[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


                         WHY EXPANDING MEDICAID
                   TO DACA RECIPIENTS WILL EXACERBATE
                           THE BORDER CRISIS

=======================================================================

                                HEARING

                               BEFORE THE

                      SUBCOMMITTEE ON HEALTH CARE
                         AND FINANCIAL SERVICES

                                 OF THE

                         COMMITTEE ON OVERSIGHT
                           AND ACCOUNTABILITY

                        HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 18, 2023

                               __________

                           Serial No. 118-51

                               __________

  Printed for the use of the Committee on Oversight and Accountability
  
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]  


                       Available on: govinfo.gov
                         oversight.house.gov or
                             docs.house.gov
                             
                               __________

                                
                    U.S. GOVERNMENT PUBLISHING OFFICE                    
53-005 PDF                  WASHINGTON : 2023                    
          
-----------------------------------------------------------------------------------                                 
                             
               COMMITTEE ON OVERSIGHT AND ACCOUNTABILITY

                    JAMES COMER, Kentucky, Chairman

Jim Jordan, Ohio                     Jamie Raskin, Maryland, Ranking 
Mike Turner, Ohio                        Minority Member
Paul Gosar, Arizona                  Eleanor Holmes Norton, District of 
Virginia Foxx, North Carolina            Columbia
Glenn Grothman, Wisconsin            Stephen F. Lynch, Massachusetts
Gary Palmer, Alabama                 Gerald E. Connolly, Virginia
Clay Higgins, Louisiana              Raja Krishnamoorthi, Illinois
Pete Sessions, Texas                 Ro Khanna, California
Andy Biggs, Arizona                  Kweisi Mfume, Maryland
Nancy Mace, South Carolina           Alexandria Ocasio-Cortez, New York
Jake LaTurner, Kansas                Katie Porter, California
Pat Fallon, Texas                    Cori Bush, Missouri
Byron Donalds, Florida               Shontel Brown, Ohio
Kelly Armstrong, North Dakota        Jimmy Gomez, California
Scott Perry, Pennsylvania            Melanie Stansbury, New Mexico
William Timmons, South Carolina      Robert Garcia, California
Tim Burchett, Tennessee              Maxwell Frost, Florida
Marjorie Taylor Greene, Georgia      Summer Lee, Pennsylvania
Lisa McClain, Michigan               Greg Casar, Texas
Lauren Boebert, Colorado             Jasmine Crockett, Texas
Russell Fry, South Carolina          Dan Goldman, New York
Anna Paulina Luna, Florida           Jared Moskowitz, Florida
Chuck Edwards, North Carolina        Vacancy
Nick Langworthy, New York
Eric Burlison, Missouri

                       Mark Marin, Staff Director
       Jessica Donlon, Deputy Staff Director and General Counsel
                    Tyler Sanderson, Senior Counsel
      Mallory Cogar, Deputy Director of Operations and Chief Clerk

                      Contact Number: 202-225-5074

                  Julie Tagen, Minority Staff Director
                      Contact Number: 202-225-5051
                                 ------                                

           Subcommittee on Health Care and Financial Services

                   Lisa McClain, Michigan, Chairwoman
Paul Gosar, Arizona                  Katie Porter, California Ranking 
Virginia Foxx, North Carolina            Minority Member
Glenn Grothman, Wisconsin            Alexandria Ocasio-Cortez, New York
Russell Fry, South Carolina          Jimmy Gomez, California
Anna Paulina Luna, Florida           Greg Casar, Texas
Nick Langworthy, New York            Summer Lee, Pennsylvania
Eric Burlison, Missouri              Jasmine Crockett, Texas
Vacancy                              Vacancy
                        
                        
                        C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Hearing held on July 18, 2023....................................     1

                               Witnesses

                              ----------                              

Dr. Ellen Montz, Deputy Administrator and Director, Center for 
  Consumer Information and Insurance Oversight, Centers for 
  Medicare and Medicaid Services
Oral Statement...................................................     4

Written opening statements and statements for the witnesses are 
  available on the U.S. House of Representatives Document 
  Repository at: docs.house.gov.

                           Index of Documents

                              ----------                              

  * Co-Sponsor Hazard Pay; submitted by Rep. Lee.

  * Statement for the Record, Center on Budget and Policy 
  Priorities; submitted by Rep. Lee.

  * Statement for the Record, National Immigration Law Center; 
  submitted by Rep. Lee.

  * Statement for the Record, from various organizations; 
  submitted by Rep. Lee.

  * Statement for the Record, FAIR; submitted by Rep. McClain.

  * Statement for the Record, National Health Law Program; 
  submitted by Rep. Porter.

Documents are available at: docs.house.gov.

 
                         WHY EXPANDING MEDICAID
                        TO DACA RECIPIENTS WILL
                      EXACERBATE THE BORDER CRISIS

                              ----------                              


                         Tuesday, July 18, 2023

                        House of Representatives

               Committee on Oversight and Accountability

           Subcommittee on Health Care And Financial Services

                                                   Washington, D.C.

