Last week, a member of the Trump administration repeated a claim that the Administration was “kicking illegal immigrants off Medicaid to protect Medicaid for AMERICANS!” This is consistent with misleading talking points that the House-passed reconciliation bill, now under consideration by the Senate, targets cuts on Medicaid spending to undocumented immigrants. But is any of this true? Does the bill go after undocumented immigrants? Let’s look at three key facts about the House bill and assess if the bill is actually an effort to reduce federal Medicaid spending on the undocumented. Spoiler alert: it’s not going to be easy to save a lot of money in Medicaid by cutting care for undocumented immigrants, since they are not eligible for traditional Medicaid, as we explained in our overview on immigrant coverage for Medicaid. But here we go.
First, the House bill clearly targets some lawfully present immigrant children and pregnant women covered by states in separate state CHIP programs under the Immigrant Child Health Improvement Act (ICHIA) option, which was established under the Children’s Health Insurance Act Reauthorization Act of 2009. The ICHIA option for separate state CHIP programs has been picked up by 21 states for children and 6 states for pregnant women. However, as we have explained, the House bill only penalizes some states, because the penalty for covering the children and pregnant women absurdly applies only to states that have expanded Medicaid. For example, Pennsylvania but not Florida, West Virginia but not Texas. The penalty, a massive reduction in Medicaid expansion funding that would require states to double their share of expansion costs, is so large that targeted states will have no choice but to drop this ICHIA CHIP coverage. But the takeaway here is: these are all lawfully present children and pregnant women – ICHIA does not cover undocumented immigrants.1
Second, the same provision in the House bill would take federal Medicaid funding away from expansion states that provide coverage to some immigrants separate and independent of Medicaid in state programs using only state dollars. These wholly state-run and funded programs are not Medicaid – which is a program run with federal funding and subject to federal requirements. Cutting off federal Medicaid funds based on what programs a state freely chooses to run would be an unprecedented and likely unconstitutional (see the NFIB case) attempt by the federal government to coerce state activity using federal Medicaid funding. In any event, any reductions to undocumented health care stemming from this policy as states drop this coverage would not lead to reductions in Medicaid coverage or federal Medicaid spending in and of itself since the coverage is entirely state-funded. Federal savings would only occur if states try to retain this state-only coverage and face the financial penalty, doubling their own spending on the Medicaid expansion. In other words, any reduced spending will be a reduction in funding states receive to care for citizens and qualified immigrants in Medicaid expansion—not the undocumented.
For those of you keeping score at home, so far we have a grand total of zero dollars of federal spending on the undocumented that has been saved.
That takes us to our third fact. There is also a provision in the bill reducing federal spending on “Reasonable Opportunity Periods” (ROP). ROPs are used to provide temporary coverage to citizens and qualified immigrants applying for Medicaid but whose citizenship or immigration status is not immediately verifiable through the comprehensive systems used by the Social Security Administration and the Department of Homeland Security. The purpose of ROPs is to ensure that citizens and qualified immigrants can get treatment, and doctors and hospitals can get paid, when immediate care is needed. Some House Republicans have argued that this coverage option is being abused, leading to improper coverage of some undocumented people. We are not aware of clear public evidence proving or disproving that this is a significant problem. But here’s what we do know: per the Congressional Budget Office’s scoring, this provision amounts to approximately one-tenth of one percent (yes, that’s 0.1%) of the savings in this bill. The other certainty is that the many citizens and qualified immigrants who we know are using ROPs would lose access to care if ROPs were eliminated. As such, even assuming that it is true that undocumented immigrants are accessing care through this provision, it’s only a fraction of the ROPs actually used. So, your takeaway here is that the dollars saved on health care for the undocumented in this provision would, at most, amount to only a fraction of 0.1% of the savings in the House bill.
Meanwhile, the only Medicaid provision that actually provides dedicated funding that benefits undocumented people—the “Emergency Medicaid” reimbursement available to hospitals and other providers that provide emergency care for immigrants—is not touched by the House bill. (For good reason—much of the spending is for labor and delivery for pregnant women.)
So, there you have it. The House bill, which would make over $860 billion in gross cuts to Medicaid, is being sold as “targeting Medicaid spending on undocumented immigrants.” But the bill, and the specific provisions highlighted by Congressional Republican leaders to support their misleading claim, is almost entirely focused on taking Medicaid coverage away from citizens and lawfully present children, families, older adults, people with disabilities, and other populations.
Notes:
- The House-passed bill would also penalize many states that provide federally funded Medicaid coverage to another group of lawfully present immigrants, known as “parolees,” even though that coverage is permitted under longstanding federal law.