By: Esther Davila
Published On: June 10, 2023
During his 1992 presidential campaign, Bill Clinton told his supporters, “‘Welfare should be a second chance, not a way of life . . . . [W]e’re going to put an end to welfare as we know it.’”[1] Four years later, his campaign promise became a reality when Congress passed the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA). PRWORA’s primary goal was to promote welfare recipients’ self-sufficiency through work by shifting the federal government’s control of public benefit programs to the states;[2] however, the Act also had the of restricting noncitizens’ use of public benefit programs.[3]
Under Title IV of PRWORA, comprehensive eligibility requirements were established for noncitizens seeking federal public benefits.[4] Before 1996, there was no uniform rule or statute that governed the eligibility requirements of noncitizens.[5] Thus, PRWORA intended to establish uniform eligibility requirements that would apply across a broad spectrum of federal public benefits programs.[7]
PRWORA’s eligibility requirements created two categories of noncitizens: qualified noncitizens and non-qualified noncitizens.[8] Qualified noncitizens are lawful permanent residents, refugees, and asylees, [9] while non-qualified noncitizens are undocumented immigrants and other immigrants without permanent status– Deferred Action for Childhood Arrivals (DACA) recipients, Temporary Protected Status (TPS) holders, and Only noncitizens who are categorized as qualified are eligible for federal public benefits programs,[11] such as Medicaid, the Supplemental Nutritional Assistance Program (SNAP), Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), and most housing assistance programs.[12] Although qualified noncitizens appear to benefit under PRWORA, the Act’s eligibility requirements also restricts them in a number of ways.
PRWORA’s eligibility requirements are restrictive to both qualified noncitizens and non-qualified noncitizen in two ways. First, undocumented immigrants and other immigrants without permanent status are barred from accessing federal benefit programs due to their non-qualified status.[13] Second, lawful permanent residents, who are authorized to live permanently in the United States, and are classified as qualified noncitizens are barred from accessing federal public benefits for five years.[14] Thus, even with the qualified status these noncitizens must still wait five years before applying and receiving federal benefits even if they meet other eligibility requirement for federal public benefit programs.
PRWORA Unjustly Excludes Noncitizens from Accessing Medicaid
The restrictive nature of PRWORA’s eligibility requirements is detrimental to the health of noncitizens. Unlike citizens, noncitizens are more likely to be uninsured.[15] In 2021, twenty-five percent of lawfully present noncitizens and forty-six percent of undocumented noncitizens were uninsured compared to eight percent of citizens.[16] This is because PRWORA’s eligibility restrictions limit noncitizens’ opportunities to obtain Medicaid by making non-qualified noncitizens ineligible for benefits and barring qualified lawful permanent residents from accessing benefits for five years. Noncitizens also cannot seek private healthcare coverage because they are more likely to be low-income and employed in jobs that are less likely to offer prohibited from purchasing coverage through the ACA Marketplace.[17] Although noncitizens may access emergency Medicaid in dire situations, [18] without consistent and proper access to healthcare coverage, noncitizens are more likely to delay or go without needed care, which ultimately worsen health outcomes.[19]
Noncitizens are unjustly precluded from Medicaid coverage despite their significant tax contributions which are critical to Medicaid’s viability.[20] To address the federal government’s shortfall, several states have expanded state-funded coverage for noncitizens including those that are undocumented. In 2022, eight states provided state-funded coverage to all income-eligible children, regardless of legal status, and eighteen states guaranteed prenatal care regardless of legal status.[21] Furthermore, several states and the District of Columbia have expanded state-funded coverage to also include adult noncitizens.[22] Research has shown that these expansions reduce uninsurance rates, increase healthcare among noncitizens, and improve health outcomes.[23]
Although several states have made it a priority to meet the healthcare needs of noncitizens, it is time for the federal government to begin acting. PRWORA restricts noncitizens’ access to federal public benefits through its eligibility requirements, which especially limits noncitizens’ abilities to access affordable healthcare through Medicaid. As states continue to expand state-funded coverage, access to healthcare coverage for noncitizens will become scattered across the country. To ensure all noncitizens have equal access to Medicaid-like coverage, the federal government must consider implementing new policies that overcome the barriers established by PRWORA’s eligibility requirements for noncitizens. Not only would this increase noncitizens’ access to Medicaid, but it would also promote access to other essential federal public benefit programs.
