Commonsense Care

By Samuel Tsoi

As the U.S. Supreme Court deliberates over the constitutionality of the Affordable Care Act, the law modeled after Massachusetts’ Health Care Reform, the Commonwealth is moving on to its next phase. Since the 2006 landmark health care reform law passed, the Commonwealth has achieved near-universal health insurance coverage (95%) of its residents, and almost all of its children. The goals ahead are maximizing efficiency, encouraging preventative measures, and recalibrating the payment system. But the inclusion of many documented immigrants was only recently affirmed after a long struggle.

The flash point in one of the most politicized Supreme Court cases in recent memory is the so-called ‘individual mandate.’ This wonky jargon has become a proxy for debating the size and role of government. Ironically, it was a pragmatic and bipartisan negotiation and policy innovation forged first in Massachusetts, under then-Governor Mitt Romney. The logic is that the more people are required to get coverage, the more solvent and sustainable the system will become, all the while avoiding the scenario of bankruptcy because of a lack of insurance. To offset those costs of buying insurance, although some might feel no need, the state created a new subsidized plan (Commonwealth Care), required more employers to offer insurance, reformed the private insurance industry, and expanded its Medicaid programs. After all, everyone uses the system at some point, so any uncompensated cost would be borne by the system in the long-run and often costlier to the taxpayer.

That experiment has overwhelmingly positive results for a majority of residents in Massachusetts, including many immigrants. Alas, that was a short-lived reality, when over 30,000 immigrants were excluded in 2009 from buying into the Commonwealth Care program. This not only contradicted the logic of incentivizing more people to create a more balanced risk pool, it increased the possibility of catastrophic costs for more people and providers.

According to the legislature, it was done in the name of saving money. This population, referred to as “Aliens with Special Status,” were mostly immigrants with legal permanent residency for less than five years, and other documented status. Those without lawful status are ineligible. The category exists with such complicated barriers based on federal laws established in the 1990s. Fortunately, Governor Patrick moved the initial group to a different plan, known as Commonwealth Care Bridge.

However, new enrollees still were not able access CommCare Bridge, and the program had higher co-pays and different hospital options, and was close to being eliminated at every turn of subsequent budget deliberations. Meanwhile, immigrant and health care advocates joined forces to challenge the targeting of this population in the state’s highest court. Victory was secured this past January, when the court ruled that the exclusion was an unconstitutional act of discrimination that violated immigrants’ right to equal protection, adding that fiscal considerations alone cannot justify discrimination against immigrants.

This was a unanimous legal decision that affirmed the rights of immigrants living Massachusetts. Moreover, as tax-payers, it is only fair for these individuals to access the system which their labor and contribution underwrite. Immigrants who qualify for the Commonwealth Care program (if they meet status and income requirements).

When Massachusetts’ law was implemented, and before certain immigrants were cut off, many immigrants feel a sense of civic duty by enrolling in health care. In fact, the process became a channel for immigrants to integrate into the system by contributing and participating. Complex laws on immigrants are the case because of generations of wrestling over who deserves to be fully considered American and who are considered residents, which still mar equal access to critical institutions such as higher education.

The lessons of health care reform in Massachusetts are clear: residents paying taxes should have access to publically-funded programs; customers enrolling in insurance should be guaranteed care. This way, immigrants are recognized as people. After all, our predicaments are interdependent, at least in our social contract of taxation and insurance that takes care of each other, in sickness and in health. If only our immigration and citizenship laws reflect that principle of shared responsibility, as opposed to exclusion.

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