Maryland legislature punts on extending ACA exchange access to undocumented immigrants

via the Washington Post:

...The proposal at issue would allow undocumented immigrants to buy health insurance through the state exchange, a policy change that state analysts predict would lead to coverage for about one-third of the state’s undocumented population, or 82,500 people. The move would add Maryland to a small number of states targeting the group in an effort to shore up gaps in health care access — a goal that has faced head winds in Congress.

Supporters say the proposal dovetails with Gov. Wes Moore’s goal of eliminating child poverty and would reduce overall premiums and care provided by hospitals free of charge to the uninsured. But instead of passing a bill that would open the insurance marketplace, which would require a federal waiver, lawmakers instead approved legislation that calls for the Maryland Health Department and the Maryland Health Benefit Exchange to study options for undocumented immigrants’ health care needs to guide their work moving forward.

...The state estimates expanding coverage eligibility would cost $550,000 in fiscal year 2025 for initial implementation costs and $250,000 a year for at least three years after that.

Ninfa Amador-Hernandez, a CASA research and policy analyst, said there is already sufficient data to show opening the exchange would be an appropriate first step toward coverage for 275,000 uninsured immigrants in Maryland. Plans cost about $800 a month for a family of four without subsidies, she said.

The District, Washington state, Massachusetts and New York City have programs to expand insurance eligibility, she said.

For the most part Maryland has been kicking ass when it comes to smart, effective heatlhcare policy reform over the past several years. They had record-breaking ACA exchange enrollment this past Open Enrollment Period. Last year they expanded postpartum Medicaid coverage to a full year. They were the first state in the nation to pass a "Tax Time EZ Enrollment" law which gives people who missed the Open Enrollment window a second opportunity to easily enroll in either exchange coverage or Medicaid by simply checking a box on their state tax form. And they recently launched their Young Adult Subsidy program which offers supplemental financial help to younger enrollees, which improves the overall risk pool.

Given their excellent track record, it's even more disappointing to seem them kick this proposal down the field. As I've noted before, opening up ACA exchange coverage eligibility without federal subsidies to undocumented immigrants is a no-brainer:

On the surface, this may not sound like that big of a deal--after all, most ACA individual market policies (QHPs) are also available off-exchange (directly via the health insurance carriers or via private brokers). In some cases these are identical to the on-exchange plan in terms of coverage, provider network, formulary, co-pays and so forth; in other cases there are slight variants. ACA-compliant off-exchange plans are still regulated exactly like on-exchange plans (no annual/lifetime benefit caps; the same maximum out-of-pocket costs; and so forth).

...since undocumented immigrants aren't eligible for [federal subsidies] anyway, you might wonder why there'd be any advantage to them enrolling on-exchange?

Well, there's actually several reasons:

  • To avoid marketing/eligibility confusion: Every fall during the annual Open Enrollment Period, both the federal and state-based ACA exchanges launch big marketing/awareness campaigns urging Americans to visit HealthCare.Gov (or their state exchange) and #GetCovered. If you're an undocumented immigrant, you may do just that, only to discover that you're not eligible to enroll at any price, which no doubt confuses, upsets and discourages people. This may even lead them not to bother trying to enroll in an off-exchange ACA plan since they may falsely assume it means they aren't eligible to enroll in those either.
  • To avoid confusion re. mixed-status households
  • To be eligible for state-based financial help: While the ACA prohibits federal ACA financial subsidies from being provided to undocumented immigrants, some states may choose to do so. This is already the case when it comes to Medicaid: California pays for Medi-Cal coverage for hundreds of thousands of undocumented immigrants themselves without any federal funding.

In short, there's really no logical reason I can think of, even from a "xenophobic/federal fiscal policy" POV, to prohibit undocumented immigrants from at least enrolling in on-exchange ACA plans (as long as they aren't receiving federal financial help to do so).

Spending $1.3 million spread out over four years to provide healthcare coverage to ~83,000 more people (or less than $16 apiece) is a fantastic return on investment. I assume that cost would mostly go towards modifying the Maryland Health Connection to be able to handle undocumented immigrants, plus marketing/promotional materials to get the word out about the policy change.

Unless there's some other details in the bill which I'm not aware of (and there could be), this sounds like a missed opportunity by the MD legislature.