DACA, the administrative relief program for eligible immigrants who arrived in the United States as children, was put into place by the Obama administration in 2012. Until now, healthcare insurance was not guaranteed under DACA, putting recipients at risk of lessened accessibility to physical and mental healthcare. In May of 2024, the Biden-Harris administration ruled that the Health and Human Services Department will no longer exclude DACA recipients from accessing insurance programs. After this ruling, criticism approached in the form of the lawsuit: Kansas et al. v. United States of America, Centers for Medicare & Medicaid Services. This paper analyzes both the ruling and the lawsuit at hand and proposes a public health strategy to create an equitable healthcare space for all individuals under DACA.
DACA recipients are still nearly three times as likely to be uninsured than the general population in the U.S. (Wong et al., 2023). Deferred Action for Childhood Arrivals is an administrative relief program that offers protections against deportation for eligible immigrants who entered the United States when they were children. A work permit is also provided to those under DACA, renewable every two years. Through this program, health care, however, does not come as a given are authorized to work, they remain ineligible for several federal programs, including the health insurance Marketplaces under the Affordable Care Act (ACA), Children’s Health Insurance Program (CHIP), and even Medicaid. These exclusionary policies have left DACA recipients with unmet challenges and health care needs that must be met.
DACA was established in June of 2012 through executive action by Barack Obama to ensure protections for undocumented immigrants. Although DACA provides protections, it does not provide a linear path to receiving United States citizenship. Individuals with DACA status do retain larger mental health benefits due to the comfort of seeking deportation protection and economic opportunity (Venkataramani et. Al, 2017). However, the benefits to mental health do not outweigh the lack of physical health representation needed, as well as the lack of health benefits that DACA recipients have been deprived of. Although some recipients are able to receive healthcare coverage through their employer, the accessibility to healthcare for all recipients has been a challenge until recently.
As of May 2, 2024, the Biden-Harris Administration finalized a rule that will expand access to healthcare for DACA recipients. Through this ruling, the United States Department of Health and Human Services ensures that DACA recipients will no longer be excluded from eligibility to enroll in a Qualified Health Care plan through the Affordable Care Act’s Health Insurance marketplace, or through joining a Basic Health Program (“Biden-Harris”, 2024). Changes in healthcare policy often come with criticism. Recent lawsuits have emerged due to the ruling. Specifically, a focus will be on Kansas et al. v. United States of America, Centers for Medicare & Medicaid Services. With this analysis, it is crucial to remember that DACA recipients and individuals are at stake in this discussion.
On January 20th, 2021, President Biden issued a memorandum stating both his and his administration's intent to both fortify and preserve the DACA program in its original form ("Preserving,” 2021). The rule comes after clear exclusion of DACA recipients from the definition of the phrase “lawfully present,” thus meaning that those individuals would now be eligible for Basic Health Plan (BHP) coverage, and ACA Health Insurance Marketplace coverage. Chiquita Brooks-LaSure, Centers for Medicare and Medicaid Services Administrator, noted that the Administration “believes health care is a right, not a privilege,” and that a vital step was made in this ruling knowing that healthcare “is available and accessible to all Americans” (“Biden-Harris”, 2024 Redefining the phrase allowed for equitability within the healthcare environment.
Through the new definition of “lawfully present” including DACA recipients, such individuals are eligible to enroll in a Qualified Health Plan (QHP) under the Health Insurance Marketplace. The Marketplace is a government service under the Affordable Care Act that provides a “one-stop” shopping experience for health insurance and plans that The Marketplace helps both people and small businesses retrieve insurance plans and assists in finding information about tax credits for private insurance programs, and cost-sharing reductions. This health plan allows
Starting November 1st, 2024, DACA recipients will have eligibility to utilize these services. This is a significant change from previous years, as DACA recipients are over three times more likely to be uninsured than the US population at large (Baron). In terms of the definition, the HHS stated that the changing of the term “lawfully present” to be more inclusive aligns with the same definition that the Department of Homeland Security utilized in applying for Social Security benefits. Many found the improper alignment of definitions before the new rule questionable, especially since the Department of Homeland Security reiterated in 2022 that DACA recipients fell under the lawfully present title as a noncitizen (Twinamatsiko & Baron, 2024) The Centers for Medicare & Medicaid Services (CMS), a sub agency of U.S. Department of Health and Human Services (HHS), estimate that this rule could lead to 200,000 previously uninsured DACA recipients enrolling in now accessible coverage plans (“FIRST AMENDED,” 2024).
The rule updated the definition of “qualified noncitizen” regarding CHIP and Medicaid, implementing existing statutory requirements and promoting transparency on state processes for policy implementation to determine noncitizen status, including training and eligibility policies. Although the Department of Health and Human Services emphasized that this new ruling would not jeopardize Marketplace coverage for United States citizens, criticism still arose.
