[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5008 Introduced in House (IH)]
<DOC>
118th CONGRESS
1st Session
H. R. 5008
To expand access to health care services for immigrants by removing
legal and policy barriers to health insurance coverage, and for other
purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 27, 2023
Ms. Jayapal (for herself, Ms. Barragan, Ms. Adams, Mr. Blumenauer, Ms.
Bonamici, Mr. Bowman, Ms. Bush, Mr. Carson, Mr. Carter of Louisiana,
Ms. Castor of Florida, Mr. Castro of Texas, Mrs. Cherfilus-McCormick,
Ms. Chu, Ms. Clarke of New York, Mr. Cleaver, Mr. Connolly, Mr. Correa,
Ms. Crockett, Mr. Doggett, Mr. Espaillat, Ms. Garcia of Texas, Mr.
Garcia of Illinois, Mr. Gomez, Mr. Grijalva, Ms. Jackson Lee, Ms.
Jacobs, Mr. Johnson of Georgia, Mr. Krishnamoorthi, Ms. Lee of
California, Ms. Lofgren, Mr. McGovern, Ms. Meng, Ms. Moore of
Wisconsin, Mr. Nadler, Mrs. Napolitano, Ms. Norton, Ms. Ocasio-Cortez,
Ms. Omar, Ms. Pingree, Mr. Pocan, Ms. Pressley, Mr. Quigley, Mrs.
Ramirez, Ms. Scanlon, Ms. Schakowsky, Ms. Sewell, Mr. Soto, Mr.
Thanedar, Ms. Tlaib, Ms. Tokuda, Mrs. Torres of California, Mr. Trone,
Mr. Veasey, Ms. Velazquez, Ms. Wasserman Schultz, Mrs. Watson Coleman,
Ms. Williams of Georgia, Ms. Wilson of Florida, Mrs. Trahan, Mr.
Panetta, and Mr. Cardenas) introduced the following bill; which was
referred to the Committee on Energy and Commerce, and in addition to
the Committee on Ways and Means, for a period to be subsequently
determined by the Speaker, in each case for consideration of such
provisions as fall within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To expand access to health care services for immigrants by removing
legal and policy barriers to health insurance coverage, and for other
purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Health Equity and Access under the
Law for Immigrant Families Act of 2023'' or the ``HEAL for Immigrant
Families Act of 2023''.
SEC. 2. FINDINGS; PURPOSE.
(a) Findings.--Congress finds as follows:
(1) Health insurance coverage reduces harmful racial,
economic, gender, and health inequities by alleviating cost
barriers to, and increasing utilization of, necessary health
care services, especially among low-income and underserved
populations.
(2) Based solely on their immigration status, many
immigrants and their families face legal and policy
restrictions on their ability to obtain affordable health
insurance coverage through Medicaid, the Children's Health
Insurance Program (CHIP), and the health insurance exchanges.
(3) Lack of health insurance coverage contributes to
persistent inequities in the prevention, diagnosis, and
treatment of health conditions. This leads to negative health
outcomes for immigrants and their families, especially Black,
Indigenous, Latinx, Asian, Pacific Islander, and other
Immigrants of Color.
(4) Black immigrant women often cite cost as a major
barrier to health care. Many who are undocumented forgo doctor
visits altogether due to the financial burden in addition to
consistent racial bias by medical practitioners and racism in
health care.
(5) Nearly half of immigrant women are of reproductive age.
Immigrant women, lesbian, gay, bisexual, transgender, and queer
(LGBTQ) immigrants, and immigrants with disabilities
disproportionately live in households with low incomes and lack
health insurance coverage. Legal and policy barriers to
affordable health insurance coverage significantly exacerbate
their risk of negative pregnancy-related and other reproductive
and sexual health outcomes, with lasting health and economic
consequences for immigrant women, LGBTQ immigrants, immigrants
with disabilities, and their families and society as a whole.
(6) Denying health insurance coverage or imposing waiting
periods for health insurance coverage on the basis of
immigration status unfairly hinders immigrants' ability to
reach and maintain their optimal levels of health and
undermines the economic well-being of their families.
