Back to Basics

The Congressional Research Service has issued their report regarding the treatment of noncitizens in H.R. 3200. There has been a lot of debate over this topic, with the president and democrats saying illegals are not covered, while those opposed to the bill saying they are. A number of loopholes in the bill, including no provisions for checking immigrations status, prove illegal immigrants can and will be covered by the bill, at the taxpayers’ expense.  The Summary of the report is include below.  If you would like to read the entire report, please click on CRS Report.

August 25, 2009
Treatment of Noncitizens in H.R. 3200
Congressional Research Service

Summary

This report outlines the treatment of noncitizens (aliens) under H.R. 3200, America’s Affordable Health Choices Act of 2009. In particular, the report analyzes specific provisions in H.R. 3200, and whether there are eligibility requirements for noncitizens in the provisions. Within the bill, noncitizens are treated differently in several provisions. In 2008, there were approximately 37.3 million foreign-born persons in the United States. The foreign-born population was comprised of approximately 15.1 million naturalized U.S. citizens and 22.2 million noncitizens.

H.R. 3200 includes an individual mandate to have health insurance, with tax penalties for noncompliance. Individuals who do not maintain acceptable health insurance coverage for themselves and their children would be required to pay an additional tax. Some individuals, including nonresident aliens, would be exempt from the individual mandate. “Nonresident alien” is a term under tax but not immigration law. For federal tax purposes, alien individuals are classified as resident or nonresident aliens. In general, an individual is a nonresident alien unless he or she meets the qualifications under a residency test. Thus, legal permanent residents, and noncitizens and unauthorized aliens who qualify as resident aliens (i.e., meet the substantial presence test), would be required under H.R. 3200 to have health insurance.

In addition, under H.R. 3200, a “Health Insurance Exchange” would begin operation in 2013 and would offer private plans alongside a public option. The Exchange would provide eligible individuals and small businesses with access to insurers’ plans, including the public option, in a comparable way. Individuals would only be eligible to enroll in an Exchange plan if they were not enrolled in other acceptable coverage (for example, from an employer, Medicare and generally Medicaid). H.R. 3200 does not contain any restrictions on noncitzens participating in the Exchange – whether the noncitizens are legally or illegally present, or in the United States temporarily or permanently. Nonetheless, only aliens who could be classified as resident aliens would be required under the bill to have health insurance.

In 2013, under H.R. 3200, some individuals would be eligible for premium credits (i.e., subsidies based on income) toward their required purchase of health insurance. To be eligible for the premium credits under H.R. 3200, individuals must be lawfully present in a state in the United States, excluding most nonimmigrants (i.e., those in the United States for a specific purpose and a specific period of time). The exceptions for nonimmigrants who could obtain premium credits under H.R. 3200 would be trafficking victims, crime victims, fiancées of U.S. citizens, and those who have had applications for legal permanent residence (LPR) status pending for three years. It is expected that almost all aliens in these excepted nonimmigrant categories will become LPRs (i.e., immigrants) and remain in the United States permanently. Furthermore, unauthorized aliens would be barred from receiving the premium credit.

H.R. 3200 as reported from the House Energy and Commerce Committee (E&C) would extend Medicaid eligibility up to 133 1/3% of poverty for populations that previously were not covered (e.g., childless adults and many parents). This extension of benefits could mean an increase in the number of noncitizens who already meet the immigration status requirements for Medicaid eligibility who would be eligible for Medicaid. Also, H.R. 3200 as reported by E & C would make eligible for full Medicaid noncitizens who lawfully reside in the United States in accordance with the Compacts of Free Association between the Government of the United States and the Governments of the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau, and are otherwise eligible for such assistance. This report will be updated.

Under the title of Public Health & Workforce Development are a number of grants, scholarships and other programs, providing training, services and a whole new array of studies relating to health care – a lot of money being spent to support the expansion of government, special interests, illegal immigrants and labor unions, but little to help solve the health care issues.