Led by Kris Kobach of Kansas, 18 other Republican state attorney general's brought upon a lawsuit challenging the HHS rule extending health care accessibility and coverage to the DACA recipients. The states included as the plaintiffs consist of Kansas, North Dakota, Alabama, Arkansas, Florida, Idaho, Indiana, Iowa, Kentucky, Missouri, Montana, Nebraska, New Hampshire, Ohio, South Carolina, South Dakota, Tennessee, Texas, and Virginia. Filed in a federal district court in North Dakota, the lawsuit was amended August 28th and has been assigned to Judge Daniel M. Traynor.
This First Amended Complaint states that the new rule will harm each state in various ways. The states of Idaho, Virginia, and Kentucky plan to administer their own state-run ACA exchange to handle Qualified Health Plan enrollment, with their own respective program names. The plaintiffs state that expanding eligibility for ACA coverage will impose additional administrative and resource burdens on states that have already established their own ACA exchange, thus creating a federal versus state conflict (“FIRST AMENDED,” 2024). Additionally, it is discussed that the rule will be fiscally draining, as public services such as education, emergency-care expenditures, legal defense, driver’s licensing, and now, public healthcare will be affected. The plaintiffs also state that individuals under DACA who otherwise would have returned to their countries of origin will instead remain in the United States because of the eligibility requirements, thus also potentially increasing immigration.
These 19 states have requested that the court postpone the November 1st eligibility date and ultimately set aside the rule completely. They state that the rule violates the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), as well as the “exclusion of unlawfully present aliens found in the ACA itself” (“FIRST AMENDED,” 2024). They argue that the HHS revised definition of “lawfully present” does not align with PRWORA’s definition of “qualified alien,” decided during a 1996 Congress hearing on prohibiting “non-qualified aliens from receiving any federal public benefit ‘'notwithstanding any other provision of law.” (“FIRST AMENDED,” 2024). The revised definition of the HHS phrase “lawfully present” now includes DACA recipients, allowing them to qualify for healthcare insurance, ensuring access to affordable and accessible care. The Plaintiffs ultimately ask the Court to postpone the effective date, vacate the Final Rule as arbitrary and unreasonable, and to enjoin the CMS from implementing the rule. A Motion for a Stay, Preliminary Injunction Hearing and oral argument date was set for October 15th, 2024.
Although the definition of “lawfully present” is still not finalized by the HHS to include DACA recipients under Medicaid and CHIP eligibility standards, it is still important to note that a great development in creating a proper definition that accounts for individuals represented under DACA has been made considering QHP and BHP.
The litigation at hand is significant, as HHS has sought out a way to address clear health inequities that arose due to the lack of uninsured individuals under the program. Through the new rule and revised definition, DACA recipients will be able to enjoy the benefits of health insurance and become properly insured. When discussing existing systems, it is important to understand that prior to the new ruling on November 1st, DACA recipients were only able to receive healthcare insurance through their employers if they had one. DACA provides a work permit that can be renewed every 2 years. Since Medicaid is still not exactly affected by the ruling, this new rule does not carry a significant impact in terms of policy change. These changes were proposed by the HHS but were not finalized in the recent definition change.
A proposed strategy to emphasize the importance of informing everyone of DACA’s new policy change is to host education campaigns that keep DACA recipients aware of their new rights. This public health campaign will strive to educate both recipients and the public on different insurance options and availability for the groups that qualify, especially DACA recipients. The recent changes in law have not been publicized enough, and the individuals eligible for all forms of healthcare must be informed and educated on their options. The different insurance options must be established in all healthcare settings, including physician’s offices, urgent cares, hospitals, and administrative settings such as financial institutions and banks. Through public health campaigns that properly advocate for individuals protected under DACA, we can make this knowledge easily accessible to those who rightfully need it. Both mental and physical health can be effectively treated in an equitable manner under this ruling, which is critical to the well-being of DACA recipients.
The concept of health insurance equity is a topic that has been discussed many times in reference to many different groups of individuals and opposing viewpoints and criticism that arose due to the ruling, efforts have clearly been made to ensure that DACA recipients are insured. Although there is still work to be done surrounding the access to programs such as
Medicaid and the Children’s Health Insurance Program (CHIP), opening accessibility to ACA’s Health Insurance Marketplace and BHPs is the first step in creating an equitable space in healthcare for all individuals. Through different educational campaigns informing both DACA recipients and the public about the change in the definition, but also different forms of healthcare insurance, recipients will be made better informed about the different options they have for retrieving healthcare. The Centers for Medicare and Medicaid Services have stated that through this new rule, approximately 200,000 DACA recipients will acquire some sort of healthcare insurance but will also simply have to option to become eligible for healthcare benefits, thus bridging the gap and decreasing prominent health inequities regarding insurance and finances with the immigration system in the United States.