    The Subcommittee met, pursuant to notice, at 2:11 p.m., in 
room 2154, Rayburn House Office Building, Hon. Lisa McClain 
[Chairwoman of the Subcommittee] presiding.
    Present: Representatives McClain, Foxx, Grothman, Luna, 
Langworthy, Burlison, Porter, Ocasio-Cortez, Casar, Lee, and 
Crockett.
    Mrs. McClain. The Subcommittee on Health Care and Financial 
Services will come to order. Welcome, everyone.
    Without objection, the Chair may declare a recess at any 
time.
    I recognize myself for the purpose of making an opening 
statement.
    Today, we are, again, conducting oversight of yet another 
disastrous policy by the Biden Administration that will only 
exacerbate the crisis along the Southern border. The Centers 
for Medicare & Medicaid Services have proposed a rule to extend 
Medicaid, CHIP, and Obamacare eligibility, Deferred Action for 
Childhood Arrivals, or DACA, recipients in direct contradiction 
to congressional intent.
    Once again, the Biden Administration officials are seeking 
to rewrite laws through agency rulemaking because they know 
their policies are not supported by the American people, and 
they would not be able to pass in the House nor the Senate. 
Instead, they are proposing a rule with dubious legal basis to 
provide taxpayer-funded Federal health benefits to individuals 
who have entered this country illegally.
    Even President Obama understood this much when his 
Administration determined in 2012 that DACA recipients should 
not be eligible for Medicaid. A Federal judge has already 
deemed the entire DACA Program, which was unilaterally created 
through nothing more than an emergency memorandum, unlawful. 
DHS is currently prohibited from accepting further applications 
by a court order. Despite this, the Administration proceeds 
with a plan to spend hundreds of millions more of taxpayer 
dollars on healthcare benefits for DACA recipients.
    CMS' own estimates show that the expansion will increase 
state expenditures for Medicaid and CHIP by $40 million, and 
Federal expenditures would expand by another $60 million per 
year, and that does not include the proposed Obamacare 
expansion, which is projected to cost another $15 million per 
year. And you know who the Biden Administration expects to pay 
for it? The American taxpayers.
    Further, the Biden Administration's proposal will 
incentivize further illegal immigration. The Biden 
Administration has chosen, unfortunately, to prioritize illegal 
immigrants over the American people. I simply do not understand 
it. These funds could be used to provide better healthcare to 
the American people, and that is why we must stop this 
Administration from rewarding illegal immigrants at the expense 
of American citizens. We must ensure that Americans are being 
put first.
    By definition, DACA recipients are still and always were 
unlawfully present in the United States. The Biden 
Administration cannot simply alter that fact. In extending 
Federal benefits to illegal immigrants, President Biden is 
signaling to the rest of the world that not only will the U.S. 
not enforce laws preventing illegal immigration, but illegal 
immigrants will be rewarded with Federal benefits. We should 
not reward individuals unlawfully present in the United States 
with benefits that were created for American citizens and those 
who are lawfully present in the country.
    The Biden Administration is responsible for one of the 
worst crises in the recent memory along our Southwest border. 
By extending Federal benefits to illegal immigrants, the Biden 
Administration is once again pouring gasoline on an out-of-
control fire that will only incentivize more illegal 
immigration, but such reckless tone, tone-deaf policies have 
become the status quo for this Administration.
    With that, I want to thank Dr. Montz for being here today. 
We look forward to your testimony.
    Now I yield to the Ranking Member, Ms. Porter for her 
opening statement. Ms. Porter?
    Ms. Porter. Thank you, Chairwoman McClain. We have done 
some really good hearings together this year. We have come 
together on a bipartisan basis to uncover the root causes 
behind the infant formula shortage, we have pointed out how 
bank regulators need oversight, and we have dug into the role 
of Chinese money laundering organizations in making the drug 
cartels rich. What do all of these things have in common? We 
have tackled real problems: deaths from fentanyl, scared 
parents unable to feed their babies, risks to our financial 
system. We have shown we are willing on a bipartisan basis to 
hold powerful people to account. We identified places where we 
need guardrails to make our government, our economy, and our 
country work better. And though we did not agree on everything, 
we came together on the big picture to achieve progress. I am 
afraid that none of those things are true for today's hearing.
    Today, we are here to discuss the proposed rule from the 
Biden and Harris Administration that would expand health 
coverage to everyone lawfully present in the United States. 
Medicaid and the Affordable Care Act plans are already 
available to people who are lawfully present in the U.S., but 
under current Federal rules, Dreamers are left out of the 
definition of ``lawfully present.'' President Biden's proposed 
rule changes that. Why would the President do that? Because, 
well, DACA recipients are, in fact, lawfully present in the 
United States. How? Because Congress passed the DACA law. There 
is not a whole lot else to unpack.
    So, what are Republicans trying to do with this hearing? It 
is not oversight because the ability to go to the doctor is not 
an abuse of power or an evasion of the law. The title of this 
hearing gives a clue: ``Why Expanding Medicaid to DACA 
Recipients Will Exacerbate the Border Crisis.'' Let us look at 
the premise here. First, some facts. Many DACA recipients 
already have health coverage through their employers, just like 
other working-age Americans. Dreamers work hard, pay taxes, and 
they get employer-provided care. So, how many Dreamers would 
even get Medicaid under this new rule? About 13,000, about the 
size of one small town. And then the other Dreamers would be 
able to buy, using their own wages, healthcare on the exchange, 
just like anyone else who lives and works here in the United 
States, and do so in compliance with the law. Somehow letting 
people who legally live in the United States buy healthcare is 
going to create a border crisis?
    It would be funny to watch this bad argument fall apart if 
it were not such a waste of time. This Subcommittee has had 
great hearings under Chairwoman McClain's leadership, hearings 
that held powerful people accountable, identified missing 
guardrails, and improved the lives of the people we serve. This 
hearing does not meet those standards because what powerful 
people are we holding to account here?
    The people who would get healthcare under this rule are not 
rich or well connected. These folks are not using their 
powerful positions to abuse the system. They are just regular 
workers trying to get insurance so they can stay healthy. OK 
then. So, what missing guardrails are we identifying? None. 
This hearing is not about putting up guardrails, it is about 
ripping away a safety net. It is telling people who have 
followed the rules of the DACA Program that they cannot access 
healthcare. OK, then. So, how does this hearing make life 
better for our constituents? All I can say is when you are 
making it harder for people to be healthy, you are going to 
have a tough sell that you are in it for the people. And 
honestly, I think that is why this hearing is framed to be 
about the border.
    Most Americans want healthy communities. Most Americans 
want Dreamers to have a future in our country. But too many 
Republican lawmakers do not want either of these things, and 
they know they are not going to convince the people by arguing 
against popular policies, like accessible healthcare. So 
instead, they are bringing in buzzwords like ``border crisis'' 
to try to save the day. Republicans need to be able to defend 
the real reasons that they continue to oppose healthcare 
expansion if this is the hearing that they want to have. 
Otherwise, I hope we will go back to having serious oversight 
hearings. I have seen that the Republicans can do it, and the 
American people deserve no less. I yield back.
    Mrs. McClain. Thank you, Ms. Porter.
    Pursuant to Rule 9(g), the witness will please stand and 
raise her right hand.
    Do you solemnly swear or affirm that the testimony that you 
are about to give is the truth, the whole truth, and nothing 
but the truth, so help you God?
    Ms. Montz. Aye.
    Mrs. McClain. Let the record show the witness has answered 
in the affirmative.
    We appreciate you being here today and look forward to your 
testimony. Let me remind the witness that we have read her 
written statement, and it will appear in full in the hearing 
record. Please limit your oral statements to 5 minutes.
    As a reminder, please press the button on the microphone in 
front of you so that it is on, and the Members can hear you. 
When you begin to speak, the light in front of you will turn 
green. After 4 minutes the light will turn yellow. When the red 
light comes on, your 5 minutes has expired, and we would ask 
that you would please wrap up.
    I recognize Ms. Montz to begin her opening statement.

