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On November 1, 2024, the Centers for Medicare and Medicaid Services (CMS) released the Physician Fee Schedule (PFS) Final Rule for Calendar Year (CY) 2025.
Immigration, health care, and public policy intersect in complex and often conflicting ways in the United States. Documented immigrants may face discrimination when seeking health care in certain states, while undocumented immigrants are generally ineligible for coverage. (But do receive emergency treatment in hospitals through the Emergency Medical Treatment and Labor Act (EMTALA). As President Trump continues to sign executive orders impacting immigrants and health care, these issues underscore the broader challenges at the nexus of immigration status, health care coverage, and policy decisions.
Let’s Start with Coverage for Legal Immigrants
Legal immigrants face multiple barriers to accessing health care services, ranging from legal restrictions to economic and cultural challenges.
For private insurance, a significant portion of immigrants work in industries such as agriculture, construction, and hospitality, where employer-sponsored insurance is often unavailable. If insurance is available, high premiums and out-of-pocket costs make coverage unobtainable. Some immigrants can purchase insurance through the Affordable Care Act’s health insurance marketplace and may qualify for premium tax credits and other savings.
For public programs, many legal immigrants are excluded from federal programs like Medicaid and the Children’s Health Insurance Program (CHIP). Even if eligible in certain states, many legal immigrants often face the “five-year bar,” requiring them to wait five years after obtaining lawful status before becoming eligible for these programs.
What About the Public Charge Rule?
The idea of denying entry to the United States for persons who may become a “public charge” dates back to an 1882 law regulating immigration. The public charge rule is a policy used by U.S. immigration officials to determine whether an individual applying for a visa or green card is likely to become primarily dependent on government assistance. If deemed a public charge, the applicant may be denied entry or permanent residency. But in 2019, the Trump Administration proposed a rule that significantly broadened the scope of public programs that could be considered in determining a person’s public charge status. Based on that 2019 rule, accessing health, nutrition, and housing programs could be used to make a legal immigrant potentially deportable. This rule caused a significant chilling effect on legal immigrants seeking health care services, housing, and economic support. An estimated 2.1 million essential workers and household members avoided enrolling in Medicaid and 1.3 million did not receive help through the Supplemental Nutrition Assistance Program (SNAP) during the COVID-19 pandemic.
While the Biden Administration implemented a new rule in 2022 which largely undid the 2019 Trump rule, advocacy organizations for immigrants are fearful the return of the 2019 rule is in the offing.
What About Coverage for Undocumented Immigrants?
Undocumented immigrants rely heavily on safety-net programs, community health clinics, or charity care. While some states have taken steps to address this gap through initiatives providing state-funded subsidies or programs, these efforts remain limited and inconsistent across the country.
States like California and Colorado have been at the forefront of expanding coverage to undocumented residents through state-funded programs. For example, Colorado’s OmniSalud provides affordable health insurance options to residents, regardless of immigration status, through Colorado Connect, ensuring privacy and security. OmniSalud offers Colorado Option plans with standardized benefits, including $0 copays for doctor visits, mental health care, maternity care, diabetic supplies, and preventive services. Financial assistance is available for those earning under 150% of the federal poverty level, potentially reducing premiums to $0. As of January 2025, seven states (CA, CO, IL, MN, NY, OR and WA) plus D.C. have also expanded fully state-funded coverage to at least some income-eligible adults regardless of immigration status.
And DACA?
Recipients of Deferred Action for Child Arrivals (DACA), often referred to as “Dreamers,” can access health insurance but in limited ways. Since DACA is a work authorization and deportation deferral program, a DACA recipient can gain coverage if their employer offers health insurance.
In general, DACA recipients are excluded from Medicaid and CHIP, but some state-based programs provide alternative coverage options, such as California’s Medi-Cal expansion.
Where Does This Leave the Provider?
Policies that deter undocumented individuals from seeking medical care often lead to a reliance on emergency services for conditions that could have been managed through preventive or proactive care. These policies not only increase health care costs but also place further strain on hospitals that must by law admit them, but who are often straddled with additional costs if patients cannot pay.
Moreover, health care providers may face ethical dilemmas when required to inquire about patients’ immigration status, potentially undermining trust and deterring individuals from seeking necessary care.
So, What Will Happen?
At the federal level, the future of immigrant health coverage is deeply tied to ongoing political debates.
