After the Senate’s approval of S. 744, the Border Security, Economic Opportunity, and Immigration Modernization Act of 2013, comprehensive immigration reform rests in the hands of the House of Representatives. Despite bipartisan support in the Senate, this legislation faces extensive challenges in the Republican-controlled House and may not be fully enacted. Instead, the bill could be picked apart, with individual reforms adopted one at a time, or could die completely. If components of the bill survive, there are potential implications to the American healthcare system and the individual health of undocumented immigrants.
- Creates a pathway to citizenship for an estimated 11 million undocumented immigrants, with an expedited process for those brought to the United States as children;
- Establishes new temporary and farm worker programs;
- Increases the number of available visas for skilled foreign workers;
- Establishes a mandatory employment eligibility verification system; and
- Expands border security
If adopted, the bill would allow individuals who have lived in the United States throughout 2012 and 2013 to apply for the newly created registered provisional immigrant (RPI) status. Legal permanent resident (LPR) status can then be obtained after 10 years of RPI status. While this provides a straightforward path to legal residence and citizenship, RPIs would not be eligible for federally funded social programs, including Medicaid and CHIP, with the exception of restricted Medicaid for pregnancies and emergencies. Additionally, new LPRs would still be subject to the five-year waiting period, meaning immigrants in transition to citizenship would have to wait 15 years to qualify for full scope federally funded coverage. Fortunately, California has historically granted full-scope Medi-Cal to new LPRs, thus the wait time for benefits would likely be reduced to 10 years for Californians.
Individuals would be eligible to purchase insurance coverage through the Exchanges once they obtain RPI status, however they would not be eligible for subsidies until they become LPRs. RPIs would not be subject to the ACA’s individual mandate.
The bill’s potential impact on the short-term health of immigrants seeking legal residency is limited. Given the average low income of undocumented households, few would purchase unsubsidized coverage through the Exchange. New RPIs would continue to rely upon state and local programs, such as Healthy Way LA unmatched, Family PACT, etc., for coverage in the absence of Medi-Cal benefits. While transitioning immigrants would have to endure a lengthy waiting period for Medi-Cal coverage, safety net providers should expect an increase in demand, in that formerly undocumented immigrants could utilize services at a higher rate because they no longer feel deterred by their immigration status.
This reform package provides a path to citizenship but still excludes transitioning immigrants from both the requirements and benefits of the Affordable Care Act. The health and well being of immigrants would improve in the long-term, as they become eligible for Exchange subsidies and Medicaid, however the consequences of 10-15 additional years without health insurance could be serious.
 S 744 Sec. 2101.
 Op. cit. 1.
 Passel Jeffrey and Cohn D’Vera, A Portrait of Unauthorized Immigrants in the United States, Pew Research Hispanic Center (April 2009).
 While some of these individuals already rely on the safety net, community clinics, etc. for care, there are likely many who avoid care due to fear of being identified as undocumented, lack of understanding of the availability of services, as well as other barriers. See Michael K. Gusmano, Undocumented Immigrants in the United States: Use of Health Care, The Hastings Center (March 2012).