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The Senate Immigration Bill’s Impact on Health Care

  • Leighton Ku

    Director, Center for Health Policy Research, Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University

  • Leighton Ku

    Director, Center for Health Policy Research, Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University

In late June, the U.S. Senate passed the Border Security, Economic Opportunity, and Immigration Modernization Act. The bill seeks to balance three policy priorities: 1) increasing legal immigration to meet America’s labor needs, 2) developing a pathway to citizenship for unauthorized immigrants, and 3) toughening border security to reduce entry of unauthorized immigrants. Improving immigrants’ access to health care is not one of its priorities.

Although the Senate approved the bill with a strong 68–32 bipartisan vote, its future is uncertain because of resistance in the House of Representatives. If passed, a comprehensive immigration reform law could have important benefits, but seems unlikely to lead to major improvements in immigrants’ health coverage or access.

New Legal Immigrants. The bill restructures rules for lawful permanent residency (LPR) and temporary work visas, particularly for highly skilled immigrants. The Congressional Budget Office estimates that these changes would increase the U.S. population by 10 million, including U.S.-born children of immigrants, by 2023. (Changes in unauthorized immigrants’ status would have no effect, since they already reside here.)

Under the Affordable Care Act, the new legal immigrants would be subject to the individual requirement to have insurance or pay a tax penalty, and would qualify for subsidies to buy insurance in the state health insurance marketplaces, or exchanges. (They generally would not qualify for Medicaid until five years after attaining LPR status.) Many would be highly skilled immigrants who could readily obtain employer-sponsored insurance.

Pathway to Citizenship. Millions of unauthorized immigrants already in the United States could apply for provisional legal status. After many years, these provisional immigrants could be eligible for lawful permanent residency and eventual citizenship. Three pathways to citizenship would be created:

  1. Registered Provisional Immigrants. This would be the major pathway, through which unauthorized individuals could apply for provisional status if they pay fees and meet stringent employment and other criteria. After at least 10 years, they could apply for permanent residency. After another three years, they could apply for citizenship.
  2. DREAMers. Unauthorized individuals who entered the United States as children could apply for provisional status and become lawful permanent residents or citizens if they enlist in the military or if they meet educational requirements.1
  3. Blue Card Agricultural Workers. Unauthorized agricultural workers could apply for a “blue card” that grants provisional status. They could apply for permanent residency after five years.

From the beginning, both Democrats and Republicans agreed that provisional immigrants on the pathway to citizenship should be ineligible for Affordable Care Act (ACA) premium assistance or cost-sharing subsidies through the marketplaces. Permitting these benefits would have increased the bill’s budgetary cost greatly and engendered great political controversy. Provisional immigrants would be exempt from the individual mandate to have insurance or pay a tax penalty. They would be permitted to purchase insurance in the marketplaces. However, since they would not receive federal subsidies, most of them would still not be able to afford coverage.

After attaining permanent residency, provisional immigrants would be eligible for ACA health subsidies. Five years afterward, they could become eligible for Medicaid if their incomes are low enough. (Some states permit Medicaid eligibility for pregnant women or children without a five-year waiting period.) The net result of these barriers is that immigrants with provisional status will continue to have high uninsurance levels and limited access to health services.

Effects on Insurance Coverage. Because of the individual mandate, most of the new legal immigrants should have private insurance coverage, sometimes with ACA subsidies. The provisional-status immigrants will largely be barred from publicly subsidized insurance. But employer-sponsored coverage might increase slightly for provisional immigrants. Recent data indicate about 29 percent of unauthorized adults already have private insurance. Gaining legal status should help immigrants get better jobs, ones that include job-based coverage. Following the 1986 passage of the Immigration Control and Reform Act, during the Reagan Administration, legalization of unauthorized immigrants led to higher earnings, more job benefits (such as insurance coverage), and reduced mortality rates among this group. Still, the overall rates of insurance coverage among immigrants would likely change only slightly.

Implications for the U.S. Health System. Because so many provisional immigrants will be uninsured, they will continue to rely on safety-net health care facilities. But, while the ACA boosted funding for health centers, those extra funds sunset after 2015. Many safety-net hospitals worry about the impacts of scheduled reductions in Medicaid Disproportionate Share Hospital payments, which help to cover the costs of caring for uninsured patients. The continued presence of a strong safety-net system will remain critical for all uninsured people, whether they are native- or foreign-born.

The Senate bill also would increase the number of immigrant physicians, nurses, and other health professionals who are able to work in the United States, particularly if they practice in underserved areas. Many immigrants would be able to work as medical aides, home health workers, or long-term care staff to help meet the health needs of an aging population. This could ease workforce shortages.

Since immigration reform would increase the number of immigrants in the United States, it would result in a greater need for language assistance in health care. Immigrants, particularly newcomers, often have limited English proficiency. While federal policy already calls on health care providers to offer free language assistance to those with limited English proficiency, language barriers would continue to be a serious problem.

If enacted, a comprehensive immigration reform bill could significantly enhance civil rights and economic opportunities and bolster the overall economy. But it would probably not mitigate the large disparities in access to care that now exist for noncitizen immigrants, compared with the native-born.

For more information, visit the website of The George Washington University.  

 1"DREAMers" refers to the DREAM Act, which stands for the Development, Relief and Education for Alien Minors Act.

Publication Details



L. Ku, The Senate Immigration Bill's Impact on Health Care, The Commonwealth Fund, August 2013.