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The Senate bill would make it impossible for some immigrants to get health insurance

Including some legal immigrants.

Open Enrollment Kicks Off For Affordable Care Act Coverage Photo by Chris Schneider/Getty Images

The Senate’s healthcare bill, the Better Care Reconciliation Act — a new version of which was released Thursday, in an attempt to assuage some Republican members’ concerns — would probably make health insurance unaffordable for many Americans if it became law. But for some legal immigrants, it would make health insurance impossible to buy, period.

The Senate bill targets certain legal immigrants (including work and student visa holders, and people currently applying for green cards) who aren’t eligible for most public benefits programs but who are included in the Affordable Care Act. Like its counterpart in the House, the American Health Care Act, the Senate bill keeps those immigrants from being able to get tax subsidies to offset the cost of purchasing insurance.

But it goes even further than the House bill, preventing them from being able to buy insurance on state Obamacare exchanges entirely. (Senate Republicans made some substantial changes to the bill before rereleasing it on Thursday, but they didn’t walk back the restrictions on immigrant eligibility.)

Since there are parts of the US where health insurance is only available through the exchanges, that means some legal immigrants will find it impossible to buy insurance altogether. And many more will find that insurance has been placed miles out of reach.

Most public benefits are only available to certain legal immigrants. But Obamacare was an exception.

Despite the persistent myth of immigrants coming to the US to take welfare benefits, immigrants’ eligibility for most public benefits in the US is pretty strictly limited. Under the 1996 welfare reform law, most public benefits programs (including Medicaid as well as food stamps, TANF, etc.) were restricted to only certain kinds of legal immigrants.

Lawful permanent residents (green card holders) as well as refugees, asylees, and some other immigrants who were in the US for humanitarian purposes were deemed “qualified aliens” for the purposes of these benefits. People who were in the US on non-immigrant visas (like work or student visas), or who were in the process of applying for asylum, a visa, or a green card (a process that can often take a while), weren’t. Furthermore, even “qualified aliens” had to wait at least five years before they’d be able to actually access the public benefits their immigration status “qualified” them for.

The Affordable Care Act took a different approach. It made everyone who was “lawfully present” in the United States — including everyone in the US here legally, as well as certain people whose legal status was still being determined or who’d been granted permission to stay — subject to the individual mandate to buy health insurance. But to help them do that, the ACA allowed all “lawfully present” immigrants to purchase insurance on the exchanges, and to qualify for tax subsidies to help them afford the insurance they purchased. (As a rule, none of this applied to unauthorized immigrants — even those who got protections from deportation under Obama’s 2012 DACA program weren’t eligible to buy insurance on the exchanges or get coverage subsidies.)

The Senate health care bill doesn’t change any of this directly, according to Matthew Lopas of the National Immigration Law Center (an advocacy group). Instead, he says, “they appear to have adjusted all the verification sections of the bill” — in other words, when checking whether someone is eligible to buy insurance on the exchanges or qualify for tax credits, agencies can only verify eligibility of immigrants who meet the more restrictive 1996 standard. “If this were to be law and carried out in the way that it’s described in the text,” Lopas says, “it would end up creating an eligibility standard based on this different verification standard.”

Immigrants who are lawfully present, but not “qualified” under the 1996 law, would be cut out.

The Senate health care bill still makes access to the exchanges (and subsidies) available to some immigrants who don’t qualify for other public benefits. While it limits benefits to “qualified aliens,” it doesn’t include the 1996 law’s requirement that they be in the US for five years before receiving benefits.

Ironically, in a campaign rally Wednesday night, President Trump promised that he would pass a new law that would bar “welfare” from immigrants until they’d been in the US for five years. The Senate health care bill, meanwhile, takes one of the few “welfare” programs that didn’t already meet that standard and changes it to a standard that still would allow qualified immigrants to get public benefits before the five-year mark.

It’s not clear how many immigrants would be affected — but many of those affected would end up unable to buy insurance at all

It’s not clear how many people this would affect — there aren’t any estimates of how many people in the US count as “qualified aliens” under the 1996 law, and how many noncitizens participate in the exchanges.

What we do know, however, is that the Affordable Care Act had a big impact on the uninsured rate among noncitizens of the US: It declined by a quarter between 2013 and 2015. Some of this was for the same reasons that the ACA expanded health insurance coverage for America as a whole: Tax subsidies made it possible for people who hadn’t been able to afford insurance to do so, and the mandate forced people who didn’t want insurance to buy it anyway.

But “lawfully present” immigrants who didn’t count as “qualified” under the 1996 law may have seen a particular benefit. They aren’t eligible for Medicaid, no matter their income (even in states that agreed to expand Medicaid eligibility under the ACA). So the tax subsidies under the ACA benefited some immigrants whose income was even lower than the citizens it helped.

Now, those immigrants still aren’t eligible for Medicaid. But they aren’t eligible for the subsidies either. Neither are “nonqualified” immigrants whose income is above the Medicaid line — and many of those probably qualify for subsidies right now, too. The Kaiser Family Foundation calculates that 84 percent of participants in the ACA marketplace receive tax credits. While there’s no separate data on noncitizens (much less legally present but not “qualified” immigrants), Lopas of NILC says, “I wouldn’t have reason to believe that fewer immigrant folks who enroll on the marketplace receive subsidies.”

Being barred from participation in the exchanges entirely, meanwhile, reduces their options for affordable coverage even further. And for some immigrants — those who live in Washington, DC, for example, where there’s no access to health insurance outside the exchanges — there will simply be no way to buy health insurance at all.