[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 2646 Introduced in Senate (IS)]

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118th CONGRESS
  1st Session
                                S. 2646

  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 SENATE OF THE UNITED STATES

                             July 27, 2023

 Mr. Booker (for himself, Mr. Markey, Ms. Hirono, Mr. Blumenthal, Mrs. 
Gillibrand, Mr. Sanders, Ms. Warren, Mr. Padilla, Mrs. Murray, and Mr. 
   Heinrich) introduced the following bill; which was read twice and 
                  referred to the Committee on Finance

_______________________________________________________________________

                                 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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