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Excluding People from the Health Care Exchange


Why Excluding People from the Health Care Exchange Is Impractical and Harmful to All of Us                                 

September 2009

It’s not about the policy, but the politics.

  • Democrats were right to reject earlier Republican amendments that would have cut out eligible Americans in order to score political points. Rather than cave in to people who insult the president and are unlikely to support comprehensive health care reform, Democrats should stay strong in defending a principled proposal.

  • The opposition is using immigration to rile up their base, which is a small minority of the population. As before, they continue to use immigration as a wedge issue to divide and conquer, and prevent real reform. Democrats finally have the chance to call them on it.

  • The GOP lost seats using anti-immigrant tactics. Democrats are equally vulnerable and should be more responsive to voters who represent our nation’s diversity and demonstrate common sense.

  • Our health care dollars should be spent on affordable health care, not wasteful bureaucracies or burdensome paperwork requirements. It is irresponsible to continue denying health coverage to Americans by creating new hoops to jump through to get health care.

  • Proponents of health care reform should call out opponents for using immigration to try to derail health care reform. Immigration will be dealt with next year in immigration reform. This is not a debate over immigration, and we will not allow our efforts to reform the health care system to be derailed.

  • Americans need access to affordable health care now. Many American families are one illness or accident away from bankruptcy. Let’s stop creating ways to keep people from getting the affordable health care they so desperately need and give them the health care they need right now.

We need more people paying into the Exchange, to make health care reform work for everyone.

  • As evidenced by the individual mandate, the U.S. needs more people, even young and healthy individuals such as immigrants, paying their fair share and buying insurance so they don’t remain uninsured.

  • Opponents want to prevent people from contributing and helping to pay into our health care system. We need more people, not fewer, paying to fix health care in the U.S. If we stop people from paying into the system, down the road it will be more costly for all of us.

  • Leaving undocumented immigrants out of the Exchange only forces them into the emergency room for care and adds to the uncompensated care costs, preventing us from solving the “hidden tax” problem that we all are paying for now.

  • An American solution — one that is practical and that affords equal opportunity — should allow anyone who is willing and able to share in the responsibility of health care reform to pay his or her fair share and purchase affordable health coverage.

  • Immigrants as a group are healthier and younger than the general population. Their addition to the pool will help spread the costs as well as the risks.[1]

  • Immigrants, in general, use less health care than citizens.[2] Why not let them pay for care they may or may not need?

  • Excluding or screening out people from buying health insurance defies the basic principles of the free market and is completely un-American.

Screening out immigrants will harm citizens.

  • The majority of people who would purchase health insurance through the Exchange are citizens and legal immigrants. Because undocumented immigrants are barred from subsidies, only some would be able to afford health insurance at full cost. Trying to keep a few undocumented immigrants from paying for health insurance will actually keep millions of eligible citizens out of affordable health care.

  • Taxpayer dollars should not be spent on complex verification schemes aimed solely at appeasing groups that are unlikely to support real health care reform.[3]

  • The wrong verification scheme will only create administrative barriers and keep citizens from getting health care they need when they need it.[4]

    • We already have wasted millions of dollars of taxpayer money on documentation rules that prevented thousands of eligible citizen children from getting Medicaid. These barriers compromised the health of citizens by delaying and denying access to health care.[5]

    • Congress reviewed six state Medicaid programs in 2007 and found that verification rules had cost the federal government an additional $8.3 million. They caught exactly eight undocumented immigrants.[6]

  • The 11-13 million U.S. citizens who lack birth certificates, passports, and driver’s licenses to prove their citizenship will face barriers in purchasing health insurance if the wrong verification system is put in place.[7]

    • In particular, many U.S.-born citizens who are elderly and/or African American, as well as certain young people, do not have ready access to proof of their identity or birth.[8]

  • In response to the anti-immigrant attacks, Congress should require the secretary of Health and Human Services and/or other federal agencies to take the time to develop the most effective, cost-efficient verification method for enrolling people in health insurance and getting them subsidies without creating harmful and unnecessary barriers for the majority of Americans.

Health care reform cannot fix the immigration system.

