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How Health Reform Bills Would – And Wouldn’t – Affect Illegal Immigrants

As lawmakers continue to shape a health care overhaul bill to increase the number of Americans with insurance while driving down costs, one group is being deliberately barred from receiving any government benefits associated with the effort: undocumented immigrants. This brief explainer looks at some of the questions surrounding immigrants and health care in the United States. 

How many are there and what is the law now?

There are nearly 12 million illegal immigrants in the U.S. In 2007, almost 60 percent of the adults had no health insurance, more than double the proportion of uninsured adults among legal immigrants and four times the share among U.S.-born adults, according to the Pew Hispanic Center.

Undocumented immigrants are barred from Medicaid and the Children’s Health Insurance Program (CHIP) – the federal/state government programs for the poor. However, everyone – including illegal immigrants – have access to emergency room care through the 1986 Emergency Medical Treatment and Labor Act, which ensures public access to emergency health services regardless of an individual’s ability to pay.

How do undocumented immigrants get medical care now? 

Low-income immigrants — both legal and undocumented — are less likely than citizens to receive primary or preventive care, and they have lower rates of emergency room use than those of citizens, according to a 2007 policy brief by the Kaiser Family Foundation. (KHN is a program of the foundation.) But low-income non-citizens turn to health centers and clinics at a significantly higher rate than insured low-income citizens, with six in 10 relying on clinics and health centers as the place to go when they need medical help. 

Who pays for their care?

Undocumented immigrants who seek care at health centers and clinics are typically billed on a sliding scale based on their ability to pay.

If illegal immigrants cannot pay their bills, hospitals and other providers first look to the federal government and charities for help in covering their uncompensated costs. The federal government, through the Disproportional Share Hospital program, allotted about $20 billion in 2009 to help hospitals and providers cover the costs they incurred treating uninsured patients, including citizens, legal immigrants and the undocumented.

But those government funds are generally not enough to cover the costs, and hospitals raise their fees for other patients to help provide the revenues needed to treat the uninsured.

Researchers estimate the cost of all uncompensated care was roughly $56 billion in 2008, according to a recent study published in the journal Health Affairs. However, because hospitals cannot inquire whether a patient is in the country illegally, it is difficult to tease out the cost of uncompensated care attributed to illegal immigrants.

How will reform proposals affect illegal immigrants?

All of the bills specifically exclude undocumented immigrants from qualifying for Medicaid or CHIP.

Neither the House bill nor Senate Health, Education, Labor and Pensions (HELP) Committee bill restricts illegal immigrants from being eligible to purchase coverage through a health insurance “exchange” or gateway set up in the legislation. However, the House bill explicitly states that undocumented immigrants would not be eligible to receive government subsidies to buy insurance, regardless of income. The Senate Committee Bill is much tougher and bars illegal immigrants from purchasing health insurance through the exchange.

Baucus’ proposal also includes verification requirements to ensure that illegal immigrants are blocked from receiving federal subsidies or entering the exchange — an effort to quell Republican concerns that loopholes would allow illegal immigrants to benefit from receiving health insurance at a reduced rate.

The Senate and House proposals also call for reducing the federal DSH payments to hospitals for uncompensated care on the assumption that health care reform would provide insurance to more people. 

None of the bills would change the requirement that hospitals offer emergency services to all patients, including illegal immigrants.


Affordable Health Choices Act, Senate HELP Committee bill, section 171

America’s Affordable Health Choices Act House bill H.R. 3200, sections 246, 1704

America’s Healthy Future Act of 2009, Senate Finance Committee bill 

Covering The Uninsured In 2008, Health Affairs

Disproportionate Share Hospital Allotments for FY 2009, U.S. Health and Human Services

Five Basic Facts on Immigrants and Their Health Care, Kaiser Family Foundation, March 2008

Health Insurance Coverage and Access to Care for Low-Income Non-Citizen Adults, Kaiser Family Foundation, June 2007 

Immigrants’ Health Coverage and Health Reform: Key Questions and Answers, Kaiser Family Foundation, September 2009 

Medicaid Disproportionate Share Hospital Payments, National Policy Forum, June 15, 2009

Portrait of Unauthorized Immigrants, Pew Hispanic Center, 2009 

Treatment of Noncitizens in H.R. 3200, Congressional Research Service, August 2009

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