(7) Like the Hyde amendment's prohibition on public
insurance coverage for abortion care, immigration-related
health care eligibility barriers have long curtailed access to
abortion. In June 2022, in Dobbs v. Jackson Women's Health
Organization, the Supreme Court of the United States overturned
the constitutional right to abortion, exacerbating pre-existing
barriers. In the year since the Dobbs decision was issued, 19
States have banned or restricted abortion--disproportionately
impacting 15 million women of color and millions of transgender
and nonbinary people. Notably, in 2022, 39 percent of all
Latinas living in States that were likely to ban abortion
following the Dobbs decision were born outside of the United
States--this group includes people with varying citizenship
statuses, among whom fear of surveillance may be particularly
prevalent, due to disproportionate investigation and
surveillance that many immigrant communities already face. Bans
and restrictions on abortion exacerbate the fear of
criminalization in immigrant communities, and contribute to a
chilling effect that leads many immigrants to forego
reproductive health care and coverage of any kind as they
navigate these intersecting risks of criminalization. Polling
conducted in 2018 found one in four Latina/o voters (24
percent) had a close family member or friend delay or avoid
health care because of fear related to discriminatory
immigration policies, and one in five (19 percent) said the
same about reproductive health care.
(8) Ensuring access to crucial coverage of reproductive and
sexual health services such as contraception and pregnancy-
related care through Medicaid and the Affordable Care Act is
imperative, with only half (52 percent) of immigrants at risk
of unintended pregnancy receiving contraceptive care in the
previous year. Many immigrants are being denied the basic human
right to make the health care decisions they believe are best
for them and their families, including abortion care, simply
because of their immigration status. In States along the
Southern Border, immigrant communities are subject to interior
checkpoints that increase the threat of family separation,
deportation, and detention, and compound the harm of abortion
restrictions that force people to travel to obtain care.
Immigrants living without documentation, in particular, may
have no way of obtaining an abortion when immigration
enforcement and abortion restrictions combine to prevent them
from traveling to a provider. Further, due to the high cost of
travel associated with the onslaught of abortion bans,
practical support organizations that assist with procedure and
travel costs have been experiencing high demand, and struggle
with inadequate resources. Accessing support services can be
out of reach for those without reliable technology to research
and maintain contact with support services, or who encounter
linguistic barriers when support services are not able to
provide translators. For many, abortion care will be entirely
inaccessible due to these compounding barriers, thus
exacerbating the need for accessible reproductive and sexual
health services such as contraception and pregnancy-related and
post-pregnancy care.
(9) International human rights standards hold that
governments have an affirmative obligation to ensure that
everyone, including immigrants, can access safe, respectful,
culturally and linguistically appropriate, and high-quality
pregnancy-related care, including postpartum care, free from
discrimination or violence. Medicaid is the Nation's single
largest payer for pregnancy-related care. Nevertheless,
barriers to health coverage persist for pregnant and postpartum
people, particularly immigrants.
(10) Immigrants--especially Black, Indigenous, Latinx,
Asian, and Pacific Islander immigrants--are among those most
harmed by the United States pregnancy-related morbidity and
mortality epidemic, which is the worst among high-income
nations. Black people are nearly four times more likely than
White people to suffer pregnancy-related death, and twice as
likely to suffer maternal morbidity. Indigenous people are two
and a half times more likely than White people to die from a
pregnancy-related death. The majority of United States
pregnancy-related deaths are preventable. Lack of access to
health care, immigration status, poverty, and exposure to
racism, sexism, and xenophobia in and beyond the health care
system contribute to the disproportionately high number of
pregnancy-related deaths among BIPOC birthing and postpartum
people. Unnecessary barriers that limit pregnant and postpartum
immigrants' access to health care undermine their health,
safety, and human rights.
(11) One in seven United States residents is foreign-born,
approximately one in four children in the United States has at
least one immigrant parent, and the population of immigrant
families in the United States is expected to continue to grow
in the coming years. It is therefore in our collective public
health and economic interest to remove legal and policy
barriers to affordable health insurance coverage that are based
on immigration status.
(12) Delaying or denying health insurance coverage because
of immigration status can impede mental health and substance
use prevention and early intervention interventions. Not
acknowledging the impacts of trauma can impact mental health
and substance use, and conditions may increase in severity
without appropriate and consistent support and treatment.
(13) Although individuals granted relief under the Deferred
Action for Childhood Arrivals (DACA) program are authorized to
live and work in the United States, they have been unfairly
excluded from the definitions of lawfully present and lawfully
residing for purposes of health insurance coverage provided
through the Department of Health and Human Services, including
Medicaid, CHIP, and the health insurance exchanges.
