Teaching the Affordable Care Act to Business School Students

Occasionally, when I am going to discuss the ACA in an academic setting, I assign the Kaiser Family Foundation's  "Health Reform Quiz" in advance as a sort of pre-test. I ask people to report their pre-test scores, anonymously if they like, so that I can track the knowledge base of the group and because I am very much interested in seeing which questions people get wrong and which they get right.  You may take the KFF Health Reform Quiz here yourself: http://kff.org/quiz/health-reform-quiz/.

I suspect none of you will be surprised to learn there are strong consistent  patterns to which questions are answered incorrectly. Today I want to talk about Question #4:

"Will the health reform law  allow undocumented immigrants to receive financial help from the government to buy health insurance?"

A majority of my business school students answered "yes" and received this response from the KFF Health Reform Quiz:

"No, the law will not do this. You answered incorreclty. Under the ACA, undocumented immigrants will remain ineligible for Medicaid and will be ineligible for the premium tax credits.  They also will be prohibited from purchasing coverage through an exchange even at full cost."

So, yes, talking to the uninitiated about the ACA is often an exercise in negative space.  Or, as I tell my students, we can hardly find time and space to discuss what is allowed under the law if we can't first discuss briefly what is not allowed under the law.  And so we discuss the fact that undocumented immigrants may not participate in either expanded Medicaid or in purchasing health insurance through the exchanges. This leads to a discussion of some related provisions, specifically the fact that lawful permanent residents may purchase from the exchange and apply for tax credits. These folks may also be eligble for expanded Medicaid with the states after a waiting period (or not) as determined by the states.

Then, how did all of this get so confusing? Hard to say. Perhaps some of my students have read the email that keeps resurfacing claiming what an "Obama Care Outrage" it is that undocumented immigrants will be covered by the ACA (you may read about it here:http://www.politifact.com/florida/statements/2013/jul/09/chain-email/illegal-immigrants-are-covered-under-health-care-l/ ) which itself may be based on a 2009 piece of draft health care legislation that never became law (which you may read here: https://www.govtrack.us/congress/bills/111/hr3200/text).

I do not fully understand how draft legislation comes to overshadow the actual content of a law (see also "death panels" under the ACA, but that's a blog for another day) but there is surely something to be learned here about the stickiness of what is perceived of as negative information, never mind something to be learned about people who gain their news from chain emails.

But there is something else going on as well. You see, some low-income undocumented immigrants are currently eligible for Emergency Medicaid coverage, including coverage for childbirth.  And then there is the fight over whether EMTALA (Emergency Medical Treatment and Labor Act of 1986) requires that undocumented immigrants be screened, stabilized, and transferred  (maintained if in active labor) along with uninsured citizens and who should pay for it.

The Medicare Modernization Act  established the Section 1011 program, setting aside a now greatly depleted amount of funding  for federal reimbursement of emergency health services furnished to undocumented immigrants.(You may see HHS's May of 2013 announcement of depleted funds for certain jurisictions here: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Section_1011_Fact_Sheet.pdf).

The ACA, however, studiously avoids any attempts to resolve our nation's conflicted immigration policy. Mixed-status families, of course, will have the trickiest situation — risk reaching out for the health care the citizen children are entitled to without attracting attention for the undocumented parents? 

I find the idea that the ACA, unable to achieve consensus on so many items (I have written elsewhere about singling out tobacco users, you may read my thoughts on how conflicted we are about them here: http://delong.typepad.com/annmariemarciarille/2013/01/up-in-smoke.html) could somehow have brokered consensus (albeit anger inducing information about a false consensus) on our nation's immigration policy both touching and sad.