                        STATEMENT OF ELLEN MONTZ

                   DEPUTY ADMINISTRATOR AND DIRECTOR

                    CENTER FOR CONSUMER INFORMATION

                        AND INSURANCE OVERSIGHT

                CENTERS FOR MEDICARE & MEDICAID SERVICES

    Ms. Montz. Good afternoon. Chairs Comer and McClain, 
Ranking Members Raskin and Porter, and Members of the 
Subcommittee, thank you for the opportunity to provide an 
update on the Centers for Medicare & Medicaid Services' work to 
expand access to healthcare by reducing barriers for Deferred 
Action for Childhood Arrival Recipients.
    Over the last decade, DACA has provided peace of mind and 
work authorization to more than 800,000 Dreamers. In April 
2023, the President announced his intention to expand health 
coverage for DACA recipients, and directed the Department of 
Health and Human Services to examine options that would allow 
DACA recipients to gain eligibility for coverage through health 
insurance marketplaces, the basic health program, and some 
Medicaid and Children's Health Insurance Programs. Accordingly, 
on April 24 of 2023, CMS released a proposed rule which, if 
finalized, would remove the current exclusion that treats DACA 
recipients differently from other individuals with deferred 
action. The proposed change to no longer exclude DACA 
recipients from CMS' definitions of lawfully present would 
align with the Department of Homeland Security's definition of 
``lawful presence'' and DHS' explanation of this definition in 
their August 2022 final rule.
    Deferred action recipients, including DACA recipients, have 
historically been considered lawfully present for purposes of 
Social Security benefits, pre-dating the DHS DACA final rule. 
Under CMS' proposed rule, DACA recipients would need to meet 
all other program eligibility requirements to qualify for 
coverage under CMS healthcare programs. As with all other 
enrollees, eligibility information, including an individual's 
U.S. citizenship or immigration status, would be verified 
electronically.
    The Affordable Care Act generally requires that in order to 
enroll in a qualified health plan through an exchange, an 
individual must either be a citizen or national of the United 
States or be lawfully present in the United States. The 
Children's Health Insurance Reauthorization Act of 2009 
provided an option for states to cover additional non-citizen 
populations, including coverage of lawfully residing children 
and pregnant individuals in Medicaid and CHIP, commonly 
referred to as the CHIPRA 214 option.
    Although HHS interpreted ``lawfully present'' to exclude 
DACA recipients in 2012, we now know how important ensuring 
access to health insurance coverage is to the well-being and 
productivity of DACA recipients. For example, a 2021 survey of 
DACA recipients found that although DACA may facilitate access 
to health insurance through employer-based plans, more than 
one-third of DACA recipients responded reported that they were 
not covered by health insurance. These findings suggest that 
without additional health coverage options, many DACA 
recipients could be left without access to affordable 
healthcare coverage. Individuals without health insurance are 
less likely to receive preventive or routine health screenings 
and may delay necessary medical care or receive uncompensated 
care in emergency rooms. The COVID-19 public health emergency 
further highlighted the need for individuals to have access to 
high-quality, affordable healthcare coverage.
    According to a demographic estimate by the Centers for 
Migration Studies, over 200,000 DACA recipients served as 
essential health workers during the COVID-19 public health 
emergency, including healthcare and in social assistance 
occupations. During the height of the pandemic, essential 
workers were disproportionately likely to contract COVID-19. 
These factors emphasize how increasing access to affordable 
health insurance would improve the health and well-being of 
many DACA recipients who are currently uninsured. If the rule 
is finalized as proposed, it could lead to 129,000 previously 
uninsured DACA recipients receiving healthcare coverage. 
Including DACA recipients in the definition of ``lawfully 
present'' would align with the goals of ACA and CHIPRA, 
specifically to reduce the number of people who are uninsured 
in the United States and make affordable health insurance 
available to more people. Thank you for the opportunity to 
testify on this important issue.
    Mrs. McClain. Thank you. The Chair now recognizes Mr. 
Grothman for 5 minutes, from Wisconsin.
    Mr. Grothman. All right. I guess President Biden did run on 
giving healthcare to people coming across the border. One of 
the arguments against DACA is the idea that once you grant it 
once, you are always going to continue granting it, and so far 
that is true. Do you feel that free healthcare for people who 
at least came here illegally will result in more illegal 
immigration, or do you have any study on that or consider 
whether that is going to be a factor?
    Ms. Montz. This rule relates to our proposal to include 
DACA recipients and eligibility----
    Mr. Grothman. Right. I know. And by giving DACA recipients 
free healthcare, people who came across the border, albeit 
maybe with their parents, although not always, illegally, will 
this encourage people in the future to come across the border 
or bring their children across the border?
    Ms. Montz. DACA recipients are a defined population of 
individuals who came to the United States as children and have 
been residing here since 2007.
    Mr. Grothman. Right, right, right. And I think the feeling 
in the past is when you give, say, even amnesty, it causes 
people abroad to think you are going to get amnesty again. When 
I have been at the Southern border, already the Border Patrol 
tells me that people are coming here for American healthcare 
because they know that America, being so generous, sure, will 
give you dialysis whenever if they come here. Do you think this 
sends a message, because I assume if it is OK for people to 
declare DACA if they came here in 2007, in the next few years, 
somebody will say, you know, you are DACA if you came here in 
2017. In that regard, don't you feel that this promotes illegal 
immigration?
    Ms. Montz. I can only speak to what is current law, and 
this proposed rule proposes to extend health coverage to DACA 
recipients and not other individuals.
    Mr. Grothman. Yes. What do you think is the annual cost of 
this program?
    Ms. Montz. Our proposed rule has estimates included in the 
regulatory impact analysis. We estimate that about 129,000 
individuals will gain coverage if this rule is finalized. That 
is about 13,000 individuals in the 35 states that have chosen 
the optional coverage in Medicaid and CHIP, and just over 
110,000 in marketplace coverage. As for costs, there are 
roughly 35 states that have chosen the option to cover pregnant 
individuals and children lawfully present, pregnant individuals 
and children, we estimate that to be about $100 million per 
year, and for marketplace coverage, we estimate that to be 
about $300 million per year.
    Mr. Grothman. OK. One of the concerns I have with Medicaid 
across the board is it does affect the way people behave in 
order to get the benefit, OK? It both discourages work and 
discourages marriage. Does that bother you at all that we are 
adding another benefit to people who are not going to get it if 
they either arrange for their own healthcare through work, or, 
like I said, all these income transfer programs discourage 
marriage. Have you thought about that or done any analysis to 
see how this will affect people's behavior?
    Ms. Montz. As I have said, CMS is committed to providing 
quality affordable healthcare coverage----
    Mr. Grothman. So, you do not care. That is not a concern to 
you?
    Ms. Montz. What we have seen in the Medicaid Program and 
other programs as well is that health insurance allows people 
to be better productive in the work force.
    Mr. Grothman. Right. You must know. Maybe you do not know, 
maybe you do not talk to people. That already in America, 
people who want to get on Medicaid, adjust their income so they 
get the benefit, correct? Are you aware of that?
    Ms. Montz. What I am aware of is that most working-age 
individuals who are enrolled in Medicaid are employed, and 
those who are not employed----
    Mr. Grothman. They may be employed, but they adjust their 
income to make sure that they are eligible for this benefit.
    Ms. Montz. I am not aware of that.
    Mr. Grothman. Correct?
    Ms. Montz. I am not aware of that.
    Mr. Grothman. OK. Would you agree to limit the program to a 
certain cost, or is it going to be the sky is the limit, 
however many people take advantage of the program?
    Ms. Montz. In our proposed rule, we have proposed to extend 
eligibility through the definition of----
    Mr. Grothman. So, in other words, it is just changing the 
eligibility standards that could cost the government an 
unlimited amount of money and that you are not limiting the 
amount the taxpayer is going to have to pay?
    Ms. Montz. As I said, we have estimated the cost of 
proposed changes under the rule.
    Mr. Grothman. OK. Thank you.
    Mrs. McClain. Thank you, Mr. Grothman. The Chair now 
recognizes the gentlewoman from New York. I can never say your 
name. I apologize.
    Ms. Ocasio-Cortez. Ocasio-Cortez.
    Mrs. McClain. Ocasio-Cortez. Thank you----
    Ms. Ocasio-Cortez. Thank you. Thank you very much. That is 
all right. Thank you so much, Dr. Montz, for joining us here 
today. I would be remiss, just for us to put into context what 
this hearing is about, we are having a hearing about why we 
should not proceed with healthcare coverage and Medicaid 
coverage to DACA recipients, people who are lawfully here in 
the United States. And we are having this hearing on the heels 
of Governor Abbott in Texas issuing an order to Texas troopers 
to push children and infants into the Rio Grande River. And now 
we are having a hearing today about why we should push people 
who were brought here as children off of healthcare coverage.
    I cannot proceed without saying that denying healthcare to 
anyone, I believe, is morally repugnant, but moreover, I also 
want to highlight a little bit of the relationship here that 
the United States has with DACA recipients. Dr. Montz, are you 
aware of how much in Federal, or state, or local taxes that 
DACA recipients pay?
    Ms. Montz. I am not.
    Ms. Ocasio-Cortez. DACA recipients pay about $6.2 billion 
in Federal taxes alone. They pay another $3.3 billion in state 
and local taxes each year. And given that, I think it also 
further highlights the relationship that the United States has 
with DACA recipients, which is that we take, and we take, and 
we take. We take taxes. We take their employment. We have 
hundreds of thousands of--yes, 345,000 DACA recipients served 
as essential workers in 2021 during the COVID pandemic alone.
    They serve in our healthcare systems, they serve our 
elderly, they are nursing home workers, and we are having a 