(14) On April 26, 2023, the Centers for Medicare & Medicaid
Services (CMS) published a proposed rule that would modify the
definition of ``lawfully present'' used to determine
eligibility for Patient Protection and Affordable Care Act
(ACA) health plans and certain other health care programs.
Codifying these protections in legislation is crucial to ensure
individuals granted relief under the Deferred Action for
Childhood Arrivals (DACA) program and those who gain new forms
of administrative relief are not similarly excluded in future
administrative action. This is even more imperative as more
than a quarter of DACA recipients are currently uninsured as
they await the finalization of the proposed rule.
(15) Since immigration law evolves constantly, new
immigration categories for individuals with federally
authorized presence in the United States may be created.
(16) Some States continue to unwisely restrict Medicaid
access for immigrants who have long resided in the United
States, fueling significant health inequities and increasing
health care costs for individuals and the public.
(17) Congress restored Medicaid eligibility for individuals
living in the United States under the Compacts of Free
Association as part of bipartisan legislation in December 2020
and should build on that success by ensuring all immigrants can
access care.
(b) Purpose.--It is the purpose of this Act to--
(1) ensure that all individuals who are lawfully present in
the United States are eligible for all federally funded health
care programs;
(2) advance the ability of undocumented individuals to
obtain health insurance coverage through the health insurance
exchanges established under part II of the Patient Protection
and Affordable Care Act, Public Law 111-148;
(3) eliminate the authority for States to restrict Medicaid
eligibility for lawful permanent residents; and
(4) eliminate other barriers to accessing Medicaid, CHIP,
and other medical assistance.
SEC. 3. REMOVING BARRIERS TO HEALTH COVERAGE FOR LAWFULLY RESIDING
INDIVIDUALS.
(a) Medicaid.--Section 1903(v)(4) of the Social Security Act (42
U.S.C. 1396b(v)(4)) is amended--
(1) by amending subparagraph (A) to read as follows:
``(A) Notwithstanding sections 401(a), 402(b), 403,
and 421 of the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996, a State shall
provide medical assistance under this title, to
individuals who are lawfully residing in the United
States (including individuals described in paragraph
(1), battered individuals described in section 431(c)
of such Act, and individuals with an approved or
pending application for deferred action or other
federally authorized presence), if they otherwise meet
the eligibility requirements for medical assistance
under the State plan approved under this title (other
than the requirement of the receipt of aid or
assistance under title IV, supplemental security income
benefits under title XVI, or a State supplementary
payment).'';
(2) by amending subparagraph (B) to read as follows:
``(B) No debt shall accrue under an affidavit of
support against any sponsor of an individual provided
medical assistance under subparagraph (A) on the basis
of provision of assistance to such individual and the
cost of such assistance shall not be considered as an
unreimbursed cost.''; and
(3) in subparagraph (C)--
(A) by striking ``an election by the State under
subparagraph (A)'' and inserting ``the application of
subparagraph (A)'';
(B) by inserting ``or be lawfully present'' after
``lawfully reside''; and
(C) by inserting ``or present'' after ``lawfully
residing'' each place it appears.
(b) CHIP.--Subparagraph (N) of section 2107(e)(1) of the Social
Security Act (42 U.S.C. 1397gg(e)(1)) is amended to read as follows:
``(N) Paragraph (4) of section 1903(v) (relating to
lawfully present individuals and undocumented
immigrants).''.
(c) Effective Date.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall take effect on the date
of enactment of this Act and shall apply to services furnished
on or after the date that is 90 days after such date of
enactment.
(2) Exception if state legislation required.--In the case
of a State plan for medical assistance under title XIX, or a
State child health plan under title XXI, of the Social Security
Act which the Secretary of Health and Human Services determines
requires State legislation (other than legislation
appropriating funds) in order for the plan to meet the
additional requirements imposed by the amendments made by this
section, the respective State plan shall not be regarded as
failing to comply with the requirements of such title solely on
the basis of its failure to meet these additional requirements
before the first day of the first calendar quarter beginning
after the close of the first regular session of the State
legislature that begins after the date of enactment of this
Act. For purposes of the previous sentence, in the case of a
State that has a 2-year legislative session, each year of such
session shall be deemed to be a separate regular session of the
State legislature.