The first expansion is the establishment of the Public Health Investment Fund, which requires deposits from the revenues of the Treasury in the amount of $88,700,000,000 over 10 years. This money is authorized to be appropriated by the Committee on Appropriations of the House and Senate for carrying out the activities under the designated public health provisions. These areas include Community Health Centers, National Health Service Corps Program, National Health Service Corps Scholarship and Loan Repayment Programs, Primary Care Loan Funds, Primary Care Education Programs, Nursing Workforce Development, The National Center for Health Statistics and the Agency For Healthcare Research and Quality.

To make these programs even more appealing is the stipulation that “Amounts appropriated under this section, and outlays flowing from such appropriations, shall not be taken into account for purposes of any budget enforcement procedures including allocations under section 302(a) and (b) of the Balanced Budget and Emergency Deficit Control Act and budget solutions for fiscal years during which appropriations are made from the fund.” More spending without any concern for balancing the budget or controlling the country’s deficit. We don’t have it, but let’s spend it!

The first program – Community Health Centers – will obtain increased funding in the amount of $38,800,000,000.

The National Health Service Corps is being amended allowing the Secretary to issue waivers to individuals who enter into a contract for obligated service to pay for their education. It further raises the loan repayment amount from $35,000 to $50,000 and will be adjusted thereafter to reflect inflation. Additional appropriated funds for this program are $796,000,000 over the next 10 years. Additional funding is authorized in the amount of $3,171,000,000 over 10 years to cover the National Health Corps Scholarship and Loan Repayment Programs.

The Frontline Health Providers Loan Repayment Program will be established to address unmet health care needs in certain areas, populations, or facilities as designated by the Secretary. Individuals participating in this program must agree to serve for a period of 2 years in a health professional needs area specified in the program. This program has a clause that if there are an insufficient number of applicants for the program, then all excess funds from the program will be transferred to the National Health Service Corps to recruit more people to take advantage of this fund.

The Secretary shall establish a primary care training and capacity building program consisting of grants and contracts to plan, develop, operate or participate in accredited professional training in the field of family medicine, general internal medicine, general pediatrics or geriatrics. Funds for this program are from the Public Health Investment Fund in the amount of $3,023,000,000 for 10 years and will include the following:

• Capacity Building in Primary Care – grants to specialties of family medicine, general internal medicine, general pediatrics or geriatrics, with preference given to entities that train individuals who are from underrepresented minority groups or disadvantaged backgrounds.
• Training of Medical Residents in Community-Based Setting – a program established for the training of medical residents in community-based settings, with preferences given to entities that support teaching programs addressing the health care needs of vulnerable populations or are a Federally qualified health center or rural health clinic, as well as preference to those training individuals from underrepresented minority groups or disadvantaged background.

• Training for General, Pediatric or Public Health Dentists and Dental Hygienists – grants and contracts to plan, develop, operate or participate in an accredited professional training program or oral health professionals, with preference given to individuals who are from underrepresented minority groups or disadvantaged backgrounds.

Grants for Health Professionals Education – Advanced Education Nursing Grants is being amended, including increases in dollar amounts for the Nurse Faculty Loan Program. Funding for this program is $1, 450,000,000 over 10 years.

The Public Health Workforce Corps is being amended and expanded by the following: Creating the Public Health Workforce Scholarship Program, Public Health Workforce Loan Repayment Program, Enhancing the Public Health Workforce, and Preventive Medicine and Public Health Training Grant Program. Appropriations for these programs total $642,000,000 over 10 years. The Enhancing the Public Health Workforce even includes provisions for veterinary medicine! I’m not sure how veterinarians will provide quality health care to people or decrease health care costs, but it’s nice to see even our animals will be included in the grant programs.

