Legal immigrants may end up with better health care than poor citizens of conservative states

Aaron Carroll has a blog post entitled A pickle for conservative states refusing the Medicaid expansion.

The background is that Obamacare was designed with the companion Medicaid expansion in mind. However, the Supreme Court threw a wrench into matters when it decided that Obamacare was constitutional but it was unconstitutional to mandate that the states expand Medicaid. Instead, now states have the option of expanding Medicaid (mostly at federal expense) or not.

Obamacare doesn’t provide subsidies for people who were supposed to qualify for Medicaid. So, you have a bit of a doughnut hole occupied by people too well off to qualify for Medicaid under current standards but not so well off that they get beyond the expanded Medicaid eligibility and begin to qualify for health insurance premium subsidies under Obamacare.

On the other hand, *legal* immigrants (and I emphasize legal because that’s so often a sticking point — illegal immigrants are out in the cold regardless) don’t qualify for Medicaid unless they’ve been here for 5 years. Because Congress knew in advance that Medicaid wasn’t going to cover them, they’ll be eligible for subsidies under Obamacare. Conservative states that reject the Medicaid expansion might well see a situation where their poor-but-not-poor-enough citizens get no medical insurance assistance but legal immigrants occupying the same economic space do get assistance by virtue of not being citizens.


  1. jharp says

    Thanks for posting.

    Can’t wait for the conservative meltdown.

    Oh and by the way I think most will opt into the Medicaid expansion. To me it’s just too sweet of a deal and it is taking a lot revenue away from hospitals not to. Just can’t see the hospitals standing for it.

      • jharp says

        It really says something about Indiana that our legislators clearly don’t give a fuck about poor people getting insurance.

        But saying no to hospitals and $8 billion taxpayer dollars of new revenue?

        We had better do something about that.

          • Carlito Brigante says

            State-level government failed miserably. That is why Medicaid was enacted in 1965. The federal government finances one-half to three-quarters of it and many states still cannot operate a competent Medicaid program.

            Jharp is right. Indiana’s failure to expand Medicaid as contemplated screws the working poor, the most deserving of some assistance.

            • Carlito Brigante says

              Perhaps I am just in a funk, but watching what is happening with states refusing to expand Medicaid as contemplated by the ACA is grossly unfair to the people that need the help the most, the working poor. People who are not categorically eligible for Medicaid but cannot afford health insurance. The needs-based eligible. Many would not be large users of services if they are of working age.

              These are folks whose lives can be destroyed by a chronic illness or a serious medical condition.

              Another thing has been occupying my mind, lately. In income tax refund season, we always see marketers hawking furniture, motorcycles or used cars for the tax refunds. But just today I saw several commercials to use your tax refund to afford you bankruptcy filing or basic auto insurance. So the tax refund check is slipping from a source of a few bucks for a little something better to a cash infusion to cover the most basics of neccessities.

              Further evidence of greater poverty in this nation.

  2. Gary Welsh says

    Doug said, “illegal immigrants are out in the cold regardless.” Not true by a long shot, Doug. Illegal immigrants receive government-paid health care services in this country every day in every state. You may recall there was a Supreme Court decision that blocked the state of California from denying health care services to its illegal immigrant population back when Pete Wilson was the state’s governor and pushed a statewide initiative that provided no free health care for illegals. A few years back, the Health & Hospital Corporation was asked to quantify how much free health care for illegal immigrants cost it annually. Its CEO said the number couldn’t be quantified because it doesn’t and can’t keep track of which of its patients are legal versus illegal residents.

    • Carlito Brigante says


      Can you point to any other services other than EMTALA stabilization services that illegals recieve? Services that generally go unreimbursed.

  3. Carlito Brigante says

    Healthcare system failure is a Republican Platform Plank:

    From Daily Kos

    It’s like trying to argue how old the earth is, or whether global warming is accelerated because of human activity. No matter the evidence to the contrary, mainstream Republican thinking refuses to acknowledge that we have an essentially non-existent health care system in the U.S. if you’re poor, and a pretty shitty one unless you’re lucky enough to have a good job with benefits, or lots of money. So it isn’t a big surprise that Mississippi’s Republican Gov. Phil Bryant would say this:

    BRYANT: Medicaid was meant to be a temporary [stop]gap for providing you medical treatment while you are looking for a job. [No, Medicaid was created for the chronic poor and elderly nursing home residents. When Medicaid was enacted, the job-based insurance system was broadly based.} Now we are saying, you can have a job and still receive Medicaid. So we have changed the whole dynamic. (Wrong.] There is very little incentive for those 940,000 people on Medicaid to find a better job, or to go back to school, or to get [into] a workforce training program because they say: Look, if I go over $33,000, [I] will lose Medicaid. There is no one who doesn’t have health care in America. No one. Now, they may end up going to the emergency room. There are better ways to deal with people that need health care than this massive new program.

    Setting aside the fact that a good portion of Mississippi’s Medicaid population is either children or elderly people in nursing homes who won’t be getting jobs no matter what the incentive, it is particularly tone-deaf of the governor of that state, the one that leads the nation in poverty, to make this statement. Mississippi doesn’t have the largest uninsured population among the states—Texas still has that distinction—but at 17 percent it’s still pretty deplorable. That’s 17 percent of Bryant’s constituency that he’s completely written off.

    Being able to pretend that nearly a fifth of his population isn’t really without health care is how Bryant justifies refusing to set up a health insurance exchange or expanding Medicaid under Obamacare. Making a huge portion of his state suffer is nothing if it provides him the opportunity to reinforce his far-right bona fides.

  4. Stuart Swenson says

    Excellent observation, Carlito. Mississippi should be held up a case study illustrating the dynamics of a death spiral. This kind of thinking, after all, couldn’t continue if the electorate wouldn’t stand for it. Somehow, many people in that state seem to believe that place is heaven on earth when so many of its citizens are suffering. We could all learn from that mess as a failure of democratic government.

  5. Carlito Brigante says


    With out billions of dollars of federal support, states like Mississippi and West Virginia would be “failed” states.

    • Jason says

      I’d be curious if that would still be the case if you removed every federal requirement at the same time as removing the federal money.

      I mean, I really would like to know the answer, not “I think they would be better/worse but debating as a question”. :)

      I feel pretty confidant that some things, like the Interstate Highway System, would not have the same quality as other states after a while. However, a poor highway system would drive away business, so there is motivation to fix it.

      As I type it, I think it would be fascinating to see all of the states operating as mini-counties, more like the EU, perhaps since I’m in Europe at the moment. Shared currency, etc, but most functions still kept at the state level.

  6. Stuart Swenson says

    That’s worth a study in itself: the constant focus on power while the state competes for last place in the measured characteristics of civilization important in the developed world.

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