SEC. 4. CONSISTENCY IN HEALTH INSURANCE COVERAGE FOR INDIVIDUALS WITH
FEDERALLY AUTHORIZED PRESENCE, INCLUDING DEFERRED ACTION.
(a) In General.--For purposes of eligibility under any of the
provisions described in subsection (b), all individuals granted
federally authorized presence in the United States shall be considered
to be lawfully present in the United States.
(b) Provisions Described.--The provisions described in this
subsection are the following:
(1) Exchange eligibility.--Section 1411 of the Patient
Protection and Affordable Care Act (42 U.S.C. 18031).
(2) Reduced cost-sharing eligibility.--Section 1402 of the
Patient Protection and Affordable Care Act (42 U.S.C. 18071).
(3) Premium subsidy eligibility.--Section 36B of the
Internal Revenue Code of 1986 (26 U.S.C. 36B).
(4) Medicaid and chip eligibility.--Titles XIX and XXI of
the Social Security Act, including under section 1903(v) of
such Act (42 U.S.C. 1396b(v)).
(c) Effective Date.--
(1) In general.--Subsection (a) shall take effect on the
date of enactment of this Act.
(2) Transition through special enrollment period.--In the
case of an individual described in subsection (a) who, before
the first day of the first annual open enrollment period under
subparagraph (B) of section 1311(c)(6) of the Patient
Protection and Affordable Care Act (42 U.S.C. 18031(c)(6))
beginning after the date of enactment of this Act, is granted
federally authorized presence in the United States and who, as
a result of such subsection, qualifies for a subsidy under a
provision described in paragraph (2) or (3) of subsection (b),
the Secretary of Health and Human Services shall establish a
special enrollment period under subparagraph (C) of such
section 1311(c)(6) during which such individual may enroll in
qualified health plans through Exchanges under title I of the
Patient Protection and Affordable Care Act and qualify for such
a subsidy. For such an individual who has been granted
federally authorized presence in the United States as of the
date of enactment of this Act, such special enrollment period
shall begin not later than 90 days after such date of
enactment. Nothing in this paragraph shall be construed as
affecting the authority of the Secretary to establish
additional special enrollment periods under such subparagraph
(C).
SEC. 5. REMOVING CITIZENSHIP AND IMMIGRATION BARRIERS TO ACCESS TO
AFFORDABLE HEALTH CARE UNDER THE ACA.
(a) In General.--
(1) Premium tax credits.--Section 36B of the Internal
Revenue Code of 1986 is amended--
(A) in subsection (c)(1)(B)--
(i) by amending the heading to read as
follows: ``Special rule for certain individuals
ineligible for medicaid due to status''; and
(ii) by amending clause (ii) to read as
follows:
``(ii) the taxpayer is a noncitizen who is
not eligible for the Medicaid program under
title XIX of the Social Security Act by reason
of the individual's immigration status,''; and
(B) by striking subsection (e).
(2) Cost-sharing reductions.--Section 1402 of the Patient
Protection and Affordable Care Act (42 U.S.C. 18071) is amended
by striking subsection (e) and redesignating subsection (f) as
subsection (e).
(3) Basic health program eligibility.--Section
1331(e)(1)(B) of the Patient Protection and Affordable Care Act
(42 U.S.C. 18051(e)(1)(B)) is amended by striking ``lawfully
present in the United States,''.
(4) Restrictions on federal payments.--Section 1412 of the
Patient Protection and Affordable Care Act (42 U.S.C. 18082) is
amended by striking subsection (d) and redesignating subsection
(e) as subsection (d).
(5) Requirement to maintain minimum essential coverage.--
Subsection (d) of section 5000A of the Internal Revenue Code of
1986 is amended by striking paragraph (3) and by redesignating
paragraph (4) as paragraph (3).
(b) Conforming Amendments.--
(1) Establishment of program.--Section 1411(a) of the
Patient Protection and Affordable Care Act (42 U.S.C. 18081(a))
is amended by striking paragraph (1) and redesignating
paragraphs (2), (3), and (4) as paragraphs (1), (2), and (3),
respectively.
(2) Qualified individuals.--Section 1312(f) of the Patient
Protection and Affordable Care Act (42 U.S.C. 18032(f)) is
amended--
(A) in the heading, by striking ``; Access Limited
to Citizens and Lawful Residents''; and
(B) by striking paragraph (3).
(c) Effective Date.--The amendments made by this section shall
apply to years, plan years, and taxable years, as applicable, beginning
after December 31, 2023.