hearing today as to why people who are American--they are 
American--do not deserve healthcare. They are here lawfully. 
They pay more taxes than Facebook does. They pay more taxes 
than many of our Federal corporations do. DACA recipients pay 
for Members of Congress' healthcare more than Facebook does, 
and we are sitting here having a hearing and saying we are 
going to return that favor by stripping them of their ability 
to engage in Medicaid when they are the ones that are changing 
our grandparents' sheets in a nursing home. I cannot believe 
this.
    The idea that this would somehow act as an incentive when 
any DACA eligibility ended in 2007, over a dozen years ago, is 
laughable. As is, I believe, the premise that the American 
healthcare system is somehow some boon for working-class people 
and the best in the world. What in the American exceptionalism 
is going on here? I do not know a group of people that 
oftentimes are more patriotic to this country than DACA 
recipients. They give, and they give, and they give to a 
country that does not love them back in their actions. Yet 74 
percent of Americans, Republican and Democrat, believe in a 
path to citizenship for DACA recipients, for children who were 
brought here and made this place their home.
    These DACA recipients are emblematic of the American Dream, 
they are America's proof of concept, and to strip and undermine 
that is to undermine ourselves in this institution. If there is 
any individual that believes in stripping Medicaid from DACA 
recipients, I would like to know if they are willing to give 
the $6.6 billion that DACA recipients pay in Federal taxes back 
to them. Are we willing to refund the $3.3 billion in state and 
local taxes that they pay back to them so that they can afford 
their own healthcare? This should not even be a question right 
now, and with that, I yield back.
    Mrs. McClain. Thank you. The Chair now recognizes Mr. 
Burlison from Missouri.
    Mr. Burlison. Thank you, Madam Chair. Thanks for this 
hearing. Dr. Montz, is the U.S. Government in debt?
    Ms. Montz. I believe we are.
    Mr. Burlison. Do you happen to know, off the top of your 
head, how much debt that we currently have?
    Ms. Montz. I do not.
    Mr. Burlison. It is $32.5 trillion. Do you know how much 
that is per citizen?
    Ms. Montz. I do not.
    Mr. Burlison. It is nearly a $100,000 per citizen. Per 
taxpayer, it is over $250,000. If the bill came due today, 
every taxpaying citizen in the United States would have to fork 
up $250,000 because this place blows money, and, you know, have 
you ever heard of the economist, Milton Friedman?
    Ms. Montz. Yes.
    Mr. Burlison. OK. Milton Friedman is famous for quoting, 
and his quote about this issue was that he said, ``It is just 
obvious, should be self-evident to anybody, that you cannot 
have free immigration and a welfare state.'' And why would he 
say that?
    Ms. Montz. I am not sure.
    Mr. Burlison. Because it is basically a run on the 
institution. You have individuals who we are now opening up to 
be charitable to. You know, at the end of the day, when the 
government taxes someone and then takes that money and gives it 
to someone, is that charity? Pays for their services, their 
healthcare.
    Ms. Montz. I believe we have taxes----
    Mr. Burlison. Yes, we are being benevolent, right? 
Benevolent. The question at hand is not that benevolence cannot 
exist in America. The government has a monopoly power on force. 
When they tax you, they are forcing you to spend money on the 
things that government wants to spend money on. They are 
forcing you to be charitable, to be benevolent with your 
dollars. I am just beside myself that we would think that this 
could occur without continuing to bankrupt a Nation that is on 
the tipping point, on the verge.
    So, one of my questions has to do with the fact that when 
DACA was created under Obama, that he explicitly excluded DACA 
recipients from Medicaid, CHIP, and ACA benefits. Why did he do 
that?
    Ms. Montz. I believe the rule referenced some DHS 
memorandum and policymaking.
    Mr. Burlison. Well, I do not know that was an answer. You 
said that they issued a memorandum.
    Ms. Montz. Sorry. The 2012 rule that used HHS' authority to 
define lawful presence as it relates to the Affordable Care 
Act, and CHIPRA 2009 referenced rulemaking done by the 
Department of Homeland Security in its rationale for excluding 
DACA recipients from the HHS' definition of lawful presence. As 
we have put forward in the proposed rule that we recently put 
out here that we are discussing today, we put forth the Biden 
Administration's rationale for changing that, for changing that 
policy interpretation under our authority.
    Mr. Burlison. OK. A question: is DHS currently allowed to 
add new applicants to DACA?
    Ms. Montz. I would defer to DHS for that answer.
    Mr. Burlison. So, the way I understand it, the answer is no 
because a Federal judge held that DACA is unlawful. And so, the 
question then becomes if it is unlawful, what justification do 
you have to add individuals on a program that has been deemed 
by the courts to be unlawful?
    Ms. Montz. The proposed rule that we put forward reflects 
current law in which DACA recipients----
    Mr. Burlison. And who directed you on the proposed rule? 
Did Congress direct you? Do you have direction from Congress?
    Ms. Montz. It is a proposed rule pursuant to HHS' authority 
under the Affordable Care Act and CHIPRA 2009.
    Mr. Burlison. Did the White House instruct you?
    Ms. Montz. Through any general kind of proposed rulemaking 
process, HHS, the White House, OMB and other affected Federal 
agencies are involved in the----
    Mr. Burlison. Thank you. At the end of the day, healthcare 
costs a lot of money. This Nation is nearly broke, and there is 
not enough to pay for everybody. I yield back.
    Mrs. McClain. Thank you. The Chair now recognizes the 
gentleman from Texas, Mr. Casar.
    Mr. Casar. Thank you. Just to be really clear about what it 
is we are debating today, the Biden Administration has chosen 
to stop discriminating against DACA recipients so they can buy 
health insurance on the exchanges like everybody else. They pay 
their taxes, billions in taxes, and thankfully, the Biden 
Administration has said we are going to stop discriminating 
against DACA recipients just like we are going to treat them 
like other legally present people. And Republicans are arguing 
that we need to undo this really commonsense change from the 
Biden Administration.
    And I have been sitting here this whole hearing, and I 
still cannot understand from the Republican Majority why they 
think that DACA recipients, who are paying billions of dollars 
in taxes to pay for healthcare programs, should not have health 
insurance and should instead go to the emergency room. So, I 
will take this moment just to hear from anybody in the Majority 
to hear why, if they are paying billions in taxes, we should 
keep discriminating against them.
    Or why, if a mom is pregnant, we all chip in, we all 
participate because we know we want her to be able to take care 
of her kids. That is why moms who are low income can get access 
to Medicaid for the folks that are prolife in this group. Why 
is it that we want moms, who are legally present in this 
country, to not have access to health insurance? That is the 
question. It is the only question, if there are any takers.
    We have been in bipartisan hearings where we have engaged 
productively. This is confounding. I want to hear why a mom who 
is legally present, who has paid her taxes, that we make sure 
we take care of moms in this country, but then we say, no, DACA 
recipients, we are going to take your labor, we are going to 
take your talents, we are going to take your sweat, we are 
going to take your blood, we are going to accept your 
brilliance, your talents, your inventions, but, no, if you get 
pregnant, we are not here, you do not need health insurance. 
Chairwoman? Anyone?
    It is shameful. It is absolutely shameful. Providing people 
healthcare is not a reward. It is not charity. It is what we do 
because people go out and work and participate in society, and 
when my seniors need access to Medicare, I do not say this is a 
reward or this is charity. I say thank you. This is what we owe 
to one another, and we should do the same thing no matter who 
you are or where you are born in this country. It is not a 
reward. We should just be doing the right thing.
    What DACA recipients have been asking for is not charity. 
It is for us to stop punishing them. They grew up in this 
country, they immigrated here as children, and they have just 
said stop punishing us. Let us live like everybody else, and 
the DACA recipients who are hearing this and their family 
members should know that you have earned it. You should not 
have to come and ask us for access to health insurance or to be 
treated like everybody else. It is something you earn every 
single day by taking care of your family members, by 
participating in this country, by taking care of school kids, 
or at nursing homes, or building amazing things in this 
country. You already have earned it, and it is just us who have 
kept you from having it.
    But thankfully, the Biden Administration wants to stop this 
one little bit of discrimination and we have a whole hearing 
about it, and nobody is willing to say why they want to take 
health insurance away from a pregnant mom, or why they do not 
want to let somebody buy health insurance, why they want to 
send them to the emergency room where it is going to cost us 
more money and where people will die. We want to stop punishing 
people. We need to get to a place where we recognize we 
actually grow our economy, grow our tax base by including more 
and more people.
    Come to Texas, come to a construction site, and tell me 
what building gets built without immigrant workers. Tell me 
what inventions get invented without immigrant workers. Just 
come. But instead, what we see from Governor Abbott is 
punishing people and, frankly, killing people because he is 
putting drowning devices in the Rio Grande. A trooper just blew 
the whistle and said that they are putting out orders that will 
kill people. We got to stop punishing people, and we should 
just actually answer the hard question, which is why should 
politicians keep on running to build their own power by 
punishing folks and threatening their lives.
    So, I want to thank the Biden Administration for doing the 
right thing on this, and I will still be here waiting to hear 
just the baseline answer for why we want to take pregnant moms 
off of healthcare.
    Mrs. McClain. Thank you. And I would like to respond to 
that is----
    Mr. Casar. Please.
    Mrs. McClain [continuing]. We are happy to have that 
conversation regarding immigration. And I think Congress is the 
appropriate body of the government to have that conversation. 
What I think people are irritated with, and I can speak for 
myself, what I am irritated with is we have three co-equal 
branches of government to do that. We need to have the 
appropriate conversations in the appropriate bodies of 
