Several 2020 candidates are proffering moral and policy arguments for providing coverage, but the politics of the move are another matter. “We” are now worried more about the undocumented immigrants than our own citizens? This is really an indication as to the idiocy seeping into all aspects of our society, especially during this competitive race for the Presidency.
Ronald Brownstein reported that anxiety spiked among many centrist Democrats when all 10 presidential candidates at a recent debate raised their hand as if pledging allegiance, to declare they would support providing health care to undocumented immigrants. The image, which drew instant ridicule from President Donald Trump on Twitter, seemed to encapsulate the primary’s larger lurch to the left during the early stages of the 2020 race, which has unnerved many moderates.
But opinion among the candidates on this polarizing question is actually much more divided than that moment suggested. And that division underscores a larger point: While the most left-leaning positions in the Democratic field have attracted the most attention in the race so far, it’s far from certain the party will pick a nominee who embodies them.
Led by Senator Bernie Sanders, nearly a half-dozen 2020 Democrats have embraced a clear position of offering full access to health-care benefits. Others, including former Vice President Joe Biden, the nominal front-runner, oppose full benefits, although that wasn’t apparent at the debate. The latter group would allow undocumented immigrants to purchase coverage through the exchanges established by the Affordable Care Act, but only with their own money. That approach would cover far fewer people, but also potentially create much less exposure to Republican counterattacks.
“If we are saying that we can put them into the pools and they can buy on the exchange, I don’t think voters are going to flip out on that because there is no subsidy,” says Matt Bennett, the executive vice president for public affairs at Third Way, a leading organization of Democratic centrists. “But I think beyond that gets pretty dicey.”
This debate affects millions of people. The Kaiser Family Foundation, using census data, has estimated that 47 percent of the country’s roughly 11 million undocumented immigrants are uninsured, compared with one-fourth of legally present immigrants and about one-tenth of American citizens. Similarly, the Urban Institute places the number of uninsured undocumented immigrants at nearly 4.9 million, or about one-sixth of the total population of uninsured people in America.
The case for expanding their health-care access rests on financial, public health, and moral arguments. Supporters contend that it’s cheaper to provide access to medical care upfront, rather than deal with health crises in emergency rooms; that allowing the undocumented to go untreated increases health risks for legal residents who come in contact with them; and that it is unjust to let people face health threats without care, regardless of their status. As Biden put it in a recent interview with CNN, “How do you say, ‘You’re undocumented. I’m going to let you die, man’? What are you going to do?” The counterargument, meanwhile, is that it’s unfair to ask taxpayers to subsidize their care, and that covering the undocumented will act as a “magnet” to incentivize more immigration.
Emergency rooms must provide aid to all who need it. But polls have consistently found that most Americans resist offering public benefits to the undocumented beyond that. In a recent CNN survey, Americans by a solid 3–2 margin said that “health insurance provided by the government” should not be available to immigrants here illegally. The idea faced resistance across a wide array of constituencies, including several that Democrats rely on: Just over half of college-educated white voters, half of young adults ages 18 to 34, and more than two-fifths of nonwhites said they opposed providing coverage for the undocumented. At the same time, three-fifths of voters who identified as Democrats or lean Democratic said they support the idea.
This mixed result leaves the 2020 candidates balancing competing political and policy considerations as they confront the question. In the process, they have reopened a debate that extends back to the consideration of the ACA during former President Barack Obama’s first year in office.
The original version of the ACA, passed by the Democratic-controlled House in November 2009, allowed undocumented immigrants to purchase insurance on the law’s exchanges with their own money. But it denied them eligibility for the subsidies the law established to help the uninsured afford such coverage, and it maintained their exclusion from Medicaid, which the ACA expanded to cover more of the working poor.
The Democratic-controlled Senate—and the Obama White House—would not even go as far as to allow them to buy into the exchanges. Republicans and conservatives had seized on the charge that the ACA would provide the undocumented with benefits as one of their talking points against the proposed law; when Republican Representative Joe Wilson of South Carolina famously yelled “You lie” at Obama during his 2009 speech to Congress about his health-care proposal, it was in response to Obama’s insistence that the law would not cover those in the U.S. illegally.
To a degree that’s been largely forgotten today, passing the ACA was a herculean political challenge. Presidents Bill Clinton, Richard Nixon, and Harry Truman had all failed to pass universal-coverage bills; indeed, none of them had even advanced their proposal as far as a floor vote in either chamber. Within the Obama administration, resolving the issue of health coverage for the undocumented was widely viewed as one brick too many on the load.
Rahm Emanuel, who directed the legislative fight for the ACA as Obama’s chief of staff, recalled in an interview that pressure for covering the undocumented never developed “in any concerted way,” and that “no one seriously demanded it.” Neera Tanden, who served as a senior adviser to former Health and Human Services Secretary Kathleen Sebelius, remembered the debate inside the administration in similar terms. “I don’t remember considering this at all,” said Tanden, now the president of the Center for American Progress, a leading liberal think tank. The “whole issue was a lot more toxic then.”
