Even with Medicaid expansion, legal and undocumented immigrants would be left behind

As the Texas legislative session heats up, the topic of Medicaid expansion understandably attracts a lot of attention. While such a move could provide millions with affordable health care, there is a very large population of Texans who would not be helped: undocumented immigrants and legal immigrants.

As a physician at a large Dallas County safety net hospital, I frequently treat uninsured immigrant patients with complex health conditions. While those who live in Dallas County can access a health care network through the county’s robust Safety Net Health Care Program, federal and state policies make it nearly impossible for Texas immigrants to obtain a health coverage.

The lack of public insurance options in Texas means that many of my patients will never have access to needed specialty care, but will continue to be hospitalized when their conditions are not well managed on an outpatient basis. It is discouraging to let patients go knowing that they will soon return with preventable complications from their illnesses.

Since 1996, undocumented immigrants — including those with Deferred Action Status for Childhood Arrival — have been barred from receiving federal benefits, including Medicaid and Medicare. By extension, undocumented immigrants also cannot qualify for tax subsidies to enroll in private health insurance plans (market plans) introduced by the Affordable Care Act. Even green card holders face restrictions in accessing public benefits. These “skilled immigrants” must wait five years after the date of entry into the United States to become eligible for federal benefits, including Medicaid and ACA market subsidies.

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Unfortunately, Texas is one of 15 states that has not implemented a 1999 rule allowing states to bypass that five-year waiting period for pregnant women trying to access Medicaid. In fact, Texas is one of six states that bar all noncitizen adults from accessing Medicaid if they arrive after 1996.

This means that with few exceptions, this group of legal Texas residents cannot enroll in Medicaid until they become legal residents and eventually citizens, a process that can take more than a decade.

So even if Texas were to expand Medicaid using 90% federal dollars (this match rate was actually temporarily increased to encourage adoption), health insurance is only available to immigrants who can afford a private plan or whose employers offer a subsidized plan. And those can get expensive — a private plan can add up to more than $1,000 in monthly premiums for a family of four, according to the Centers for Medicare & Medicaid Services.

A handful of states have recently introduced programs to circumvent federal restrictions on public benefits. For example, six states plus Washington, DC, use state dollars to extend Medicaid eligibility to children, regardless of immigration status. Colorado will soon provide state grants to low-income immigrant residents who would otherwise not be eligible for market grants.

Other states like California, Illinois and Oregon are preparing to use state dollars only to cover certain income-eligible adults in their Medicaid programs, regardless of status. Only California will offer access to Medicaid for adults of all ages starting in 2024.

While establishing a similar pool of public funds to help connect our immigrant neighbors with needed medical coverage would be ideal, it would represent a dramatic shift in state policy toward expanding Medicaid. Other than that, Texas could take several smaller steps to make it easier for this hard-working population to get needed care this legislative cycle.

On the one hand, Texas could eliminate the near total ban on Medicaid for skilled immigrants who arrived after 1996. It is unconscionable that these Texans, who have lived and worked in Texas, cannot obtain the public benefits to which their taxes contribute. .

Additionally, Texas has one of the highest maternal mortality rates in the nation, according to a recent state report, and numerous studies have suggested that better Medicaid coverage for pregnant women would significantly improve this situation. Texas lawmakers recently extended postpartum Medicaid coverage from two months to six months (although the federal government is still considering this proposal). In a similar notion, Texas could join the other 35 states in allowing legally present pregnant women to skip the five-year waiting period before being eligible for Medicaid. This could connect thousands of women to needed perinatal health services. And, such an investment would not only help mothers, but also promote the health of their young children.

Due to the lack of affordable health insurance options, many Texas immigrants rely on a patchwork of care programs. Federally licensed health centers, community health clinics, and migrant health centers are not classified as health benefits, and therefore anyone can access them. These centers offer a range of important preventive health services, including primary care, dental care, women’s health counseling and mental health. However, they still have several limitations, including low access to specialist care and inequitable distribution. Thus, many patients cannot fully rely on these safety net clinics to follow recommended care after leaving the hospital.

As things stand, it’s difficult to connect immigrant patients to needed follow-up care because they can’t access public health care options available in the state. Recently, a bipartisan team of lawmakers recognized the vital role public health insurance plays in voting to expand Medicaid coverage postpartum. If they’re really serious about improving the health of all Texans, it’s time for them to put their money where their mouth is and commit more fully to the mission.

Aman Narayan is a Dallas County physician. He wrote this column for The Dallas Morning News.

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