As of 2024, the federal public charge rule does not consider most health programs, including Medicaid (except for long-term care), CHIP, ACA subsidies, and Colorado’s OmniSalud, when determining immigration status. However, that policy could change with the new Congress and Administration.
Specifically related to DACA, there have been efforts to restrict Medicaid and ACA eligibility for DACA recipients. In 2020, President Trump attempted to end the DACA program entirely but was blocked by the Supreme Court. However, it currently does not appear President Trump will try to end these programs in his current administration.
And at the state level, some states are pushing forward with innovative approaches, such as creating health insurance marketplaces that are open to all residents, regardless of immigration status. As more states observe the economic and public health benefits of expanded immigrant health coverage, there is speculation that others will adopt similar measures. The question then becomes if the Trump Administration would approve waiver applications from these progressive states through the Medicaid 1115 waiver program.
On November 26, 2024, the Centers for Medicare and Medicaid (CMS) released their proposed rule with technical changes to Medicare Advantage (MA) and Medicare Part D Prescription Drug plans for Contract Year 2026. This rule creates policy changes based on last year’s final MA payment rule and the Inflation Reduction Act.
For those who had Presidents’ Day off, we hope you enjoyed the holiday weekend. Even with the holiday, things continue to move quickly here in Washington. So, let’s get into it, Welcome to the Week Ahead!
The Administration
Something is cooking at the Department of Health and Human Services (HHS), and given the swearing-in of RFK Jr. as Secretary, we assume the food is not processed. His first full week on the job coincides with the first full week for the Make America Healthy Again (MAHA) Commission. The Secretary and his assistant chefs will have their hands full as the Executive Order creating the Commission calls for an assessment of how to address the childhood chronic disease crisis within 100 days.
Even with all the excitement of a new cook in the kitchen, it’s important to remember that the President remains the top chef and hasn’t been waiting for his staff to arrive. In just 4 weeks, President Trump has issued over 60 Executive Orders since January 20, more than he signed in the first year of his first term! These orders are on top of dozens of other Administration actions that include limiting National Institutes of Health grant funding for “indirect costs” to cutting funding for the Affordable Care Act (ACA) Navigator Program—and we can assume there will be more to come. So, what will he be cooking up this week? We don’t expect Trump to take off his apron any time soon.
The Senate
Senate Budget Committee Chair Lindsey Graham (R-SC) is also eager to serve up his own special dish after the passage of a Senate budget resolution out of committee on February 12. Look for the full Senate to debate the measure soon— possibly as early as this week.
Regarding the ingredients list, several Senate Republicans have said they want to ensure a permanent extension of the 2017 Trump tax cuts makes it into the final recipe. To make that easier, Republicans would have to use the Congressional Budget Office’s “current policy” baseline instead of using “current law” as the baseline. Using “current policy” means making the tax cuts permanent would cost significantly less dough.
Why does that matter? For health care, that means 2 big things. One, Republicans may be less inclined to take a big chunk out of Medicaid spending to offset the cost of extending the tax cuts if the tax cuts cost less. Two, other policies like the enhanced ACA premium tax credits, due to expire at the end of 2025, would also cost less. What Republicans want to do with the ACA tax credits is far from being baked at this point.
In non-budget news, the Senate Health, Education, Labor, and Pensions (HELP) Committee will hold a hearing to consider the nomination of Lori Chavez-DeRemer to be the Secretary of Labor. In that role, she will be in a position to impact health care policy in several ways, including through the administration of the Employee Retirement Income Security Act which sets minimum standards for private, employer-based health plans. While some of her positions have garnered praise from Democrats, we will see if her confirmation will be more like Secretary of Agriculture Rollins, who garnered 19 Democratic votes, or if she will face united Democratic opposition like HHS Secretary Kennedy.
The House
After the House Budget Committee came together to pass its own version of a budget resolution, the House of Representatives adjourned on February 13. This gives the cooks in the House a chance to take their menu on the road and hear from the diners directly while allowing critics to organize their messaging about why the menu should be rejected.
Don’t forget that the expiration of the continuing resolution is less than a month away. Appropriators are rumored to release topline numbers to come out for fiscal year 2025 any day now.
There You Have It
In honor of Presidents’ Day, we wanted to share some presidential trivia with you all, courtesy of the Library of Congress. How many did you get right? Let us know! Make it a great week!
