health benefits under the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), which was enacted during another period of intense anti-immigrant sentiment. In that sense, the ACA liberalized immigrants’ access to health insurance.
Like the American Health Care Act that the House passed in May, BCRA would prevent immigrants who are lawfully present, but not “qualified” under PRWORA to receive premium tax credits on the exchanges. But BCRA goes even further by altering the verification provisions to require non-citizens to show that they are qualified as defined by PRWORA. This will likely have the effect of keeping non-qualified immigrants from buying insurance, even if they can afford to do so without receiving a subsidy. As a policy matter, this makes no sense. Immigrants as a group are younger and healthier than the native-born population. As noted above, the class of immigrants who are lawfully present but not qualified includes many students, who are especially likely to be young and healthy. From an insurance perspective these are exactly the sort of people you’d want to have participating in the exchanges, especially if they don’t require a subsidy.
As a political statement, to the long-time foes of the ACA, however, BRCA’s immigration provisions make perfect sense. They placate the activists who focused on immigration in opposing the ACA.
Of course in a bill that would cause tens of millions to lose comprehensive coverage, BCRA’s immigration provisions may seem relatively minor. But its placement on page 2 reveals an important point: the politics of resentment continue to distort health policy.