Under the Subtitle “Adapting Workforce to Evolving Health System Needs” there are a number of grants and programs including:

• Health Professionals Training for Diversity, which includes scholarships for disadvantaged students, loan repayments and fellowships regarding faculty positions, and educational assistant in health professions regarding individuals from disadvantaged background.

• The Nursing Workforce Diversity Grants is being amended and adding the Coordination of Diversity and Cultural Competency Programs.

• The Secretary will establish a cultural and linguistic competency training program for health care professionals, including nurses, consisting of grants and contracts to develop and implement models of cultural and linguistic competency training. Preference will be given to entities that address cultural and linguistic needs of the population and health disparities, and placing health professionals in regions experiencing significant changes in the cultural and linguistic demographics of populations, including communities along the United States-Mexico border. Obviously this program will benefit all the illegal immigrants coming from Mexico to obtain free health care.

Appropriations for these programs total $1,138,000,000 over 10 years.

Grants and contracts are given to develop training programs to promote the delivery of health services through interdisciplinary and team-based models, with preferences given to entities that demonstrated training to the greatest number of health professionals who serve in underserved communities.

House Democratic Bill H.R.3200

Listed below are key provisions from H.R. 3200 – the health care “reform” bill currently moving through the U.S. House of Representatives.

Forcing Employer-Based Plans to Change
Page 17 – Section 102(b)(1)(A) forces every employer-based plan to conform to new benefit mandates, uniform marketing standards, cost-sharing, actuarial value, medical-loss ratio and other new requirements of this bill. Even if you are happy with your coverage, you will be forced to change your plan.

Prohibition on the Sale of Coverage in the Individual Market
Page 18 – Section 102(c) prohibits the sale of private health insurance policies on the individual market, beginning in 2013, and forces individuals to purchase federal government-approved coverage through a new “National Exchange.” Plans sold in the Exchange will be forced to comply with new benefit mandates, uniform marketing standards, cost-sharing, actuarial value, medical-loss ratio and other new requirements of this bill – making private health coverage less affordable and more expensive for the average American.

Creation of a Health Benefits Advisory Committee to Dictate the Terms of Your Health Coverage
Page 30 – Section 123 establishes a new board of federal bureaucrats (the “Health Benefits Advisory Committee”) to dictate the content of health plans that all individuals must purchase. Along with the Secretary of HHS and a new “Health Choices Commissioner,” this new Committee will decide what type of health plans will be available to you and your family.

Unelected Bureaucrat Becomes Second Most Powerful Government Official in America
Page 41 – Section 141 creates a new “Health Choices Commissioner:” an unelected bureaucrat who can impose penalties, take away your current health coverage, and will become the second most powerful person in Washington behind President Obama.

Protection for Members of Congress
Page 74 – Sections 202(c) and (d) protects Members of Congress with existing federal employee coverage (as defined in Section 100(c)(6) on page 9) from joining the government-run health plan offered through the Exchange.

Establishment of a New Government-Run Health Plan
Page 116 – Section 221 establishes a new government-run health plan that, according to non-partisan actuaries at the Lewin Group, would cause as many as 114 million Americans to lose their existing coverage.

Penalties for Individuals without Health Coverage or Government-Approved Health Care
Page 168 – Section 401 imposes a 2.5 percent tax on all individuals who do not purchase health insurance or who fail to purchase “bureaucrat-approved” health insurance.

Penalties on Employers who Cannot Afford to Provide Government-Approved Health Coverage
Page 183 – Section 412 imposes a new payroll tax as high as 8 percent for firms that cannot afford to purchase “bureaucrat-approved” health coverage. This new penalty will lead to job loss, decreased wages and impose a massive burden on American small businesses. Though Democrats have argued this bill would give an exemption to small businesses, firms with payroll as little as $250,000 would be forced to comply with the new tax.

The U.S. health care system is the best in the world, spurring advancements in new medical treatments and technologies.  Such innovation helps physicians treat and prevent diseases better than ever before, eradicates once fatal epidemics, and helps Americans lead longer, healthier lives.

