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How Might Immigration Reform Affect Implementation of the Affordable Care Act?

A raging debate continues in Congress between those who want a legalization pathway for the nation’s 11.2 million undocumented workers and others who view such an approach as amnesty. Even so, there appears to be a growing consensus on a marquee issue, namely creating a guest worker program that benefits employers, according to a recent issue of Roll Call (May 13, 2013). By removing the bureaucratic hurdles to using the temporary/guest-worker (H-2 visa) program, this approach might be a “win-win” for everyone.

The 2010 health care reform extended affordable coverage to immigrants with legal resident status via employer-based and insurance exchange pathways. The legislation also made this class of residents eligible for means-based tax subsidies geared to make coverage for low-income populations affordable. The question remains whether these benefits will be extended to guest-workers, and if so, what the impact on health care costs will be. According to the Office of Immigration Statistics of the U.S. Department of Homeland Security, Mexican immigrants constitute 59 percent of all those who could receive legal residential status under immigration reform. At a recent House Ways and Means Committee hearing, Health and Human Services Secretary Kathleen Sebelius admitted that her department has not assessed the costs of providing coverage to immigrants who could achieve legal residential status under immigration reform. Our research team addressed this question in a recent study and found that immigration reform would benefit health insurance companies and all subscribers who purchase coverage through the insurance exchanges legislated to open by 2014. This research reveals that Mexican immigrants who would fall into the temporary-worker category would have lower than average health care costs, resulting in lower per person costs. While these results may appear counter-intuitive on the surface, they are not so when viewed in light of the health and health care needs of this population.

It is well-documented that individuals of Mexican-origin residing in the U.S. have higher rates of obesity and diabetes than non-Mexican populations, which should translate to higher medical costs. However, despite these health risks and lower levels of education and income, they exhibit lower rates of mortality than their non-Hispanic white counterparts, a phenomenon known as the Hispanic paradox. Temporary workers also tend to be younger on average, and healthier, than permanent legal residents and U.S. citizens of Mexican origin.

Using data from the Mexican Migrant Project, we assessed the frequency of U.S. health care utilization and insurance coverage for a sample of 648 predominantly undocumented workers (12.5 percent had either a green card or were U.S. citizens). We also estimated the key predictors of health care expenditures using data from the 2009-2010 Medical Expenditures Panel Survey. All of the predictors were practically and statistically influential in predicting expenditures. Notably, age, self-assessed health, and insurance status were the strongest predictors of health care expenditures. Being of Mexican-origin and having spent less than 10 years in the U.S. were both significant factors associated with reduced health care expenditures.

The benefits of providing coverage to this population (likely candidates for the temporary/guest-worker program) are clear. Given that not having insurance coverage creates barriers to timely care, providing coverage options to this group will increase the probability that they get appropriate levels of care when needed, thereby lowering sick-day costs otherwise borne by employers. This in turn would benefit employers from a worker productivity perspective. As well, some have argued that including this relatively healthy population, which is normally excluded for a variety of reasons, in the insurance exchange subscriber pool might lower average premiums for everyone else.

How would including guest workers in exchanges affect policy administrators? While it is obvious that rolling out the exchanges will make 2014 a challenging year, at least the responsibility for the documentation of eligibility status of immigrants will be determined by the federal government’s immigration status verification system.

The one group, though, that would experience added costs from including this population are state agencies responsible for implementing the day-to-day operations of the insurance exchanges. Already, public administrators are grappling with implementation of the Affordable Care Act (ACA) and the creation of insurance exchanges. Twenty-six states have elected to run their own exchanges. For those that have chosen not to create an exchange (like Texas – which has the highest percentage of uninsured and ranks second in the number of Mexican-origin immigrants), the ACA requires the federal government to set one up. A critical element for successful program administration will be raising awareness among people who are most likely to benefit from it. A recent Kaiser Family opinion poll found that 47 percent of people surveyed and 68 percent of low-income respondents lacked adequate information about the law and were unaware of how it would affect them. An outreach campaign is badly needed and efforts are underway to inform the public.

Besides finding ways to promote enrollment in the insurance exchanges, the program must work once people are enrolled. Designing an insurance exchange is an enormously complicated task that entails multi-agency cooperation in developing a user-friendly website for consumers to compare complex insurance plans. States will be given funds to support Health Exchange Navigators in a Federally-facilitated Exchange (FFE) to help Hispanic-Americans select a specific type of plan they can afford according to May 2012 General Guidance by the Centers for Medicare and Medicaid Services. For states with high levels of poverty and a large uninsured, uneducated immigrant population with low English proficiency, the influx of applications by the newly eligible may overwhelm management of such an enrollment system.

These are but a few of the issues confronting states as the deadline for participation draws closer. There is a great deal of uncertainty ahead for public administrators across all levels of government. One thing is certain: compliance with the law is mandatory. In light of this, public policymakers and administrators will need to cooperate in organizing a reliable and enduring program that will not only ensure coverage among the most vulnerable, but will benefit the nation as a whole. All segments of the population, including those undocumented immigrants who play an important role in the nation’s labor force, will invariably need to be incorporated into this plan.


Authors: Jacqueline L. Angel, Ph.D., Austin Lyndon B. Johnson School of Public Affairs at the University of Texas.  She can be reached at [email protected]  Kimberly J. Wilson, MPIA, University of Texas Health Science Center School of Public Health, Austin, TX; H. Shelton Brown, III, Ph.D., University of Texas Health Science Center School of Public Health, Austin, TX.


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