Entry into the United States by individuals “liable to be a public charge” was first restricted in 1882, and such restriction has repeatedly been reaffirmed as a principle of U.S. immigration law, most recently by the welfare-reform legislation of 1996. Yet, until recent reforms proposed by the Trump administration, health-insurance coverage has not been included in such determinations. That may have made sense in earlier decades, when health-care entitlements were small. But, as health care in 2018 accounted for 64 percent of federal spending on means-tested benefits, this omission looks increasingly outdated.
The proposed public-charge rule, which is currently blocked by a federal judge, has been supplemented by a proclamation that would deny immigrant visas to those who lack insurance coverage or other means to cover medical costs after becoming permanent residents. The administration’s proposals focus primarily on those seeking immigration on the basis of family ties and do not affect immigration by refugees, college students, or immigrants already in the country.
The Clinton, Bush, and Obama administrations had interpreted the public-charge rule as referring narrowly to cash benefits — specifically, to whether immigrants would rely on the government for more than half their income. However, it is hard to justify ignoring health-care benefits, particularly in the aftermath of the Affordable Care Act. In 2008, the federal government spent $225 billion on means-tested health-care programs — a number that the Congressional Budget Office estimates will increase to $813 billion in 2028 under current law, even if no additional spending commitments are made.
Until recently, health-care entitlements by their nature tended to exclude immigrants. Medicare eligibility is limited to those aged over 65 and disabled individuals who have made at least ten years of payroll-tax contributions. Medicaid eligibility was generally limited to specific categories of low-income residents, such as the disabled, pregnant women, children, and their parents. But the ACA’s expansion of Medicaid changed the nature of public health-care assistance, providing for the first time a comprehensive entitlement to low-income adults not belonging to any of those specific categories. Furthermore, the ACA also provides subsidies for middle-income individuals to purchase coverage from the exchange.
Although the 1996 welfare-reform legislation requires immigrants to be legal permanent residents for five years before becoming eligible for Medicaid, all the Democratic candidates on stage in the first presidential primary debate expressed support for eliminating all remaining restrictions on immigrants’ eligibility for health-care entitlements.
Estimating that 4.9 million currently uninsured immigrants had incomes under the threshold necessary to qualify for subsidies on the exchange, the Center for Immigration Studies finds that the Democrats’ proposal could cost up to $23 billion per year, depending on the level of enrollment. That may well be an underestimate of the likely cost. First, it assumes that the expansion of eligibility would not cause employers currently providing coverage to shift any eligible enrollees to public programs. Second, it assumes that such a change in the law would not induce more immigrants to enter the country. And, third, it assumes that this proposal is not combined with any other change in health-care policy, such as the establishment of “Medicare for All.”
Most countries publicly fund only emergency hospital care for foreign visitors and illegal immigrants — as the United States currently does indirectly, with public subsidies for uncompensated hospital care. None propose, as the Democratic presidential candidates do, to pay for comprehensive coverage of scheduled medical services for individuals who lack legal permanent residence.
America’s Medicaid program funds many surgical procedures and cutting-edge drug therapies that are unavailable through public health-care systems abroad. In 2012, twelve or 13 new cancer drugs entering the market cost over $100,000. If entitlement to such therapies is not subject to any legal residency requirement, U.S. taxpayers would conceivably be on the hook for treating any cancer patient in the world who is able to pay for a flight to the country.
The current administration’s proposed policies instead insist on personal responsibility. They require that immigrants coming to the United States purchase insurance that covers their own medical risks. This differs greatly from Obamacare’s mandate, which was designed to force people to purchase plans that cost far more than their own likely medical costs, in order to raise funds to cover individuals with pre-existing conditions. Coverage by employer-sponsored insurance or relatives’ family plans would also be deemed sufficient.
There may be arguments in various circumstances for admitting immigrants who do impose a public charge. But, to the extent that the provision is intended to apply and be taken seriously, it surely must include health care.