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With infrastructure negotiations in Congress continuing into the fall, health care policies that eliminate barriers to affordable health care need to be prioritized for inclusion in the upcoming reconciliation package. State advocates have an opportunity to push their members of congress to commit to the elimination of arbitrary barriers to health care, including for immigrant communities.
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) limited certain immigrants, including lawful permanent residents (LPR/Green Card Holder), access to federally funded benefits by establishing a five-year waiting period, also known as the five-year bar. Our new issue brief on the five-year bar explores its impact on immigrant communities and potential solutions. The bar prohibits them from enrolling into programs like Medicaid, the Children's Health Insurance Program (CHIP) and Supplemental Nutrition Assistance Program (SNAP) during the first five years of their lawful status while residing in the U.S. Furthermore, PRWORA and the Affordable Care Act of 2010 explicitly excluded undocumented immigrants from all federally funded programs and from accessing health care coverage through Medicaid, Medicare, the Children’s Health Insurance Program (CHIP) and the ACA Marketplace.
Both undocumented immigrants and those immigrants subject to the five-year bar have few options for health insurance, which often results in delay of vitally needed care. They may access health care through community health centers that offer services at a sliding-scale fee or, for LPR’s, through the ACA Marketplace. However, these routes present challenges such as limited services available and long wait times at community health centers, as well as high out-of-pocket costs associated with private health insurance, which are particularly difficult on immigrants and their families with low or moderate incomes.
As a result, non-citizens are more likely to be uninsured compared to U.S. citizens. In 2019, lawfully present non-elderly immigrants were estimated to have an uninsured rate of 25%, non-elderly undocumented immigrants an estimated uninsured rate of 46%, while non-elderly citizens had an uninsured rate of only 9%. To put this into perspective, noncitizen immigrants account for 7% of the U.S. population, but account for nearly a quarter of the entire non-elderly uninsured population in the United States.
Congress has an opportunity to eliminate the five-year bar and undocumented communities' exclusion in the highly anticipated infrastructure package by including the Health Equity and Access under the Law for Immigrant Families Act (HEAL Act) and the Lifting Immigrant Families Through Benefits Access Restoration Act (LIFT the BAR Act).
The HEAL Act would:
- Ensure all authorized immigrants who are otherwise eligible can enroll for Medicaid and CHIP and eliminate the five-year bar.
- Allow everyone regardless of status to purchase coverage through the ACA Marketplace if they meet the income requirements.
- Ensure Deferred Action for Childhood Arrivals (DACA) recipients and any future deferred action recipients can enroll in Medicaid and CHIP.
- Eliminate states’ ability to further restrict Medicaid eligibility for immigrant communities.
The LIFT the BAR Act would:
- Eliminate the five-year waiting period for all qualified immigrants for all federally funded public benefits programs, including Medicaid, CHIP, SNAP, TANF and SSI.
- Ensure all lawfully present immigrants are considered “qualified” immigrants for the purpose of federally funded benefit programs eligibility.
In addition to including both these pieces of legislation in the next reconciliation package, Congress must also consider the impacts of the Trump administration's proposed public charge rule. The package should include funding for state and local governments to increase their capacities to educate eligible immigrants about Medicaid coverage, SNAP, TANF and other similar benefits, similar to a recently-released recommendation from the Centers for Medicare and Medicaid Services, for successful implementation.
What States Can Do Now to Improve Access to Health Care for Immigrants
While the HEAL Act and LIFT the Bar Act await action in Congress, states can implement less restrictive eligibility requirements for Medicaid and CHIP for lawfully present children and/or pregnant people by adopting the Immigrant Children’s Health Insurance Program Reauthorization Act (CHIPRA) option. Presently, 35 states have eliminated the five-year bar for lawfully residing immigrant children for Medicaid and CHIP coverage and twenty-five states have eliminated the five-year bar for lawfully-residing pregnant immigrants to provide prenatal care and postnatal care up to 60 days or 12 months postpartum. State-only funds have also been used to create substitutes for SNAP and TANF benefits and to expand access to healthcare for immigrant communities. Illinois provides coverage to noncitizen older adults, 65 years and older, through a Medicaid-like program paid entirely by state funds.
Though many states have taken steps to improve immigrants' access to health care, a federal approach would guarantee consistency across all states, as well as timely access to services and safety nets among immigrant communities.
Congress must include the HEAL Act for Immigrant Families and LIFT the BAR Act in the next reconciliation package. Combined, both policies would improve access to affordable health care for lawfully present immigrants who fall within the five-year waiting period and for undocumented communities as we continue to look forward to recovering from the COVID-19 pandemic.