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Recently, a bipartisan group of Senators unveiled a plan to overhaul our nation's immigration system, a key portion of which aims to provide a pathway to citizenship for the 11 million undocumented immigrants living in the United States, including older immigrants. Access to affordable health care is a serious issue for lawfully present and undocumented immigrants. With limited options and restrictions under Medicaid, CHIP, Medicare, and benefits under the Affordable Care Act, many non-citizens and immigrants forego needed care including critical preventive services.[1] Limitations and barriers to affordable coverage options lead to higher uninsured rates and further health disparities among non-citizens.[2] In addition, the lack of affordable options leaves many to seek care in the costliest settings, including emergency departments, which contribute to higher overall health costs.[3]

The current Senate bill contains provisions of concern to health advocates.[4]  These provisions essentially put immigrants on a path to citizenship, while locking them out of the health care system. This Alert highlights some of these provisions.

Access to Medicaid

Low-income seniors and people with disabilities rely on Medicaid.  Medicaid is the primary payer of long-term services and supports, and is a critical source of coverage for vulnerable populations. In the current bill, individuals in Registered Provisional Immigrant (RPI) status – the status granted to currently undocumented individuals who qualify under certain criteria, and which last as long as 10 years – are ineligible for Medicaid and other federal means-tested programs. When individuals eventually transfer from RPI status to Lawfully Permanent Resident (LPR), they face an additional 5-year waiting period for Medicaid.  This means that most individuals on the path to citizenship will not have access to Medicaid for at least 15 years, and likely longer, given implementation and processing time.

For the duration of their time in provisional status, individuals will not be eligible for the Affordable Care Act's (ACA's) premium tax credits to purchase coverage in the private marketplace, but can purchase these health insurance plans at full cost – an unaffordable option for many.[5] States have the option to waive the 5 year Medicaid bar for pregnant women and children, but not for other adults.  The continued lack of access to Medicaid will harm families and overall community health.

Access to Medicare

Medicare is a health and economic lifeline for millions of families. Older adults and people with disabilities rely on Medicare for vital health insurance coverage, including access to critical preventive services. As with Medicaid in the Senate bill, individuals transitioning from RPI status (5-10 years) to LPR status must wait an additional 5 years for Medicare eligibility. This means many older immigrants will not have access to Medicare for 15 years. In addition, once eligible, many older immigrants will face an additional barrier to becoming Medicare beneficiaries: accessing and affording Medicare Part A.

Medicare Part A Access and Affordability for Immigrants: The Importance of State Buy-in Programs

Medicare Part A pays for hospital, nursing home, home health and hospice services. Most people receive Part A premium-free based on work history (individuals are required to have 40 quarters, or 10 years, of work history to receive premium-free Part A). However, as many as 5% of eligible Medicare beneficiaries do not have sufficient work history to qualify for premium-free Part A.[6] In 2013, the full Part A premium is $441 per month.

Many immigrants who have lived in the country for a short period of time have insufficient work history to qualify for premium-free Part A. Likewise, many people who work outside of the Social Security payroll tax system – people who hold jobs as domestic, restaurant, seasonal or construction workers – do not qualify for premium-free Part A. These low-wage workers are often least able to afford the over-$5,000 per year to pay Part A premiums.

Without a subsidy, most people eligible for Part A with a premium will simply forego enrollment in Medicare because they cannot afford it. These people will either remain uninsured or enroll in their state's Medicaid program.

Subsidy programs to help people with the cost of their Part A premium exist, but it is virtually impossible for many eligible individuals to successfully enroll in these programs.[7] Medicare Savings Programs (MSPs, also known as buy-in programs because the state subsidy "buys" the beneficiary into Medicare) are state Medicaid assistance programs designed to help low-income people pay their Medicare premiums. The most generous Medicare Savings Program, the Qualified Medicare Beneficiary Program, pays for enrollees' Medicare Part A and B premiums and cost sharing. However, structural barriers, lack of knowledge and onerous application requirements make it extremely difficult for most people to access the Part A buy-in subsidy.[8]

Currently, states can choose whether to enter into a Part A buy-in agreement with CMS. Thirty-six states have such an agreement.[9] However, many large states with substantial immigrant populations – including California, Illinois, New Jersey, New Mexico and Arizona – do not have a Part-A buy in agreement with CMS. These are known as "group payer states."

The Part A buy-in option does exist in group payer states, however, lack of formal buy-in agreements between CMS and group payer states lead to structural barriers that create hurdles to enrollment. Part A buy-in agreements between states and CMS address barriers to Part A buy-in participation in three key ways[10]:

  1. Part A buy-in agreements make it easier for eligible persons to enroll in Medicare Part A with a subsidy during any time of year, not just during an enrollment period.
  2. Part A buy-in agreements help address a paradoxical statutory requirement that applicants already have Medicare Part A before they enroll in the MSP which is necessary to pay the Part A premium.
  3. Part A buy-in agreements allow applicants to apply for the benefit by visiting only their local Medicaid office. In group payer states, individuals must go to the Medicaid office and Social Security to get the benefit.