The final ACA bill that Obama signed into law, on March 2010, completely excluded undocumented immigrants from the system. Even when Obama later instituted the Deferred Action for Childhood Arrivals program to block the deportation of young people brought into the country illegally by their parents, the administration denied them access to benefits under the ACA, notes Eric Rodriguez, the vice president for policy and advocacy at UnidosUS, a leading Latino group.
Toward the end of 2016, the Obama administration had an opportunity to reconsider at least one aspect of that policy. California passed legislation allowing the undocumented to buy coverage on state-run exchanges with their own money (without any public subsidy) and requested a waiver from the federal government to implement the policy. Anthony Wright, the executive director of the advocacy group Health Access California, which helped pass the law, said the state argued that opening up the exchanges made sense because as many as 70 percent of undocumented Californians were in “blended” families that included American citizens. “The argument we made was … isn’t there a benefit to allowing the whole family to buy into coverage at the same time? Rather than to tell these families we can cover the kid and maybe the mother, but the father has to go to buy coverage from a broker independently?” Wright recalled in an interview.
The issue was never resolved. The state submitted its waiver request too late in 2016 for the Obama administration to rule before it left the office. Once Trump took control, California withdrew its request because he was virtually certain to reject it.
Hillary Clinton had moved the party’s position in a more inclusive direction during the 2016 campaign, although her policy didn’t attract nearly as much attention as the hand-raising moment at last week’s debate. Clinton ran, essentially, on House Democrats’ initial proposal in the early days of the ACA debate: that the undocumented should be allowed to buy coverage on the exchanges, though without any subsidies to help.
Three years later, the current slate of candidates seems to have significant differences in how they would treat the undocumented, even if, as a group, they have moved beyond the Obama administration’s more cautious position on the ACA. Biden and Senator Michael Bennet of Colorado, both of whom raised their hand at the debate last month, are taking a similar position to House Democrats’ in 2009 and Clinton’s in 2016: In addition to opening the ACA exchanges to the undocumented, they would also allow them to buy into the new public insurance option they would create through an expanded Medicare system. But they would still deny the undocumented any public assistance. Biden, in his CNN interview, put greater emphasis on expanding federally funded community-health clinics as a means of delivering more health care to undocumented immigrants than he has on offering them insurance.
At the other pole of the debate is Sanders’s Medicare for All proposal, which would entitle the undocumented to the same health-care services as anyone else in America. The actual language of the bill is less definitive: It says that while “every individual who is a resident of the United States is entitled to benefits for health care services under this Act,” the federal government will promulgate regulations for “determining residency for eligibility purposes.” But in response to a health-care questionnaire from The New York Times, Sanders unequivocally included the undocumented in his system: “Medicare for All means just that: all. Bernie’s plan would provide coverage to all U.S. residents, regardless of immigration status,” his campaign wrote.
In response to my questions, the campaigns of Senators Kamala Harris of California, Elizabeth Warren of Massachusetts, and Cory Booker of New Jersey said they would provide full benefits to the undocumented; so would former Housing and Urban Development Secretary Julián Castro.
South Bend, Indiana, Mayor Pete Buttigieg made a passionate case for covering the uninsured during last month’s debate, but his campaign would not specify his exact plan for doing so, particularly whether he would subsidize coverage with public dollars. Former Representative Beto O’Rourke of Texas likewise would not nail down his position on that point.
“This issue is one of many reasons Beto believes that comprehensive immigration reform must be a top priority,” Aleigha Cavalier, his national press secretary, said in a statement. “Because our laws rightly require hospitals to provide care to everyone, the cost of care for uninsured individuals is currently shifted onto other consumers. Therefore, it is in everyone’s interest to provide a pathway for obtaining insurance, whether through the ACA, a new universal healthcare program, or on the private market.”
The rub for both health-care and immigration advocacy groups seems to be the matter of public subsidies. What has become the more centrist position—of allowing undocumented people to purchase coverage on their own—generates mixed feelings: The advocates consider it a valuable gesture, but little more than that, because so few could afford health coverage without assistance.
Wright, for instance, says, “any step toward inclusion is a positive one.” But he notes that when California offered its coverage proposal to the Obama administration, his group estimated that probably fewer than 30,000 of the estimated 1.5 to 2 million uninsured undocumented immigrants in California could afford to buy coverage.
Rodriguez stressed the limited practical impact of the position Biden and Bennet are endorsing now. “If you don’t have subsidies, there is no affordability to get into the system,” he says. “Symbolism these days are still important. The fact that all the candidates raised their hands [to cover the undocumented], that’s not insignificant. But what would be meaningful is proposals that would enable families [to] afford coverage.”
