O’Neill Institute for National and Global Health LawO’Neill Institute for National and Global Health LawLegal Issues in Health Reform

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Immigrants and Reform: An Interview with Kara Ryan, the National Council of La Raza

Kara Ryan is a research analyst at the Health Policy Project of the National Council of La Raza. The O’Neill Institute’s Lester Feder spoke with her on March 22.

Kara Ryan: We were excited for the House to pass the health reform bill last night.

Lester Feder: Well, let me ask you about that, because I thought NCLR came out opposing the bill right before the vote.

Kara Ryan: We didn’t actually oppose it, though it got reported that way. The point that we were trying to make is that we weren’t going to be able to support the bill if there were no changes made from the Senate version. So what the House did last night was to pass the bill, but also the reconciliation bill. The reconciliation language came out with a number of important changes that we thought on balance made a lot of sense to support the bill.

Lester Feder: So overall, what does the passage of the legislation mean for Latinos?

Kara Ryan: We are happy that the health care reform bill builds on the current employer-sponsored system, we know that that’s how a lot of immigrant families are able to access coverage, and we’re very happy to see that it expands the Medicaid program to everyone living under 133% of poverty, which includes legal immigrants who have had qualified status for at least five years. (There could be cases in which a legal immigrant has been present for more than five years, but became categorized as a “qualified” immigrant for fewer than five years.) And of course it creates the new health insurance marketplace in the form of these state-based exchanges, and it includes a lot of important consumer and patient protections. And legal immigrants can actually access the affordability tax credits, without any sort of waiting period for purchasing coverage in the exchange.

One of the things that the bill did was make a very large investment in community health centers. Community health centers are already on the front lines serving folks that are uninsured, having very little access to care. Many of them are immigrants, many of them are undocumented. And they’re already doing a great job at providing family-centered, high quality care. However, I don’t think that makes up for the fact that these populations were excluded from access to coverage.

Lester Feder: So what were the changes in the reconciliation bill that were so important to you?

Kara Ryan: One of the major things is that previously, Puerto Rico residents were not able to participate in the exchange, and the reconciliation language fixed that. The reconciliation language also provides a major boost to their Medicaid program in Puerto Rico, which had previously been capped and the island would not have the ability to draw down on the federal funds to implement that extension. There were also some small fixes in legal immigrant affordability. It also removed a penalty for the very poorest legal immigrants who are unable to buy coverage.

Lester Feder: You didn’t mention some of the provisions that were of concern to a lot of advocates, such as barring undocumented immigrants from using their own money to purchase insurance and the five-year waiting period for legal immigrants to be able to participate in Medicaid. What is the status of those, and how do you feel about them?

Kara Ryan: Unfortunately, those were not fixed in the reconciliation language, and we continue to have great concerns about how undocumented and legal immigrants subject to the bar will be able to access coverage. However, we received some assurances from the administration that we’re going to work on connecting folks with coverage and care in the implementation phase.

The bill doesn’t make any changes to state programs that are already covering legal immigrants inside that waiting period, with state-only money.  The problem with that, though, is that when state budgets are tight—as we’ve seen in California and Massachusetts—legal immigrants’ coverage is first on the chopping block. So while those programs can be maintained with state-only money, it would have been a much better situation if the five-year bar had been removed and states were able to draw down on federal funds to cover those populations.

Lester Feder: Are legal immigrants subject to the mandate, once it kicks in? And are they subject to the mandate before they are eligible for participation in Medicaid?

Kara Ryan: Yes they are. In the reconciliation language that was passed by the House and not yet passed by the Senate, there were a couple of fixes for very poor immigrants, who would be subject to the mandate, but they are no longer subject to penalties.

Lester Feder: The CBO estimates that some eight percent of US residents will remain uninsured. Do we know what portion are likely to be immigrants? Do we know how many of those are undocumented folks, and how many of those will be legal immigrants who are just not yet eligible for Medicaid?

Kara Ryan: We haven’t actually been able to do those calculations yet. But if you look at all of the barriers that have been put in place—such as the prohibition and the exchange for undocumented folks—if you look at not lifting the five-year bar it is reasonable to assume that a lot of the folks that are uninsured at the end of the day will be composed of non-citizens.

We’re also concerned that one of the things that the legislators did, in order to make doubly sure that undocumented immigrants wouldn’t be able to access the exchange or the subsidies, was to require several layers of verification. That’s verifying your citizenship, legal status, and your identity. We have seen when, for example, documentation requirements were imposed on the Medicaid and CHIP programs, that it ends up impacting citizens and legal immigrants especially. It prevents folks from getting enrolled, it creates delays, and—while costing states a lot of money to implement—and really not finding very many ineligible people receiving benefits. A GAO study said that they only found eight people receiving benefits who shouldn’t be in all the states they researched.

Lester Feder: Eight?

Kara Ryan: Eight.

The Brennan Center for Justice did a study a couple of years ago about how many working age adults had the ready availability of some of these documents that were required. Folks who were especially affected were elderly folks, particularly in the black community, who may not have access to their original birth certificates. Very few working age women—I think about half—have access to their original birth certificate with their current name, and then children, of course.

Lester Feder: So, once everything is in place, will the uninsured primarily be immigrants? Do we know how heavily immigrant that pool will be?

Kara Ryan: I don’t actually know, but if you look at all of the barriers that have been put in place—such as the prohibition in the exchange for undocumented folks and not lifting the five-year bar—it is reasonable to assume that a lot of the folks that are uninsured at the end of the day will be composed of non-citizens. Since obviously coverage is very important in access to care, at the end of the day what we’re really concerned about is people being able to access care.

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