Increasing Part A buy-in enrollment makes financial sense for states because it would shift some of the state's health care and prescription drug costs to the federal government. Since Medicare pays before Medicaid, boosting enrollment in Medicare Part A would transfer health costs from Medicaid to Medicare, and reduce Medicaid spending.

Enrollment in Medicare Part A also helps immigrants. In many states, access to Medicare providers is greater than access to Medicaid providers. Enrollment in QMB with full Part A and B subsidies means access to any provider that accepts Medicare, with no premiums or cost sharing, ensuring that the enrollees receive key primary care and critical preventive services.[11] It also means access to the full Low Income Subsidy (LIS, "Extra Help") for Medicare Part D prescription drug coverage. Being able to access the services and coverage available under Medicare means fewer people turning to costly institutional and emergency care.

Solutions for the Senate Bill

As outlined above, the current Senate bill contains provisions with potential negative consequences for public health. However, there are solutions to help ensure that aspiring citizens have access to needed health coverage and services while keeping in line with the overall health system's movement toward expanding coverage and emphasizing prevention to avoid more costly emergency care.

  • End the 5 year mandatory waiting periods for Medicaid and Medicare for Lawfully Permanent Residents (LPR): Once immigrants are granted legal permanent resident status, the 5 year bar for Medicaid and Medicare leaves older and low-income immigrants with few options. Though immigrants in this category should be made eligible for tax credits for coverage in the private marketplace under the Affordable Care Act, comprehensive coverage may still be unaffordable.
  • Count time spent in Registered Provisional Immigrant (RPI) status toward the 5-year waiting periods ("Deemed Time"): If the 5 year waiting periods for Medicare and Medicaid are not eliminated, policymakers should ensure that any time spent in RPI status is counted toward the 5-years. This ensures that older and low-income immigrants are afforded quicker access to critical coverage options.  
  • Revise current law to encourage all states to have Part A buy-in agreements with CMS: By simply encouraging all states to have a Part-A buy-in agreement with CMS, Congress could dramatically improve access to Medicare Part A for immigrants who will otherwise go without care or turn to Medicaid, despite being eligible for Medicare. Having Part A buy-in agreements with CMS won't solve all the issues facing low-income beneficiaries and immigrants eligible for Medicare, but it is a powerful first step in making this under-utilized benefit available to low-income immigrants who will otherwise turn to costly emergency and institutional settings for their health care.


Under the Senate Immigration Reform bill as it is currently drafted, aspiring citizens are arbitrarily and harmfully denied access to affordable health care for 5 to 15 years. They are expected to work to provide for themselves and their families, but illness and injuries are unpredictable. Without access to affordable care, many will remain uninsured, and turn to care in the costliest settings, contributing to higher overall health costs.  They will face high rates of medical bankruptcy, and suffer further health disparities. Providing better access to affordable care is both good budget policy and good public health policy.

Update – Amendment to Improve Access to Health Care for Immigrants and Aspiring Citizens Introduced

As the Senate Judiciary Committee is set to begin mark-up of the Immigration reform bill, Senator Mazie Hirono of Hawaii introduced an amendment that addresses several of the concerns our Alert, above, highlighted.[13]

The amendment would:

  • Remove the 5-year bar for Medicaid and provide full-scope Medicaid coverage to lawfully present immigrant adults who are otherwise eligible, as well as children and pregnant women, regardless of immigration status.
  • Make Medicare available to lawfully present individuals who are otherwise eligible for the program.

Senator Horono's Amendment would ensure that aspiring citizens have access to the health care options to which they contribute through their taxes, including critical preventive services and screenings under Medicare, which often reduce the need for more expensive care.  The Amendment would be a step forward in improving health disparities among immigrant and minority communities across America. It is good economic policy and good public health policy.  Policymakers and advocates should support and build on Sen. Hirono's Amendment as they continue discussions about comprehensive immigration reform.

[1] Kaiser Family Foundation, Key Facts on Health Coverage for Low-Income Immigrants Today and Under the ACA, available at
[2] Kaiser Family Foundation, Disparities in Health and Health Care, available at
[3] USA Today, Rising Health Care Costs Puts Focus on Illegal Immigration, available at
[4] Senate Immigration Reform bill text available at
[5] National Immigration Law Center, Summary and Analysis: The Senate Bill as Introduced, available at
[6] United Hospital Fund, Michael Birnbaum, Elizabeth M. Patchias, Measuring Coverage for Seniors in Medicare Part A and Estimating the Cost of Making It Universal
[7] Kim Glaun, The Medicare Rights Center, Streamlining Medicare and QMB Enrollment for New Yorkers: Medicare Part A Buy-In Analysis and Policy Recommendations
[8] Id.
[9] The Social Security Program Operations Manual, HI 00801.140 State Buy-In and Group Payer Provisions for QMBs,
[10] Glaun at FN 7
[11] Patricia Nemore, The Center for Medicare Advocacy, The QMB Benefit: How to Get it, How to Use It, 
[13] Amendment language available at




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