The PPACA does not provide undocumented immigrants with eligibility for public insurance programs. Because undocumented immigrants are not regarded as “qualified individuals” under the law, it also does not allow undocumented immigrants to purchase health insurance through the new state health exchanges even if they are able to do so with their own money.21 Section 1312 of the Act states, “If an individual is not, or is not reasonably expected to be for the entire period for which enrollment is sought, a citizen or national of the United States or an alien lawfully present in the United States, the individual shall not be treated as a qualified individual and may not be covered under a qualified health plan in the individual market that is offered through an Exchange.”22
Despite these restrictions, the law does include additional funding for the health care safety-net, including an $11 billion increase for FQHCs and the law’s expansion of the Medicaid program may provide additional revenue to many FQHCs and other safety-net providers. Yet, the PPACA also calls for an $18 billion dollar reduction in Medicaid DSH payments and a $22 billion reduction in Medicare DSH payments through 2020. The DSH cuts are based on the assumption that hospitals will not need to provide as much charity care once the health reform is implemented. Because undocumented immigrants will not receive public or private insurance coverage under health reform, they are likely to represent a larger percentage of the nation’s uninsured population. This raises important question about future political support for the health care safety-net.23
Access to health care for undocumented immigrants in the U.S. is shaped by several policies and programs at the federal state and local level. With the exception of emergency medical care, undocumented immigrants are not eligible for federally funded public health insurance programs, including Medicare, Medicaid and the Child Health Insurance Program (CHIP).1Medicare is a social insurance program that provides health insurance to people age 65 and over, as well as people with permanent disabilities and end-stage renal disease. Medicaid is a means-tested social welfare program that provides health insurance to certain categories of poor people. CHIP, created in 1997, is a block grant program to expand coverage to children in families with incomes that exceed Medicaid eligibility.2 There is no organized, national program to provide health care for undocumented children. U.S.-born children in mixed-status families may be eligible for Medicaid or CHIP if they qualify on the basis of income and age. Although federal funds may not be used to provide non-emergency health care to undocumented immigrants, some states and local governments use their own funds to offer coverage to undocumented children.3 For example, the Healthy Kids program in San Francisco covers uninsured children under the age of 19, including undocumented children.4 Similarly, the All Kids program Illinois covers all children under the age of 19 who meet program income requirements, regardless of immigration status.5 PRUCOL (Permanent Residence Under Color of Law) is a public benefits eligibility category that refers to individuals who are in the U.S. with the knowledge of immigration services and are not likely to be deported.Before the adoption of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996,6 people with PRUCOL status were eligible for Medicaid, but PRWORA eliminated their eligibility with the exception of emergency services. In New York, the State Court of Appeals (Aliessa et al. v. Novello) concluded that denying access to Medicaid violated the equal protection clauses of