[1] Dylan Matthews, “If the Goal Was to Get Rid of Poverty, We Failed”: The Legacy of the 1996 Welfare Reform, Vox (June 20, 2016, 9:10 AM), https://www.vox.com/2016/6/20/11789988/clintons-welfare-reform.
[2] See Mary Pilon, How Bill Clinton’s Welfare Reform Changed America, History, https://www.history.com/news/clinton-1990s-welfare-reform-facts (Aug. 19, 2018), (discussing how PRWORA ended six decades of federal government control of welfare programs by having the federal government only directly fund the programs through block grants).
[3] See Neeraj Kaushal & Robert Kaestner, Welfare Reform and Health Insurance of Immigrants, 40 Health Servs. Rsch. 697, 698 (2005), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361164/pdf/hesr_00381.pdf (analyzing the effect of PRWORA on the health insurance coverage of foreign- and U.S.-born, unmarried women and their children).
[4] 8 U.S.C. §§ 1601, 1611–1615 (stating that “it is a compelling government interest to enact new rules for eligibility and sponsorship agreements in order to assure that [noncitizens] be self-reliant in accordance with national immigration policy”).
[5] Cong. Rsch, Serv., Unauthorized Immigrants’ Eligibility for Federal and State Benefits: Overview and Resources, 1, 1 (2022), https://sgp.fas.org/crs/misc/R47318.pdf [hereinafter “Unauthorized Immigrants”].
[6] Cong. Rsch. Serv., PRWORA’s Restrictions on Noncitizen Eligibility for Federal Public Benefits: Legal Issues 1, 1-2 (2020), https://crsreports.congress.gov/product/pdf/R/R46510.
[7] Id. at 2.
[8] See Tanya Broder et al., Overview of Immigrant Eligibility for Federal Programs, Nat’l Immigr. L. Ctr., https://www.nilc.org/issues/economic-support/overview-immeligfedprograms/ (Oct. 2022) (explaining the eligibility requirements of major federal benefit programs and barriers that noncitizens face).
[9] See Non-Citizens, MAPAC, https://www.macpac.gov/subtopic/noncitizens/ (last visited Jan. 27, 2023) (presenting a table with a breakdown of the eligibility requirements of qualified noncitizens).
[10] See Fact Sheet: Undocumented Immigrants and Federal Health Care Benefits, Nat’l Immigr. F. (Sept. 21, 2022), https://immigrationforum.org/article/fact-sheet-undocumented-immigrants-and-federal-health-care-benefits/ [hereinafter “Fact Sheet”] (describing the health care benefits that undocumented noncitizens are and are not eligible for).
[11] Noncitizens, supra note 9.
[12] Unauthorized Immigrants, supra note 5, at 3.
[13] Fact Sheet, supra note 10.
[14] Noncitizens, supra note 9.
[15] Health Coverage and Care of Immigrants, Kaiser Fam. Found. (Dec. 20, 2022), https://www.kff.org/racial-equity-and-health-policy/fact-sheet/health-coverage-and-care-of-immigrants/ [hereinafter “Health Coverage”].
[16] Id.
[17] See Louise Norris, How Immigrants Can Obtain Health Coverage, Healthinsurance.org (Aug. 18, 2022), https://www.healthinsurance.org/obamacare/how-immigrants-are-getting-health-coverage/ (emphasizing that noncitizens must meet all of Medicaid’s other eligibility requirements to be eligible for emergency services).
[18] Fact Sheet, supra note 10.
[19] See Health Coverage, supra note 15 (demonstrating that thirty-two percent of noncitizens went a year without visiting a doctor and ten percent of noncitizens went a year without medical care due to costs).
[20] Fact Sheet, supra note 10.
[21] Id.
[22] Health Coverage, supra note 15.
[23] Id.