government agencies, not by with the swipe of a pen with either 
the agency or the executive branch. So again, sir, I am happy 
to have those conversations, and that is what----
    Mr. Casar. So, Chairwoman, would you--go ahead.
    Mrs. McClain. If the gentleman will let me finish in 
response to your question. That is why we need to have the 
conversations. But what I am tired of is the agencies playing 
the end-all be-all and with a swipe of a pen reinterpreting 
definitions or just changing the rules, changing the 
definitions altogether. I mean, we talk about DACA recipients 
being children. The average age is 29. So, sir, again, I think 
you bring up a very, very valid point. This is the body to have 
those conversations. We have got to stop letting the agencies 
run with these. We have to follow the law. We are a land and a 
Nation of laws. So, with that, I yield.
    Mr. Casar. So, Chairwoman, would you co-sponsor a bill with 
me to say pregnant moms legally present in the country should 
have access to Medicaid? You know, pregnant moms should not 
have gone without health insurance.
    Mrs. McClain. And again, sir, I think what we need to get 
back to is legally present. I am here----
    Mr. Casar. And they are legally present.
    Mrs. McClain. If you could let me respond again, sir.
    Mr. Casar. Go ahead.
    Mrs. McClain. Just finish my response--those are the types 
of conversations that we need to have. But what I think people 
are sick of is--let us not redefine the definitions, and maybe 
we need to spend some time on the definitions. So, again, happy 
to have that conversation, but with that, I yield to Mr. 
Langworthy from New York. Thank you.
    Mr. Casar. If we overturn this rule, we are taking pregnant 
moms off Medicaid.
    Mr. Langworthy. Thank you very much, Madam Chair, and I 
would like to thank Dr. Montz for joining us today to discuss 
the proposed CMS rule. This rule has far-reaching implications, 
particularly in our home state of New York where Medicaid is 
funded through property taxes and many other taxes. New York 
state firmly holds its place near the very top of the list that 
has the highest property values, and property taxes are a 
tremendous burden throughout my district and throughout the 
entire state.
    The consequences of this entire rule are clear. To increase 
Federal spending and inevitable higher costs will burden 
hardworking American taxpayers, especially those in New York's 
23d congressional District. And while we could engage in 
debates about costs and figures, it is essential to take a 
closer look at the actual development of these rules and others 
like this, just as my colleagues have just discussed. Far too 
often, we witness unelected officials within this 
Administration, especially in this particular Biden 
Administration, pushing their own agenda without giving 
consideration to due process or the impact on the American 
taxpayer. It is crucial that we hold the government accountable 
and ensure that policies are thoroughly examined, transparent 
and genuinely beneficial to all of our constituents.
    So, Dr. Montz, why did CMS decide to develop this rule, and 
what was the rationale to extend benefits to DACA recipients 
when the Obama Administration did not do this in 2012?
    Ms. Montz. Thank you for that question. The CMS is 
committed to expanding quality, affordable health insurance 
coverage throughout all of our programs consistent with the 
law. To that end, we proposed this rule which would align with 
the current definition. The Department of Homeland Security's 
longstanding definition of ``lawful presence'' would align HHS' 
definition of ``lawfully present'' with that of the Department 
of Homeland Security, ensuring that DACA recipients are treated 
the same as any other recipients of deferred action under the 
law.
    The reason why we pursued this proposed change in addition 
to those two things I mentioned is, you know, with time and 
experience, under the DACA Program, we have learned that while 
the majority of DACA recipients receive health insurance 
coverage through their employer, still a third of DACA 
recipients remain uninsured. And we know that uninsurance can 
lead to certainly detrimental impacts to both individuals, but 
also our economy.
    Mr. Langworthy. So just to be clear, no congressional 
authority has been granted to CMS to make this rule change, and 
the Biden Administration has not issued an executive order 
dictating this rule change?
    Ms. Montz. Under this proposed rule, HHS is pursuing this 
proposed rule under our authorities, under the Affordable Care 
Act and CHIPRA 2009 to define ``lawfully present'' and 
``lawfully residing.''
    Mr. Langworthy. So, in developing this rule, did CMS seek 
feedback from Customs and Border Protection or U.S. Immigration 
and Customs Enforcement?
    Ms. Montz. Just like any development of a proposed rule, 
that rule is looked at by our HHS, OMB, the White House, and 
any other affected agencies.
    Mr. Langworthy. Yes or no, did you talk to those two 
specific agencies?
    Ms. Montz. The Department of Homeland Security did review 
the role of going through clearance.
    Mr. Langworthy. OK. And what was your feedback?
    Ms. Montz. I would need to get back to you on the 
specifics.
    Mr. Langworthy. OK. With my remaining time, I want to shift 
and speak about the impacts of this rule and what it would have 
on the healthcare systems, especially rural hospitals that are 
already overwhelmed. In the Southwest, we have seen immense 
stress and overflowed healthcare facilities. Did CMS consider 
the impacts that this rule would have on these sorts of 
healthcare facilities?
    Ms. Montz. In the proposed rule's regulatory impact 
analysis, we do note that one benefit of this proposed rule 
would be lower uncompensated care costs borne by the healthcare 
system that are ultimately borne by local, state, and Federal 
Government.
    Mr. Langworthy. And all the taxpayers. Dr. Montz, New York 
state pays some of the highest taxes in the country for 
Medicaid. We spend more than California and Texas combined on 
the program. How would you justify to my constituents in 
Western New York, which consists of some of the poorest 
counties in New York State, that their taxes could go up to pay 
for illegal immigrants' health insurance when they are 
struggling to pay for their own?
    Ms. Montz. What this proposed rule does is propose to 
modify HHS' definition of ``lawful presence'' to align with 
that longstanding definition for the Department of Homeland 
Security. Under the Affordable Care Act, individuals who are 
lawfully present are eligible for benefits.
    Mr. Langworthy. I yield back, Madam Chair.
    Mrs. McClain. Thank you. The Chair now recognizes Ranking 
Member Porter.
    Ms. Porter. Many Republican lawmakers seem to believe that 
President Trump had some great system going at the border when 
we had kids being separated from their parents, and families 
being housed in inhumane conditions, and Border Patrol agents 
put in danger trying to help migrants who are being smuggled by 
cartels, and that somehow President Biden changed all that 
awesomeness and started a border crisis. We hear this from them 
all the time.
    Dr. Montz, let us just assume for a moment that there is, 
and I do not agree with this, a Biden border crisis. That is, 
like, the Republican's reference in this hearing title. When 
could that possibly have started? When could the beginning of 
Biden border crisis possible have started? When was President 
Biden elected, ma'am?
    Ms. Montz. I was going say in 2021.
    Ms. Porter. January 20, 2021. Would immigration that 
happened, let us say, 14 years before that date count as part 
of the Biden border crisis?
    Ms. Montz. I do not believe so.
    Ms. Porter. Dr. Montz, tell us, do you know what date 
Dreamers had to be physically present here in the United States 
to qualify for DACA?
    Ms. Montz. 2007.
    Ms. Porter. June 15, 2007. If Dreamers had to be present in 
the United States 14 years before President Biden was 
inaugurated in order to become DACA recipients, can you tell me 
how their immigration in the years before 2007 changed and 
created a crisis on or after January 20, 2021?
    Ms. Montz. I cannot.
    Ms. Porter. So, Republicans really cannot blame the DACA 
Program for any of their grievances, legitimate or, in my 
opinion, illegitimate, at the border. The DACA Program has 
nothing to do with what is happening today at our border. So 
then, what Republicans seem to be saying is that if we provide 
DACA recipients with healthcare, somehow more people eligible 
for DACA might cross the border, that might be some bad 
incentive. So, Dr. Montz, can anyone get DACA status who is not 
in the United States and has not been living here since 2007? 
Like, if someone crosses today, can they get DACA status?
    Ms. Montz. I do not believe so.
    Ms. Porter. What if they crossed, like, 3 years ago? Can 
they get DACA status?
    Ms. Montz. I do not believe so.
    Ms. Porter. Five years ago?
    Ms. Montz. I do not believe so.
    Ms. Porter. Ten years ago?
    Ms. Montz. Now you are forcing me to do math. I do not 
believe so.
    Ms. Porter. So, is President Biden expanding who can 
receive DACA status as part of his rulemaking?
    Ms. Montz. Our rule strictly pertains to eligibility for 
CMS health insurance programs.
    Ms. Porter. Eligibility for DACA recipients who have all 
been here since at least 2007, following the rules, applying 
for renewals, going to school, and working. So, I do not get 
it, Dr. Montz. Can you think of any connection between how 
giving DACA recipients, like children and pregnant women, 
healthcare incentivizes new immigrants to cross the border if 
they would not even be eligible for this expanded healthcare 
that we are talking about?
    Ms. Montz. I cannot.
    Ms. Porter. So, DACA did not cause a border crisis because 
stuff that happened before 2007 does not create a border crisis 
today. And two, giving DACA recipients the healthcare that they 
need to continue to work, and to earn, and to pay taxes, and to 
start businesses, and to flourish is not going to increase 
border crossings. This hearing is called ``Why Expanding 
Medicaid to DACA Recipients Will Exacerbate the Border 
Crisis.'' I am sorry, there is no real connection between 
healthcare for DACA recipients who have been here since before 
2007 and anything that is happening at our border, just no 
connection at all.
    I want to close by pointing out, in response to one of my 
colleagues on the other side's comment about what border agents 
had told him, the Minority has done numerous hours of 
questioning of U.S. Border Patrol chief agents. And during all 
of those numerous hours of questioning, which are transcribed 
interviews that anybody can read, not one U.S. Border Patrol 
chief agent mentioned access to healthcare as a reason for 
migration to the Southwest border or a concern for border 
security. I yield back.
    Mrs. McClain. Thank you, Ranking Member Porter. The Chair 
now recognizes Dr. Foxx.
    Ms. Foxx. Thank you, Madam Chair. You know, I think it is a 