Despite these advances, millions of Americans struggle to find affordable health insurance options.  From 1999 to 2008, the average cost of a family health plan increased by 119 percent from $5,791 to $12,680.  Meanwhile, workers’ wages increased 34 percent during the same nine-year period.  Ensuring access to quality, affordable health care is a laudable goal.  I support targeted solutions that lower health care costs and improve health care by building upon, not completely dismantling, our health care system.

Unfortunately, many of the proposals being considered in the U.S. Senate will make health insurance more expensive, jeopardize Arizonans’ current coverage, and expand the government’s control over health care.  While you will not find the words “ration,” “withhold coverage,” or “delay access to care” in the pending plans, that is what will result from the web of federally-dictated insurance reforms, new legal obligations, and provider reimbursement schemes that are part of them.  Such policies centralize the power of medical decisions with politicians and bureaucrats, not patients and doctors, and they will result in the delay or denial of care.

There are three main problems with the Majority party’s proposals: the implementation of a government-run insurance plan, the use of comparative effectiveness research, and spending.

Government-Run Insurance Plan:

First, the Majority’s proposals would create a new, government-run health insurance plan to compete against private insurance plans.  The argument is that a government-run plan would give consumers a better range of choices and make the health care market more competitive –”keep the insurance companies honest,” as the President put it.  However, well-respected, independent analysis provides evidence to the contrary.  For one thing, a government-run plan would be subsidized by the taxpayers, giving the government plan a huge advantage over competitors.  Yet, even government resources are not unlimited.  To save money after tens of millions of people are added to the public plan, the government would cut reimbursement to doctors and hospitals, exacerbating the difficulty Arizonans’ already encounter in trying to schedule doctor appointments.  To make up for low government reimbursements to providers, insurance companies would have to charge more for private insurance, making it less attractive than the government plan.

Over time, there will only be room for the government plan according to the respected Lewin Group, as 119 million Americans would lose their current coverage.  Remember, Fannie Mae and Freddie Mac were designed as independent “government-sponsored enterprises” to complement the private mortgage market.  Now, Fannie and Freddie account for a combined share of 73 percent of mortgage originations in the second half of 2008.  The two “government-sponsored enterprises” are now effectively owned and run by the federal government, after having sustained losses of over $100 billion last year alone.  A Washington-run health care plan will do to the health care market what Fannie and Freddie did to the housing market.

Comparative Effectiveness Research

Second, the Majority’s plan would create a new research entity to conduct so-called comparative effectiveness research (CER).  CER is a mechanism used by medical professionals to provide information on the relative strengths and weaknesses of various procedures and treatments.  In the hands of doctors, medical researchers, and other health professionals, CER can help patients and their own doctors make informed health care decisions.  However, in the hands of government, CER can become a tool to delay or deny care.  For example, the National Institute for Health and Clinical Effectiveness in Britain uses “cost-effectiveness research” to make health care decisions.  By basing treatment decisions on cost rather than need, Britain prescribes fewer cancer drugs than any of the other big five European nations; its patients therefore have the lowest survival rate according to a May edition of National Review.  The UK’s system provides only half of the care for end-stage renal disease patients that we do in the United States.  Obviously, such rationing of care is not something we should replicate in the United States.

It is telling that none of the Majority’s proposals in Congress would bar the federal government from using CER to deny access to care.  In fact, when I offered an amendment in April to explicitly bar the use of CER to ration care, it was defeated on a near party-line vote.  I have now introduced a free standing bill to ensure that any information obtained through CER cannot be used to deny access to care.  The Preserving Access to Targeted, Individualized, and Effective New Treatments and Service (PATIENTS) Act of 2009 (S. 1259) will protect the doctor-patient relationship and ensure access to the highest quality medical care.  I will fight at every opportunity to ensure that any health care reform plan the Senate considers later this year protects patients’ access to care.