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Health Insurance Test for Green-Card Applicants Could Sharply Cut Future U.S. Legal Immigration
October 2019

Health Insurance Test for Green-Card Applicants Could Sharply Cut Future U.S. Legal Immigration

medical insurance
Nick Youngson/Alpha Stock Images

The Trump administration on a Friday evening earlier this month quietly issued a presidential proclamation decreeing that new immigrants be denied entry to the United States unless they prove they can obtain eligible health insurance within 30 days of arrival or will have sufficient resources to pay for foreseeable medical costs. This new policy has the potential to block fully two-thirds of those who apply for legal permanent residence from abroad, according to Migration Policy Institute (MPI) estimates—and thus could have as significant an impact on reshaping future legal immigration as the sweeping public-charge regulation finalized earlier this year.

MPI estimates the new health insurance requirement could prohibit the entry of roughly 375,000 immigrants annually— mainly family-based immigrants who make up the majority of those getting green cards from abroad. With the Trump administration pressing to curtail the family-based immigration that has long been a cornerstone of the U.S. immigration system, the new proclamation could in some ways help achieve the changes the White House is seeking without needing action by Congress.

Scoping the Impact

The proclamation would apply to future legal permanent residents coming from abroad, not to immigrants already in the United States who are adjusting to a green card from another status. Refugees and other humanitarian entrants are excluded from the policy, scheduled to take effect November 3.

In order to assess the impact that this could have on future immigration, MPI looked at the best available proxy: recent immigrants. To determine the health insurance status of adult green-card holders in the United States less than two years, researchers analyzed data from the Census Bureau’s 2014-16 American Community Survey (ACS) using a unique MPI methodology that permits assignment of immigration status to noncitizens.

These analyses reveal that 65 percent of recent green-card recipients lack health insurance that would qualify under the Trump proclamation, including 34 percent who have no health insurance coverage and 31 percent who have Medicaid or subsidized insurance that would not count under the policy. Because slightly less than half of green cards issued annually are given to people who are already in the United States, the proclamation could affect one-third of overall green-card applicants.

The effects could change over time if markets adjust. For example, some insurers could decide to offer skeletal products expressly designed to meet the requirements of the proclamation. But unless and until that happens, the 65 percent estimate for arriving immigrants represents the best estimate of those who would not meet the proclamation’s requirements.

MPI’s estimates are of adults, not children. Minors are exempt from needing to prove insurance coverage if they are the principal green-card applicant, as is the case for adoptees and could be the case for children reuniting with a parent in the United States after living with the other parent abroad. But children coming to the United States with a parent would be subject to the test. Unlike adults, children could surmount the new test by showing they would be eligible for Medicaid in their intended state of residence (most, but not all, states, offer Medicaid to green card-holding children who are in their first five years in the United States).

Implementation Challenges

The new proclamation was issued without warning and minus the level of detail one would expect of a new policy set to be implemented in just one month. So it remains to be established how future legal permanent residents will be asked to prove they can find insurance coverage within 30 days of arrival—a very short window given the complexity of health insurance options in the United States. Based on the absence of implementing language, it also remains to be seen by how much the proclamation would cut overall immigration versus shifting the composition of arriving immigrants, given there is a backlog of nearly 4 million green-card petitions.

Some may have an easier time meeting the requirements: Immigrants arriving based on an employment offer that includes health insurance; those joining a spouse whose private, unsubsidized health insurance plan would cover them; and children or young adults reuniting with a parent whose unsubsidized plan would cover them.

For others, this insurance test could be more difficult. The easiest way for State Department staff to implement the new policy may be a straight income test. Those with high enough incomes could convincingly argue they can afford unsubsidized, private insurance or pay for foreseeable medical costs; those with lower incomes could not.

Implementation challenges are likely, partly because this proclamation works at cross-purposes with the Affordable Care Act (ACA). Green-card holders are eligible to purchase health insurance through an ACA health insurance marketplace and are eligible for subsidies or tax credits to afford the cost of coverage if their income is below 400 percent of the federal poverty line (below $49,960 for an individual; $67,640 for a family of two; or $103,000 for a family of four). But those who anticipate receiving subsidies or tax credits will not qualify under the new health insurance test.

One strategy for overcoming the new requirement will be for immigrants to establish they will be able to quickly purchase time-limited, individual health insurance plans that are available outside of the ACA marketplace and can last for up to one year. Such plans, allowed under the proclamation, have been made more broadly available under the Trump administration. These plans have lower premiums, but often exclude pre-existing conditions or charge more, and often cover only a portion of subscribers’ health-care costs. As a result, a dozen states have restricted or banned these plans. Others have limited them to three or six months’ duration, too short a period to qualify under the proclamation. Further, it is unclear what income level applicants would need to convince State Department consular officers that new immigrants could afford one of these plans.

Restrictions upon Restrictions

The Trump proclamation comes on top of the new public-charge rule and would result in denials for many immigrants who are able to meet those requirements. Under the public-charge rule, which will govern green-card applications submitted on or after October 15, access to unsubsidized, private health insurance coverage would be one of many factors considered in determining whether someone is likely to become a public charge in the future. Other factors include age, income, assets, English ability, educational attainment, health status, and past public benefits use. MPI previously estimated that the public-charge rule could greatly restrict future legal immigration and shift immigrants’ national origins away from Mexico and Central America and toward Europe, Canada, and Oceania.

The new health insurance requirement under the Trump proclamation creates an even stricter test, because it looks at just one factor: the ability to quickly find health insurance coverage. It seems highly possible that someone could pass the public-charge test by showing relatively high educational attainment, strong English skills, age, and other factors, only to be denied access to a green card because of the new proclamation.

Reshaping Immigration by Decree

The proclamation is sure to face legal challenges, given there are currently eight lawsuits against the public-charge rule, which went through much more deliberation and a formal process of notice-and-comment rulemaking.

As with the public-charge rule, the proclamation represents a major step in the administration’s efforts to restrict family-based immigration and privilege those arriving with higher incomes. And, like the public-charge rule, the administration is seeking to profoundly alter the legal immigration system through executive fiat rather than congressional action.

Coming without warning, clarity about implementation, advance planning, or consultation with key stakeholders, this proclamation seems to add up to a recipe for more chaos in the already chaotic U.S. immigration system.