  • We can’t fix the immigration system through health care reform. All Americans, including immigrants, need better access to health care. Preventing immigrants from paying their fair share will only make our nation weaker, less healthy, and less secure.

  • Undocumented immigrants will still need health care — before and after immigration reform.  We need to address the reality and provide reasonable solutions.

  • No one gets free care in the U.S.  By forcing people who don’t have the ability to buy insurance into the hospital emergency rooms for primary care, we will end up subsidizing health care for undocumented immigrants by continuing to pay higher health care costs.

America’s families include immigrants.

Excluding them will harm everyone. 

  • Everyone should be allowed to buy health insurance through the Exchange, including undocumented immigrants who are part of our families and communities. 

  • Undocumented immigrants live with family members, including children, who are citizens and legal immigrants.  Attempts to exclude the undocumented from buying health insurance will prevent eligible individuals from getting affordable health care. 

  • Costly verification or documentation requirements will divide our families and keep eligible Americans from receiving care.  We need to remove, not add, obstacles that will stand in the way of quality, affordable health care for everyone. 

  • Mixed status families — in which one or more family member is undocumented and others are citizens or legal immigrants — are a reality in the U.S., and they live in all 50 states:[9]

    • The great majority of immigrant families have children who are U.S. citizens.

    • In 2007, about 16.4 million children, or more than one in five children in the U.S., had at least one immigrant parent.

    • Almost a third of children of immigrants live in mixed-status families in which the children are U.S. citizens but their parents are noncitizens.

    • The youngest children are the most likely to have immigrant parents:  24 percent of children ages 0 to 5 have immigrant parents versus 21 percent of children ages 6 to 17.


1 Sharing the Costs, Sharing the Benefits: Inclusion Is the Best Medicine (Immigrant Policy Center, July 22, 2009).
2 Id.;  Leighton Ku, “Health Insurance Coverage and Medical Expenditures of Immigrants and Native-Born Citizens in the United States,” American Journal of Public Health, July 2009.
3 Medicaid: States Reported That Citizenship Documentation Requirement Resulted in Enrollment Declines for Eligible Citizens and Posed Administrative Burdens (U.S. Govt. Accountability Office, GAO-07-889, June 2007), (hereinafter “GAO-07-889”);  “Highlights of GAO-07-889” (GAO, June 2007);  Majority Staff, Committee on Oversight and Government Reform, Summary of GAO and Staff Findings: Medicaid Citizenship Documentation Requirements Deny Coverage to Citizens and Cost Taxpayers Millions, July 24, 2007.
4 Donna Cohen Ross, New Medicaid Citizenship Documentation Requirement is Taking a Toll: States Report Enrollment Is Down and Administrative Costs Are Up (Center on Budget and Policy Priorities, Mar. 13, 2007).
5 GAO-07-889, supra note 2;  Donna Cohen Ross, Medicaid Documentation Requirement Disproportionately Harms Non-Hispanics, New State Data Show: Rule Mostly Hurts U.S. Citizen Children, Not Undocumented Immigrants (Center on Budget and Policy Priorities, July 10, 2007).
6 “Highlights of GAO-07-889,” supra note 2.
7 GAO-07-889, supra note 2.
8 See, e.g., Leighton Ku, Donna Cohen Ross, and Matt Broaddus, Survey Indicates Deficit Reduction Act Jeopardizes Medicaid Coverage for 3 to 5 Million U.S. Citizens (Center on Budget and Policy Priorities, Feb. 17, 2006).
9 Jeffrey S. Passel and D’Vera Cohn, A Portrait of Unauthorized Immigrants in the United States (Pew Hispanic Center, April 14, 2009);  Karina Fortuny, Randolph Capps, Margaret Simms, Ajay Chaudry, Children of Immigrants: National and State Characteristics (Urban Institute, May 13, 2009, updated in Aug. 2009).  For additional data about immigrants, see Kara Ryan, Fast Facts: Immigrants and Health Coverage (a PowerPoint presentation) (National Council of La Raza, Aug.12, 2009).


Sonal Ambegaokar, Health Policy Attorney | | 213.639.3900 x. 114