stretch to say that there is no connection at all between 
people receiving free healthcare in this country who are here 
illegally, people here illegally, getting free healthcare and 
there not being people thinking, oh, maybe I could get that 
free healthcare, too.
    Dr. Montz, thank you for being here today. The number of 
people illegally crossing the border has dramatically increased 
in recent years, nearly 3 million crossings in 2022, a full 
million more than occurred in 2021, which was itself a record 
year for crossings. Do you think that this unilateral expansion 
of Medicaid by CMS could lead to an additional increase in 
illegal immigration?
    Ms. Montz. It is the Department of Homeland Security's 
longstanding policy that individuals that are subject to 
deferred action are considered lawfully present in this 
country. What our proposed rule does is propose to modify the 
definition of ``lawfully present'' as it relates to our CMS 
healthcare programs to ensure that DACA recipients, who are 
individuals who came to the United States as children and have 
resided here----
    Ms. Foxx. OK. Just answer my question. So, it is the 
Department of Homeland Security's considered opinion that they 
can change the definition of who is legal and who is illegal in 
this country. Is that what you are saying?
    Ms. Montz. I could not speak for the Department of Homeland 
Security. What I can say is that under this proposed rule, HHS 
is using its authority under the Affordable Care Act and CHIPRA 
2009 to propose----
    Ms. Foxx. Just like the Administration thought it had the 
authority to pay off student loans under a law passed in 2011. 
So, would it be fair to call the prospect of receiving free 
healthcare and other benefits an incentive for people to 
illegally cross into the United States?
    Ms. Montz. Under our proposed rule that focuses on DACA 
recipients, individuals would have had to have resided in the 
United States since 2007.
    Ms. Foxx. OK. So, DACA was ruled unlawful by the Fifth 
Circuit Court in October 2022. In that case, the state of Texas 
argued DACA was not only unlawful, but that the program cost 
the state hundreds of million dollars in healthcare and welfare 
costs. Can you tell me how much we can expect this unilateral 
expansion of Medicaid to cost both the states themselves and 
the Federal Government?
    Ms. Montz. Our proposed rule includes a regulatory impact 
analysis, and we estimate for the roughly 35 states that have 
taken up the option to cover lawfully present pregnant women 
and children in the Medicaid and CHIP Program, that that would 
cost about $100 million total a year.
    Ms. Foxx. OK. Well, that is what I understand too, that it 
would be about $100 million, but, again, that it is a program 
that we believe is illegal. Just last week, this Committee 
passed the Unfunded Mandates Accountability and Transparency 
Act, UMATA, a bill I introduced, which aims to prevent exactly 
this scenario where the Federal Government passes significant 
costs onto the states, $40 million, we believe, in this case. 
What kind of input did CMS seek from states before advancing 
this rulemaking that will cause state budgets an extra $40 
million in 2024?
    Ms. Montz. Thank you for that question. I would note that 
this is a proposed rule and the comment period just closed, and 
we are looking at comments that we have received on the rule. I 
would also note what I indicated before, which is under CHIPRA 
2009, it is a state option to cover lawfully residing pregnant 
individuals as well as children, that continue--nothing in the 
rule changes. It is a state option.
    Ms. Foxx. I have a quick follow-up. In 2012, CMS made a 
specific decision not to extend healthcare benefits, like 
Medicaid, CHIPS, and the ACA, to DACA recipients. What does the 
Agency believe has changed, besides DACA being declared 
unlawful, to evidence that such a dramatic expansion of 
eligibility? What has changed?
    Ms. Montz. Our proposed rule references several reasons why 
we are proposing this change. First is that CMS is committed to 
expanding access under the law. Second is that the Biden 
Administration has indicated commitment to the DACA Program and 
DACA recipients. And the Department of Homeland Security 
recently published a final rule that reaffirmed that DACA 
recipients, like other recipients of deferred action, are 
considered lawfully present. One of the reasons why we are 
pursuing this rule is to better align with DHS' definition of 
``lawfully present.'' And finally, we have through time and 
experience come to understand that while the majority of DACA 
recipients receive health insurance coverage through their 
employers, still a third remain uninsured. And we want to 
ensure that DACA recipients are able to keep themselves healthy 
and productive in the work force.
    Ms. Foxx. Thank you. Madam Chair, I yield back.
    Mrs. McClain. Thank you. The Chair now recognizes the 
gentlewoman from Pennsylvania, Ms. Lee.
    Ms. Lee. Thank you, Madam Chair. Folks, this hearing, like 
so many before it, is nothing more than par-for-course fear 
mongering by my Republican colleagues. To be very clear, we are 
not talking about millions of people at the border, a racist 
myth disproven annually at this point. We are talking about 
closing a gap in healthcare coverage for about 129,000 people, 
people with a legal status in this country.
    Healthcare is a human right, and it should be available to 
everyone who resides in this country, no matter who they are. 
As those of us who care for our fellow man continue to push 
toward a Medicare for All system, a stop on the fight is fixing 
a technical wrong, which was not extending the Affordable Care 
Act to DACA recipients back in 2012. This should be an easy 
fix. Healthcare coverage ensures that people are accessing 
services before they are critically sick. It encourages the use 
of preventative resources, like cancer screenings and routine 
vaccinations, something that people who grew up with insurance 
often take for granted.
    Dr. Montz, what are the collective public health benefits 
of expanding healthcare coverage to more people?
    Ms. Montz. Thank you for that question. What studies have 
indicated and certainly experience shows is that when an 
individual is insured, that individual is better able to keep 
themselves healthy, for example, go to the doctor to receive 
preventive services. Keeping yourself healthy also means that 
you can be more productive at your job and the work force for 
the economy. Studies have shown that individuals who are 
insured have 70 percent lower rates of absenteeism in the work 
force. Additionally, from a, you know, global economy 
perspective for the United States, being insured means that you 
are not incurring uncompensated care costs to the healthcare 
system, which, I have said before, are ultimately incurred by 
local, state, and Federal Government.
    Ms. Lee. Thank you. Our Republican colleagues pretend that 
DACA recipients are not already here, paying taxes, picking up 
kids from school and accessing our public health system. This 
fix not only helps people who have legal status in our country, 
but all Americans. We are one of the only Western nations that 
does not have universal healthcare. I do not think our system 
is as appealing as Republicans are making it out to be. 
Further, many DACA recipients receive health insurance through 
work and rely on their benefits, just like nearly everyone on 
this dais today. Others live in states like California or New 
York, states that have successfully allowed DACA recipients to 
enroll in Medicaid and other state-funded plans for years.
    What we are talking about today is a proposed rule to 
extend Affordable Care Act benefits to an estimated 129,000 
uninsured DACA recipients. And make no mistake, these 
individuals are still getting sick and going to taxpayer-funded 
clinics and emergency rooms, but just like everyone else in 
this country, they deserve more than just emergency care. They 
deserve affordable prescription drugs and access to 
comprehensive healthcare and preventative treatments.
    Dr. Montz, knowing that many DACA recipients already rely 
on our healthcare system, why would it be beneficial to expand 
their access to affordable insurance?
    Ms. Montz. Thank you for that question. As I said, there 
are multiple benefits to being insured versus uninsured, 
including healthier, more productive life, your, you know, 
limited risk, receiving high medical bills that you are not 
able to pay for that then are incurred by the health insurance 
system.
    Ms. Lee. Let me ask. When we are talking about the 
expansion of Medicaid, who would it apply to and about how many 
people would that include?
    Ms. Montz. Our proposed rule estimates that in the roughly 
35 states that have elected this option under CHIPRA 214 to 
cover pregnant individuals and children who are lawfully 
residing, that that would extend coverage to about 13,000 
individuals.
    Ms. Lee. Thirteen thousand individuals. Would those states 
be required to expand healthcare coverage for Medicaid?
    Ms. Montz. The CHIPRA 214 coverage option is an option for 
states. They are allowed to cover or not cover lawfully 
residing.
    Ms. Lee. Thank you. Just to conclude, the Affordable Care 
Act takes important steps to ensure that people are not denied 
basic healthcare because of their gender, disability status, 
zip code, or income, but we still need Medicare for All, and we 
will keep fighting for it. But cutting healthcare is par for 
the course for the so-called pro-life party. This is just 
another attempt to gut and block access to programs that help 
keep vulnerable moms and babies alive as our maternal mortality 
crisis and rates keep arising. To oppose such a small but 
important change shows a blatant disregard for human life 
because no one should be without healthcare. I yield back.
    Mrs. McClain. Thank you. The Chair now recognizes the 
gentlelady from Florida, Mrs. Luna.
    Mrs. Luna. The Centers for Medicare and Medical Services 
has proposed a new rule that would reinterpret the term 
``lawfully present'' to expand taxpayer-funded Federal health 
benefits, specifically Medicaid, Affordable Care Act healthcare 
coverages, and the Children's Health Insurance Program, to DACA 
recipients. Expanding benefits in this way would not deter 
illegal immigration. In fact, it encourages more individuals to 
take the dangerous trek across our borders illegally. And to 
put the cost of illegal immigration into perspective, illegal 
immigration has a net cost of approximately $151 billion per 
year. This cost is not incurred by illegal aliens that are 
coming to United States but instead paid for by hardworking 
Americans, while those breaking the law have zero financial 
accountability.
    This is not the only costs the American taxpayer have taken 
on. In fact, the U.S. Government spends more than $23 billion 
annually on Federal medical expenditures and which services are 
used by illegal aliens to participate. One service costs 
taxpayers over $5 billion in medical assistance for those born 
of illegal aliens. Even more concerning are the incentives that 
