Paige Winfield Cunningham | The Washington Post | 10/10/2019
WASHINGTON - President Donald Trump repealed Obamacare's penalty for lacking health coverage. Now he's reinstating a coverage requirement for immigrants seeking to enter the United States - yet refusing to let them access Obamacare's benefits.
Under the president's latest tightening of immigration rules, people seeking visas to enter the United States will have to prove to consular officers that they either have health insurance or are wealthy enough to cover their own medical costs. The White House issued the proclamation Friday evening, in a statement that blasted uninsured immigrants with burdening the country's hospital system.
"Immigrants who enter this country should not further saddle our health care system, and subsequently American taxpayers, with higher costs," the proclamation says.
It would be one thing if these immigrants could meet the requirement by enrolling in the Medicaid program or use federal subsidies to buy private plans in the Affordable Care Act's marketplaces. Those are the main tools available to lower-income Americans to help them afford coverage.
But most of them can't.
While legal immigrants may buy subsidized private plans on the ACA marketplaces, the Trump administration won't count such coverage as fulfilling its new requirement. Only unsubsidized plans will count. That means someone making as little as $16,000 a year would have to show they can cover the entire cost of a plan on their own to gain admittance to the United States, even though as a citizen they'd be eligible for sizable subsidies.
The situation is even bleaker for applicants who earn below 133 percent of the federal poverty level - the threshold in most states to qualify for Medicaid. Most adult immigrants in the country legally, except for refugees, asylum seekers and pregnant women, are barred from enrolling until they've been in the country for at least five years. So that's also out of the picture for immigrants trying to obtain health coverage under this new proclamation.
The administration has characterized this move - and other crackdowns on immigrants - as a way to ensure that only people who are financially self-sufficient can enter the United States. But to critics of Trump's immigration policies, it's yet another way to discourage immigration by poorer people while favoring the wealthy.
"This is consistent with past efforts to remake the composition of immigrants in this country," said Steven Lopez, associate director of health policy for the immigrant advocacy group UnidosUS. "To move toward a more merit-based system, between those who are deemed desirable and contributors to the United States, and those characterized as taking from this country."
Requiring people to buy health coverage isn't a new idea, by any means. In fact, the Democrats and liberals who are criticizing Trump's new requirement for immigrants to be covered also protested when he signed a 2017 law effectively removing just such a mandate for the American public.
Health care advocates have long argued that having everyone - not just sick people who prove expensive for insurance companies - buy in to the insurance system is key to making health care affordable for everyone. Generally speaking, it's a good thing for immigrants to have health insurance, to ensure they can access needed medical services and to protect them from heavy debt should an emergency arise. And in the long run, having insurance means less health care spending.
And even though legal immigrants can't access ACA subsidies or Medicaid, there may be some more-affordable insurance options available to them. Visa applicants could find a job with employer-sponsored coverage. They could also join the family plan of a spouse or family member already in the country. Or they could purchase either "catastrophic" plans (that protect only from the steepest medical costs) or leaner but cheaper short-term plans recently expanded by the Trump administration.
Supporters of Trump's proclamation pointed me to those options, arguing that even without public assistance, immigrants should be able to afford at least bare-bones insurance coverage to meet the new requirement.
"Although we'll need to see more details, it appears that only the most destitute applicants will be barred due to the new policy," said Steven Camarota, director of research for the Center for Immigration Studies, a group that advocates reduced immigration.
But the administration's strategy on the issue - releasing a proclamation - is highly unusual. It could have included the requirement to have coverage in a set of controversial revisions to the "public charge rule" set to take effect next week (we explained the public charge rule here). Immigrant advocates say they're frustrated the new requirement was issued via proclamation - which means the public had no chance to weigh in.
"Even for this administration, it's a shocking bypassing of legal procedures in order to change immigration law," said Jackie Vimo, a policy analyst for the National Immigration Law Center.
Here's another odd thing about the president's move. Trump had long railed against the individual mandate, calling it "the absolute worst part of Obamacare." Yet in his proclamation, the president levied the same arguments used by ACA advocates to promote such a mandate, saying the uninsured burden the country's health care system by obtaining care they can't pay for and thereby raising costs for everyone else.
"While our health care system grapples with the challenges caused by uncompensated care, the United States Government is making the problem worse by admitting thousands of aliens who have not demonstrated any ability to pay for their health care costs," the proclamation says.