• Repost: A pickle for conservative states refusing the Medicaid expansion

    Every once in a while, I get asked a question which I’ve already answered. Sometimes, I want to respond in a post. But it seems silly to write a new post when I’ve already done the work. I’m not paid for this, and I don’t care if someone accuses me of plagiarizing myself on my own blog. Still, let me make this clear: this is a recycled post.

    We all know that illegal immigrants are totally excluded from the ACA. But what about legal immigrants? They do better than you might think. Read on:

    From by the AP:

    Governors who reject health insurance for the poor under the federal health care overhaul could wind up in a politically awkward position on immigration: A quirk in the law means some U.S. citizens would be forced to go without coverage, while legal immigrants residing in the same state could still get it.

    It’s an unintended consequence of how last year’s Supreme Court decision changed the Medicaid provisions of President Barack Obama’s health care law.

    Here’s what happened.

    The ACA covers most Americans making less than 138% of the poverty line through the Medicaid expansion. Because everyone thought the expansion would happen nationwide, they only wrote in subsidies for people making more than 100% of the poverty line. No one thought there would be a need for subsidies for people at the lowest earning levels because they would get Medicaid. Now there’s a problem – people making too little in states that refuse the expansion may not get subsidies, and therefore they may not be able to get insurance in the exchanges. They’ll be uninsured.

    Things are different for legal immigrants*, though. Under current Medicaid regulations, they have to live in the country for five years before they can qualify for Mediaid. The ACA did not change that policy, even though people tried to alter it. So immigrants still won’t be able to get Medicaid for five years, even in the future. In order to make sure that all legal citizens were covered, the ACA instead provides subsidies for legal immigrants to go get inurance in the exchanges, no matter how little they make.

    So we’re going to have a potential situation next year where poor non-immigrants will get nothing in states that refuse the Medicaid expansion, but poor immigrants will get subsidies to buy private insurance in the exchanges. This is most likely to occur in conservative states, which are refusing the expansion. It’s hard to see this playing out well politically for them.


    *Undocumented immigrants will still be unable to get insurance through the exchanges or Medicaid at all. This applies only to legal immigrants.

    • Though there has been some conflicting information from HHS on this, I don’t think this is quite accurate.

      The ACA allows PTCs for immigrants below 100% FPL who have not been in the country for 5 years if they are “not eligible for the medicaid program . . . by reason of such alien status.” This is a “but for” test. So if an immigrant has been in the country less than 5 years but meets all other categorical and income requirements for a state Medicaid program, they can get PTCs. Thus, a 10-year-old citizen at 95% would be eligible for Medicaid. A 10-year-old immigrant in the country for 2 years would be eligible for PTCs.

      If, on the other hand, an immigrant of less than 5 years does not meet all other categorical and income requirements (in a non-expansion state, for example, a childless adult at 95% FPL), they are not eligible for PTCs. Such immigrants in non-expansion states are ineligible not only because of immigration status, but also because they do not meet other categorical and income requirements. I don’t think there isn’t a situation in which immigrants would get PTCs while citizens with the same income and categorical characteristics would get nothing.

    • I agree this is unlikely to be a popular situation. But doesn’t it seem more likely that in these conservative states this will be taken as yet another reason to oppose the ACA?

      It would seem conservatives could have two reactions:

      1. We should expand Medicaid so that citizens receive the same benefits as do legal immigrants.


      2. We should repeal the ACA so the federal government stops giving subsidies to legal immigrants.

      I suspect conservatives are more likely to chose option 2.