A panel of judges on the 9th Circuit Court of Appeals on Dec. 31 concluded that a 2019 presidential proclamation limiting immigrant entry on health care grounds was within the president’s statutory authority and reversed the district court’s order enjoining the proclamation’s implementation.
Although these restrictions are in President Donald Trump’s authority, researchers and experts have found multiple barriers for immigrants, both citizens and noncitizens, in accessing the U.S. health care system.
Trump issued Proclamation 9945 in October 2019 stating that a defined class of aliens — generally those lacking approved health insurance or the financial resources to pay for reasonably foreseeable medical costs — would be detrimental to the interests of the country.
The proclamation generally restricts entry of immigrant visa applicants who can’t show they’ll acquire qualifying health care coverage within 30 days of entry or don’t have the ability to pay for foreseeable expenses, according to the opinion. The proclamation also notes uninsured individuals, both citizen and noncitizen, are huge costs to health care providers and taxpayers.
Applicants need only show they would be covered by insurance within a 30-day limit, and not necessarily before entry, according to the opinion. Aliens allowed before the effective date, those under 18, those using other means than immigrant visas and several other categories are not affected by the proclamation.
While this creates new challenges for some seeking entry to the U.S., plenty of problems exist for those already here. When talking about immigration and health care, “you’re talking about two of the most complicated systems in the United States,” said Maggie Gómez, deputy director at the Center for Health Progress. She added that both systems are difficult for anyone individually, let alone combined.
For immigrants, the health care system can be a challenge, she added. Because English often isn’t the first language of immigrants, and the system is totally foreign to them, immigrants can find themselves facing challenges with language, regulations, law and literacy navigating the health care system. They may also face difficulty accessing all of the people able to help — lawyers, doctors, nurses, other professionals — and sometimes without translators, not to mention plenty of paperwork.
The proclamation provides options for showing that an applicant will have healthcare coverage ranging from employer-sponsored coverage to a family member’s plans. However, Gómez said that options for employer coverage can be scarce.
When thinking of health care and immigration from a workforce perspective, Gómez said some folks may be in rural communities working on farms or factories without a hospital close by, and often immigrants work physically demanding jobs, such as custodians, field workers or factory workers. Often, in the work immigrants perform, their employer does not offer healthcare coverage, and thus immigrants are “cut out” of health care systems.
And immigrants face obstacles obtaining healthcare coverage even after being in the U.S. for some time. While true that lawfully present immigrants can purchase health care coverage through Affordable Care Act marketplaces, receive subsidies and apply for Medicare there are limitations, according to the Kaiser Family Foundation, a nonprofit focusing on national health issues.
Generally, lawfully present immigrants have to obtain “qualified” immigration status to be eligible for Medicaid or Children’s Health Insurance Program. However, many green card holders must wait five years after obtaining qualified status before they may enroll.
“Many lawfully present immigrants who are eligible for coverage remain uninsured because immigrant families face a range of enrollment barriers, including fear, confusion about eligibility policies, difficulty navigating the enrollment process, and language and literacy challenges,” according to the KFF.
As of 2018, nearly three-quarters of uninsured lawfully present immigrants were eligible for ACA coverage, including 27% eligible for Medicaid and 47% for tax credit subsidies, according to KFF.
While lawfully present immigrants can purchase coverage through ACA marketplaces, and can receive subsidies, undocumented immigrants and Deferred Action for Childhood Arrivals cannot, according to KFF.
Uninsured undocumented immigrants are ineligible for coverage options due to their status, according to KFF. “In the absence of coverage, they remain reliant on safety net clinics and hospitals for care and often go without needed care.”
“Folks are often delaying care,” Gómez said. Both fear and confusion about the health care system can make things tricky for immigrants. The confusion can arise from difficulties with language and communication, the fear arises from the public charge rule.
According to the National Immigration Law Center, public charge is defined by U.S. Citizenship and Immigration Services as an individual who is likely to become primarily dependent on the government for subsistence.” The term describes those who cannot support themselves and depend on benefits or benefits providing cash. In turn, the NILC notes that any individual who is likely at any time to become a public charge becomes inadmissible to the U.S. and ineligible to become a lawful permanent resident.
The constantly changing waters of what is legal and illegal in terms of immigrant programs and laws can cause immigrants to fear seeking medical help, according to Gómez. This fear comes from worry that somehow their information being provided at health centers will come back to get them.
If someone is unsure how public charge records or laws or coverage will affect them, people can give up “a little bit of hope,” Gómez said. In the current pandemic world, Gómez said many discussions have taken place with undocumented immigrants about the fact they’re uninsured and concerns about the current health crisis.
And because of confusion and fear amongst immigrants, those who could qualify for health care are often suspicious of seeking both healthcare and coverage.
KFF cited changes in public charge policy allowing federal officials to consider use of certain non-cash programs, such as Medicaid for non-pregnant adults, in determination of whether or not to provide green cards or entry to the U.S. as leading to fear that “likely will lead to coverage decline.”
In fact, KFF pointed to a USCIS alert in March 2019 encouraging anyone with COVID-esque symptoms to seek medical treatment and “noted that such treatment of services will not negatively affect future public charge tests.”
For mixed families, meaning those who might be undocumented immigrants with U.S. citizen children, the children may be eligible for Medicaid, Gómez said. However, if they choose to enroll them, that now that means trying to understand the Medicaid system — and fear of what might come from it.
“And it can be really scary when you’re trying to fill out forms,” Gómez said. “It can be really scary when you’re not applying for yourself, but your child.”
—Avery Martinez