SEC. 6. STATE OPTION TO EXPAND MEDICAID AND CHIP TO INDIVIDUALS WITHOUT
LAWFUL PRESENCE.
(a) Medicaid.--
(1) In general.--Section 1902(a)(10)(A)(ii) of the Social
Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)) is amended--
(A) in subclause (XXII), by striking ``or'' at the
end;
(B) in subclause (XXIII), by striking the semicolon
and inserting ``; or''; and
(C) by adding at the end the following new
subclause:
``(XXIV) who would be eligible
under the State plan (or waiver of such
plan) under this title if they were
citizens of the United States;''.
(2) Conforming amendment.--Section 1905(a) of the Social
Security Act (42 U.S.C. 1396d(a)) is amended, in the matter
preceding paragraph (1)--
(A) in the matter designated as clause (xxvi), by
striking ``or'' at the end;
(B) in the matter designated as clause (xxvii), by
adding ``or'' at the end; and
(C) by inserting after the matter designated as
clause (xxvii) the following:
``(xxviii) individuals described in section
1902(a)(10)(A)(ii)(XXIV),''.
(b) CHIP.--Title XXI of the Social Security Act (42 U.S.C. 1397aa
et seq.) is amended by inserting after section 2112 the following new
section:
``SEC. 2112A. STATE OPTION TO PROVIDE COVERAGE FOR INDIVIDUALS WITHOUT
LAWFUL PRESENCE.
``A State may elect through an amendment to its State child health
plan under section 2102 to treat an individual as a targeted low-income
child or a targeted low-income pregnant woman for purposes of this
title if such individual would otherwise be included as such a child or
such a pregnant woman (as applicable) under such plan if the individual
were a citizen of the United States.''.
(c) Nonapplication of Eligibility Prohibition.--Section 401(a) of
the Personal Responsibility and Work Opportunity Reconciliation Act of
1996 (42 U.S.C. 1611(a)) is amended by adding at the end the following
new sentence: ``The preceding sentence shall not apply with respect to
a noncitizen's eligibility under a State plan (or waiver of such plan)
under title XIX of the Social Security Act or under a State child
health plan (or waiver of such plan) under title XXI of such Act to the
extent that such State has elected to make such individual so eligible
pursuant to section 1902(a)(10)(A)(ii)(XXIV) or 2112A of such Act,
respectively.''.
SEC. 7. PRESERVING ACCESS TO COVERAGE.
(a) In General.--Nothing in this Act, including the amendments made
by this Act, shall prevent lawfully present noncitizens who are
ineligible for full benefits under the Medicaid program under title XIX
of the Social Security Act from securing a credit for which such
lawfully present noncitizens would be eligible under section
36B(c)(1)(B) of the Internal Revenue Code of 1986 and under the
Medicaid provisions for lawfully present noncitizens, as in effect on
the date prior to the date of enactment of this Act.
(b) Definition.--For purposes of subsection (a), the term ``full
benefits'' means, with respect to an individual and State, medical
assistance for all services covered under the State plan under title
XIX of the Social Security Act that is not less in amount, duration, or
scope, or is determined by the Secretary of Health and Human Services
to be substantially equivalent to the medical assistance available for
an individual described in section 1902(a)(10)(A)(i) of the Social
Security Act (42 U.S.C. 1396a(a)(10)(A)(i)).
SEC. 8. REMOVING BARRIERS TO HEALTH COVERAGE FOR LAWFULLY PRESENT
INDIVIDUALS IN MEDICARE.
(a) Part A.--Section 1818(a)(3) of the Social Security Act (42
U.S.C. 1395i-2(a)(3)) is amended by striking ``an alien'' and all that
follows through ``under this section'' and inserting ``an individual
who is lawfully present in the United States, including individuals
with an approved or pending application for deferred action or other
federally authorized presence''.
(b) Part B.--Section 1836(2) of the Social Security Act (42 U.S.C.
1395o(2)) is amended by striking ``an alien'' and all that follows
through ``under this part'' and inserting ``an individual who is
lawfully present in the United States, including individuals with an
approved or pending application for deferred action or other federally
authorized presence''.
(c) Lawfully Present Defined.--The term ``lawfully present'' shall
include, at a minimum, all immigration categories that are treated as
lawfully present for purposes of the title XIX program as amended by
section 3.
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