those exploiting birth tourism and international commercial 
surrogacies receive, which will only worsen our immigration 
crisis that we are facing in our country and defraud the 
American people. Dr. Montz, are you aware of what birth tourism 
is?
    Ms. Montz. I am sorry. Could you repeat the question?
    Mrs. Luna. Are you aware of what birth tourism is?
    Ms. Montz. No.
    Mrs. Luna. OK. So, birth tourism is when a pregnant woman 
will come to the United States, basically about to give birth, 
have their child here, they might not be a citizen, and then 
ultimately end up leaving the country. Meanwhile, the child 
will receive citizenship status, but it is a huge problem in 
this country, mainly because what we are finding is other 
countries that are more nefarious, like Russia and China, are 
exploiting the system. Are you aware that some nations that are 
participating in these illegal activities and exploiting birth 
tourism and international commercial surrogacy practices are 
from Russia and China?
    Ms. Montz. I am not aware of that.
    Mrs. Luna. Are you aware that these two countries have long 
histories of anti-American espionage activities?
    Ms. Montz. I would not have any knowledge of that.
    Mrs. Luna. You do not know that Russia does not like us? 
That is a question.
    Ms. Montz. I know that Russia is currently at war with 
Ukraine.
    Mrs. Luna. So, you do not like Russia, correct?
    Ms. Montz. I do not have any particular opinions that 
pertain to this hearing.
    Mrs. Luna. OK. Are you aware that China does not like the 
United States and has engaged in espionage activities against 
United States?
    Ms. Montz. I do not have any personal professional 
knowledge of that.
    Mrs. Luna. OK. Well, I suggest you read Breitbart. Do you 
believe that allowing these practices puts the national 
security of the United States at risk?
    Ms. Montz. I do not believe so.
    Mrs. Luna. You do not believe that allowing a country that 
engages in espionage against the United States, exploiting 
birth tourism could potentially open us up for risk?
    Ms. Montz. I do not have the professional knowledge to 
opine on that issue.
    Mrs. Luna. Do you believe that individuals from these 
countries and illegal aliens in general should be allowed to 
exploit the medical system that you help oversee?
    Ms. Montz. Again, I am here to talk about the HHS' proposed 
rule to extend benefits to DACA recipients to ensure that their 
treatment is in line with other deferred action recipients.
    Mrs. Luna. So, you cannot answer the question. Do you have 
an opinion on any of that?
    Ms. Montz. Again, I am here to talk about the proposed rule 
that CMS has put forward. I am happy to take your questions.
    Mrs. Luna. OK. What would be your solution then for that 
proposed rule?
    Ms. Montz. Under the proposed rule, this pertains to DACA 
recipients. As you know, DACA recipients are a defined 
population of individuals that came to the United States as 
children and have been lawfully residing here since 2007.
    Mrs. Luna. When Obama created the program in the Rose 
Garden?
    Ms. Montz. I am not familiar with that.
    Mrs. Luna. OK. Can you just briefly tell me about how Nancy 
Pelosi treated DACA recipients when given the option to make 
them legal?
    Ms. Montz. What I can talk about is the proposed rule. What 
we have proposed to do is further align HHS' definition of 
lawfully present with that of the Department of Homeland 
Security's longstanding definition----
    Mrs. Luna. And what is that definition?
    Ms. Montz. That definition includes all individuals who are 
subject to deferred action.
    Mrs. Luna. OK. In my opinion, ma'am, you are obviously in 
charge of a very important program, but this program was 
created with the intent of making it political, and let us be 
clear. Whenever they show pictures of DACA recipients, they 
typically tend to show Hispanic children when, in actuality, it 
is more than just the Hispanic demographic. So, I guess the 
question for you would be, you are in charge of a program that 
is costing American taxpayers millions and billions of dollars, 
and yet you are sitting here refusing to answer questions about 
whether or not that is fair or there is certain terminology 
being used for these programs.
    I guess my suggestion to you is that our rules that we have 
in place are in place for a reason, and, ultimately, what ends 
up happening is when you have these programs that are 
exploited, it does harm people long term. Chairwoman, I yield 
my time. Thank you.
    Mrs. McClain. Thank you. The Chair now recognizes the 
gentlelady from Texas, Ms. Crockett.
    Ms. Crockett. It never ceases to amaze me what will come 
out of some of my colleagues' mouths. So, it was suggested that 
you should read Breitbart, and I could not let it go. And so 
just for the general public, because I do not want anybody to 
believe this is a good idea, I just got on Google, which if you 
have a cellphone, we can all do that. Breitbart News Network is 
an American far-right syndicated news opinion and commentary 
website founded in mid-2007 by American conservative 
commentator, Andrew Breitbart. Breitbart News' content has been 
described as misogynistic, xenophobic, and racist by academics 
and journalists. So, I do not know that that is where I want 
anybody to take their cues from, especially when they are 
trying to run this country. That part, and then let me clear up 
another little part real quick. DACA is political is what I 
heard just now. Just to be clear, you have testified that DACA 
recipients are considered to be lawfully present, correct?
    Ms. Montz. That is correct. I have said that under the 
Department of Homeland Security's longstanding definition, DACA 
recipients are considered lawfully present----
    Ms. Crockett. Right. They are not considered illegals. They 
are considered to be lawfully present, but ``lawfully present'' 
does not mean that you have the right to vote, correct?
    Ms. Montz. I would defer to----
    Ms. Crockett. Well, I will give it to you. Only U.S. 
citizens can vote, and so, therefore, this idea that it is 
political or as if the Biden Administration is about to rack up 
some votes, is just another falsehood. In fact, all we continue 
to get is half-baked ideas, or half lies, or half-truths, 
whichever way you want to look at it. Let us talk about the 
half-baked ideas first, though. My colleague, Ms. Lee, brought 
up the fact that we are talking about expanding access to 
pregnant women and children, correct?
    Ms. Montz. In the Medicaid Program, yes.
    Ms. Crockett. OK. And this is only in states that have 
extended Medicaid, correct?
    Ms. Montz. This is under the proposal. This would impact 
the roughly 35 states who have chosen the option to cover 
lawfully residing pregnant individuals as well as children.
    Ms. Crockett. OK. So, we are talking about pregnant women, 
and have you heard of the Dobbs decision?
    Ms. Montz. I have.
    Ms. Crockett. OK. All right. So, we have a party that says, 
seemingly, what would Jesus do. Seemingly, that is how they 
govern themselves, and so they have decided that all women 
should just bear all the children and not have any rights to 
decide what they are going to do. And so even under this set of 
circumstances, they think that it is great that all women 
should just be pregnant, but they do not want them to have any 
access to healthcare. That sounds like a half-baked idea to me 
to say that forget life when it comes to, say, the life of the 
mother, because that is a real thing, because if you have 
healthcare, and I do not know how deeply you have delved into 
this, but we have been talking, and when I say ``we,'' I mean 
the Democrats, have been talking about the fact that we have a 
terrible maternal mortality rate in this country. And when you 
start talking about people of color or people of lower social 
economic means, that rate goes up even more astronomically. 
And, so the idea that people are already dying----
    Let me be clear. Are there people that tend to be at a 
higher risk when they do not have access to healthcare when 
they are pregnant?
    Ms. Montz. Yes, it is. It is our belief that being insured 
leads to better health outcomes.
    Ms. Crockett. Thank you. Let us also just talk about these 
half-truths. Really they are just full lies. I was trying to be 
nice. The reality is that they are trying to make this into the 
immigration boogeyman that they always talk about. Yet, we have 
yet to have a bill on the Floor that has been proposed in the 
form of a policy around immigration. Instead, what they want to 
do is continue to treat immigrants as if they are the big, bad 
boogeyman.
    And so we are sitting here and we are talking about a 
program, and you have remained composed, so let me compliment 
you for that because my colleagues on the other side of the 
aisle continue to ask you about the border. What in this rule 
change has anything to do with the border? Just give me one 
thing that it has to do with the border, one.
    [No response.]
    Ms. Crockett. OK. Exactly. It does not, right? It does not, 
but for some reason they believe if they say it, that is true. 
I would love to live in a world where whatever I say somehow is 
true, but the reality is that if they want immigration reform, 
they are in control of the House, and they can put a bill on 
the Floor, but they do not want to do that because they want to 
continue to say that immigrants are the big bad boogeyman.
    Thank you for your service. This has nothing to do with 
immigration. It has everything to do with being good citizens, 
and good lawmakers, and good public servants who actually just 
give a darn about people. Thank you.
    Mrs. McClain. Thank you. I now recognize myself. I think 
what it has to do, to answer your question, is incentives. I 
think people are logical and people do things that they believe 
is in their best interest, and we incentivize people and we 
incentivize their behaviors, so that is what it has to do with 
immigration. When we incentivize certain behavior, people 
respond in a logical fashion.
    But with that said, Dr. Montz, in 2012 the Obama 
Administration created the Deferred Action for Childhood 
Arrival Program via agency memorandum without any authorization 
from Congress. But notably, the Obama Administration was 
careful to clarify that DACA recipients would not be eligible 
for participation in Federal healthcare benefits, such as 
Medicaid, CHIP, and Obamacare. And again, what I want to point 
out is we have three co-equal branches of government, and we 
have to stop changing the definitions, and we have to follow 
the rules of law. And if we do not like the laws, then we have 
the ability and the authority to change those laws.
    Now, CMS has suddenly reversed course and has concluded 
that DACA recipients should receive Medicaid, CHIP, and 
Obamacare eligibility, OK? Dr. Montz, did CMS base its decision 
to reinterpret the Agency's definition of ``lawful presence'' 
on a 2021 survey which found that 34 percent of DACA recipients 
reported not to be covered by health insurance?