California pushed the debate into another front this week. Governor Gavin Newsom signed a budget that makes California the first state to cover undocumented young adults ages 19 to 26 under its Medicaid program; the state had already extended eligibility to undocumented children under 18 and to pregnant women.
Wright noted that the expansion was, from a cost perspective, a relatively small component of a much larger package, one that focused on providing middle-class families more financial help to afford health care. That linkage, he argues, is the key to winning public acceptance for greater aid to the undocumented.
“There will always be a group of folks who are animated by the immigration issue and that just might be something they are opposed to, period,” he said, basing his analysis on focus groups and polls his group has conducted in California. “But if they see an effort to help people broadly, most people don’t begrudge others being helped as part of that process.”
With either modest steps—or big leaps—toward providing undocumented immigrants health coverage, that may be exactly the wager Democrats are placing in 2020.
The poll of The Day: Faith in Trump’s Phantom Health Care Plan
Yuval Rosenberg of the Fiscal Times noted that American voters aren’t quite sure what to make of the latest lawsuit seeking to strike down the Affordable Care Act.
While legal experts have largely dismissed the lawsuit, now before a federal appeals court, as meritless, a new Morning Consult survey of 1,988 registered voters finds a much more divided electorate.
Nearly half of voters, 44%, say the GOP-led lawsuit isn’t likely to bring down Obamacare, compared to 37% who say it might. Those views fall along predictably partisan lines:
More surprising is that voters who expect the ACA to be overturned express a fairly high level of confidence that President Trump has a plan to replace it. The GOP has thus far failed to come to a consensus about how to replace Obamacare, and Trump has yet to reveal a promised health care plan. Yet 60% of voters who think Obamacare may be struck down are confident the administration has a plan of its own, including 87% of Republicans.
Analysts and pundits have warned that, if the lawsuit were to succeed, it would be a disaster for Republicans — and GOP lawmakers have shown little desire to grapple with a health care overhaul again before the 2020 elections.
The Morning Consult poll also found that voters are increasingly placing responsibility for the state of the U.S. health care system on Trump — and half of the voters say the system has gotten worse over the past decade.
And now back to our discussion on the history of Medicare:
The benefits that the various states were required to provide recipients were:
- Inpatient hospital care (other than in an institution for tuberculosis or mental disease),
- Outpatient hospital services
- Laboratory and x-ray services
- Nursing facility services for those over the ages of twenty-one (and, after July 1, 1970, to home health services
- Physicians” services, regardless of the location of treatment.
Also, the states could underwrite many other services such as physical therapy, dental care, diagnostic, preventive, and rehabilitative services, and the cost of prescribed drugs, dentures, prosthetic devices, and eyeglasses. Those elderly that were insured by Medicare but were also eligible because of the incomes for Medicaid had their hospital deductibles and copayments paid by Medicaid.
The Johnson administration then went on in 1967 to propose amendments to the Social Security program that included extending Medicare benefits to the disabled who were otherwise eligible for cash payments. To pay for this extension, a higher earnings base on which Medicare taxes would be levied was recommended. So, from then on the current $6,600, the amount as to rise to $7,800 in 1968, to $9,00 in 1971, and in 1974 and thereafter would rise to $10,800.
However, despite the strong support from the Johnson administration, the House Ways and Means Committee voted to defer consideration of the extension in light of the substantial costs associated with the amendment. The administration tried to present the case that the medical costs for each disabled beneficiary would be about the same as those associated with Medicare recipients over the age of 65. But a study released while the bill was before the committee indicated that in fact, these costs would be about two and a half to three times as high.
And to no one’s surprise looking at healthcare today, following the first year of operation of the Hospital Insurance program that its costs significantly exceeded the estimates put forward by the program’s proponents. You have to remember that the main purpose of enacting a national health insurance bill had been, after all, to encourage greater use of health care facilities by the elderly. It was therefore not surprising that with the measure’s passage there should have been an increased demand for hospital and medical services. However, not only was there greater utilization of medical facilities on the part of those covered by the Medicare program, but there followed a far higher increase in the prices of covered services than had been expected. Congress reviewed the data and increased the contribution schedule along the lines suggested by the administration despite its not having incorporated the disabled among the program’s beneficiaries.
By 1972 the costs associated with Medicare had increased at such a rate that even the administration and Congress were expressing concern. What followed was a number of studies to examine the causes and I will discuss this more next week. So, imagine the passage of Medicare for All and the true costs!!
I have finally decided that our society is crazy and I probably have said this before. I was reading about Nike’s decision to not sell the sneakers with the Betsy Ross flag on the back of the shoe because Mr. Kaepernick decided that the flag was racist. Did the company realize that Betsy Ross was a Quaker and that Quakers were Abolitionists who helped ban slavery in England? Also, Quakers were vital to the American Underground Railroad to free slaves. Objecting to the Betsy Ross flag, because it represents slavery, shows complete and utter ignorance of history!!
More next week!