    Ms. Montz. As I have mentioned to a few of your colleagues, 
as we stated in the proposed rule, we have had several reasons 
for making this proposed change to treat DACA recipients the 
same as other recipients of deferred action.
    Mrs. McClain. So, is that a ``yes'' or ``no?''
    Ms. Montz. Yes, one of the reasons----
    Mrs. McClain. OK. Under the law, are DACA recipients U.S. 
citizens or lawful permanent residents?
    Ms. Montz. Under longstanding DHS policy, DACA recipients, 
just like other recipients of deferred action, are considered 
lawfully present.
    Mrs. McClain. They are lawful. So, are they U.S. citizens?
    Ms. Montz. They are not U.S. citizens.
    Mrs. McClain. OK.
    Ms. Montz. They are lawfully present.
    Mrs. McClain. Yet under the law, do we owe a legal duty to 
provide healthcare to DACA recipients over American citizens?
    Ms. Montz. Under the Affordable Care Act, eligibility for 
the exchanges, as well as premium tax credits and cost sharing 
reductions, is extended to U.S. citizens, U.S. nationals, and 
those that are lawfully present.
    Mrs. McClain. So, the answer is yes?
    Ms. Montz. Yes. The Affordable Care Act covers those that 
are lawfully present.
    Mrs. McClain. OK. But do we have a legal duty to provide 
their healthcare over the American citizens?
    Ms. Montz. What this rule does is extend eligibility. It 
does not restrict eligibility for any other categories.
    Mrs. McClain. OK. So, I am a firm believer in following the 
law. Some laws I do not like. Some laws I do not agree with. 
Unfortunately, we all took an oath to uphold the law. Dr. 
Montz, are you aware that in 2022 the Fifth U.S. Circuit Court 
of Appeals affirmed that DACA was unlawful?
    Ms. Montz. I am aware that there is an injunction for any 
new DACA recipients.
    Mrs. McClain. OK. Let me try this a different way. Can you 
tell me how many illegal border crossings the U.S. Border 
Patrol recorded in Fiscal Year 2021?
    Ms. Montz. I would defer that answer to----
    Mrs. McClain. Let me help you. It is 6.5 million illegal 
border crossings. So, what does that have to do, it has to do 
with incentives, right, and with all of those incentives comes 
money, and that money comes at the cost. I have two issues. Who 
is going to pay, and if we do not like the law, it is up to 
this body in Congress to change the law. We have got to stop 
allowing these agencies to redefine and reinterpret the 
definition. Can you tell me did CMS at all consider how 
external Federal benefits to DACA recipients would spur future 
waves of illegal immigration? Did that come into your status at 
all or your decision at all?
    Ms. Montz. We endeavor to do our proposed rulemaking under 
current law, and, as you know, DACA recipients----
    Mrs. McClain. I am sorry. I am running out of time. Yes or 
no, did that play into your decision at all?
    Ms. Montz. DACA recipients have been here since 2007, and 
so we did not believe that there is any impact.
    Mrs. McClain. OK. So, no. So, can you please identify the 
section of U.S. Code that provides CMS with the authority to 
set U.S. immigration policy?
    Ms. Montz. HHS does not set immigration policy. However, we 
have the authority to set the definition of ``lawful presence'' 
as it relates to HHS' programs under the Affordable Care Act.
    Mrs. McClain. OK. So, there is no code that provides CMS 
with the authority to set the immigration policy? Just, I want 
to hear that.
    Ms. Montz. HHS does not set immigration policy.
    Mrs. McClain. All right. So in my opinion, you altered the 
law in direct contradiction to the decision of the Federal 
court judge which stated that DACA was unlawful, and you did 
not consult with the agencies who oversee our immigration 
system or whether this would exacerbate President Biden's 
border crisis. Instead, you chose to rewrite the law based on a 
single study that said 34 percent of DACA recipients who are 
here in violation of law had difficulty getting healthcare. And 
I am out of time, so I want to be respectful to my other 
colleagues.
    So with that, I yield to Ms. Lee for her closing statement. 
Thank you so much.
    Ms. Lee. Thank you, Madam Chair. All Americans deserve 
healthcare, and DACA recipients deserve to have a secure and 
healthy future in our country. Today we are here because too 
many Republican lawmakers on this Committee reject this vision 
and continue to fear monger, lying to the American people to 
buy into their twisted thinking. Again, Republicans are holding 
a hearing to deny 129,000 people healthcare. Sad.
    Republicans like to paint a picture of America in crisis, 
millions of people lined up at the border all coming to destroy 
your way of life. They tell you that if you do not support 
their policies, the crisis will only get worse. But today, we 
have not heard any compelling argument that there is any kind 
of connection between DACA recipients being provided with 
healthcare and our failing immigration system. DACA recipients 
cannot just become DACA recipients to get healthcare.
    So, let me explain the law. DACA recipients would have had 
to, one, have come to the United States back in 2007; and two, 
have been younger than 16 in order to qualify today for 
healthcare under the Biden Administration's proposed rule. 
Unless migrants who come or who want to come to the United 
States for healthcare are going to go back in time to meet 
those qualifications, this rule is not going to incentivize any 
new ones to come to our country for healthcare. The coverage 
under this rule does not apply to them.
    Today, I am disappointed to say that not only has this 
hearing been disingenuous with the American people, it has 
wasted an opportunity to go after real waste, fraud, and abuse. 
It has wasted an opportunity to make our government, our 
economy, and our country work better. Next time the 
Subcommittee meets, let us do better.
    In closing, Madam Chairwoman, I have statements with me 
today from pediatricians, budget and policy experts, and 
immigration rights advocates all stating that President Biden's 
proposed rulemakes our healthcare statements stronger and 
affirms that allowing more people to have health insurance is 
beneficial to our collective well-being.
    I ask unanimous consent to enter these enter three 
statements into the record: one from the National Immigration 
Law Center; another from the Center on Budget and Policy 
Priorities; and another jointly from the American Academy of 
Pediatrics, Center for Law and Social Policy, First Focus on 
Children, Georgetown Center for Children and Families, Kids in 
Need of Defense, the Children's Partnership and the Young 
Center for Immigrant Children's Rights.
    Mrs. McClain. Without objection.
    Ms. Lee. Thank you. I yield back.
    Mrs. McClain. Thank you, Ms. Lee. The reason why we are 
having this hearing is because it is law, right? We are a land 
and a Nation of laws. Today's hearing demonstrated that the 
Biden Administration is prioritizing illegal immigrants over 
the American people. This Administration has chosen to reward 
those who enter the country illegally, with release from 
custody in many cases, and now with access to public benefits 
at the cost of taxpayers and Americans who need it.
    We learned that CMS' proposed rule to expand access to 
Medicaid, CHIP, and Obamacare to DACA recipients will cost 
American taxpayers millions per year. Last I checked, this body 
is supposed to be the steward of American taxpayer dollars. 
That is our job, and that is what we are doing. CMS' own 
estimates show that Medicaid and CHIP state expenditures would 
increase by $40 million, and Federal expenditures would 
increase by $40 million in just the first year. Total 
expenditures would then balloon up to $130 million per year, 
and that does not even include the proposed Obamacare expansion 
which will cost another $15 million to $20 million annually.
    Now, I just say that because people have a tendency when 
they spend other people's money, the taxpayers' money, not to 
respect it as much as it is their money. That is our job. As 
messy as it may be, that is our job to be stewards of the 
American taxpayers' money. I am curious on how we are going to 
pay for this. Last I checked, we have a major deficit in this 
country, and I have yet to hear any explanation of how we are 
paying with this.
    So, forget about the changing of the rules. Forget about 
the reinterpretation. Now we have the cost. It is our 
responsibility to ask those tough questions, and I will remind 
everybody that DACA stands for ``Deferred Action for Childhood 
Arrivals.'' That means that DACA recipients are still and 
always have been unlawfully present in the United States. We 
may not like that, people may not agree with that, but that is 
the law. And it is up to this chamber to change it, not 
reinterpret the definition with the stroke of a pen. They would 
not have even been eligible for Deferred Action otherwise.
    Lawless Democrats have deferred the prosecution of these 
immigration cases, despite Federal judges holding DACA is 
unlawful and DHS being prohibited from accepting further 
applicants, and, again, we may not like that, but it is the 
law. Only in Biden's America can bureaucrats defy Congress and 
the courts to change the laws and extend benefits to 
individuals who are unlawfully present in the United States. 
There is already a crisis at the Southwest border caused by the 
Biden Administration's failed policy. This proposed rule would 
only further signal to the world that illegal immigration is 
rewarded by the current Administration. We put a welcome mat at 
the door. That is why you see the immigration numbers 
skyrocketing.
    The Biden Administration sees no difference between an 
American citizen and a non-citizen unlawfully present in this 
country. That, for me, is simply unacceptable. We should not 
reward individuals unlawfully present in the United States with 
benefits reserved for American citizens and those who lawfully 
present in this country. Even President Obama's HHS knew that 
expanding public health benefits to DACA recipients was 
unlawful and a bad idea, but in Biden's America, it seems that 
wrong is right and up is down, and 2 plus 2 equals 5, and all 
we have to do is change the definition and say it is so.
    Illegal aliens are entitled to the same taxpayer-funded 
health benefits as American citizens? That does not comprehend 
with me. I will continue to fight to fix Biden's border crisis 
and to fight against the Administration's policies that reward 
those who violate the law because I believe in the rule of law. 
And make law-abiding citizens pay for it, it does not make 
sense.
    In closing, I want to thank our witness once again for your 
important testimony.
    And without objection, the Members will have 5 legislative 
days to submit materials and to submit additional written 
questions for the witnesses, which will be forwarded to the 
witnesses for their response.
    Mrs. McClain. If there is no further business, without 
objection, the Subcommittee stands adjourned.

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