The truth about the shutdown and health care for immigrants

[Thiệu Ngô]

The shutdown messaging war is in full effect, and early indications are that Republicans have been put in something of a bind, given the Democrats’ demand to extend enhanced Obamacare subsidies appears quite popular.

Analysis by Aaron Blake

So Republican leaders have returned to a very familiar strategy – making false generalizations and misleading claims about undocumented immigrants, in an attempt to center the debate on more favorable terrain.

They’ve argued over and over again that Democrats are trying to provide health care to undocumented immigrants.

In fact, as CNN’s Tami Luhby has fact-checked, the changes Democrats are seeking on Obamacare and Medicaid would not directly provide coverage to undocumented immigrants, since they aren’t and still wouldn’t be eligible for either program.

That’s not to say there aren’t kernels of truth behind their claims, and the issue is complicated. Medicaid dollars do, in some situations, end up paying health care costs for those in the country without documentation as a matter of longstanding federal law. But the GOP’s political strategy to cast Democrats as holding government funding hostage over the issue rests on a rather Machiavellian and factually challenged effort to demonize migrants.

Let’s break it down.

After Republicans spent days largely just making this claim without detailing it, Vice President JD Vance stepped forward at Wednesday’s White House press briefing to at least put some meat on the bone.

His case boiled down to two things.

His first point was that the asylum-seekers and others with temporary legal status who would be eligible for these programs under the Democrats’ shutdown-ending proposal should nonetheless be treated as “illegal aliens.” He said this was because the Biden administration granted such designations too freely.

House Speaker Mike Johnson of Louisiana has also been vehement about this claim.

“Joe Biden used executive orders, and he expanded benefits, health care to illegal aliens in his four-year term,” Johnson said Thursday. “That was an outrageous violation of the existing federal law and of the principles of good stewardship.”

It’s an argument that could seemingly have plenty of appeal. Americans turned very sour on the Biden administration’s handling of immigration and asylum in recent years, before Biden moved to toughen up his approach. A Reuters-Ipsos earlier this year showed 56% of Americans wanted to “dramatically reduce” the number of migrants allowed to claim asylum at the border.

But saying these migrants should be considered “illegal” – even if Republicans genuinely believe that – doesn’t make them so, at least under current law.

To the extent Republicans want to treat them as illegal, they could take other steps to try to strip them of legal status. Unless and until they do, though, these people have legal status under US law and aren’t “illegal aliens.”

Vance’s second point was that there is at least one way in which federal dollars can be used to pay for the health care of immigrants who are actually undocumented – i.e. not just classes of people who he would prefer to treat as such.

A federal law called the Emergency Medical Treatment and Active Labor Act (EMTALA) mandates that any hospital that receives Medicare funds must treat anyone requiring emergency treatment, regardless of ability to pay, insurance or legal status. And the federal government reimburses hospitals for this treatment.

Vance painted undocumented immigrants in emergency rooms as a scourge, connecting it to longer waiting times because “very often, somebody who’s there in the emergency room waiting is an illegal alien.”

But in fact, new data shows federal reimbursements for emergency care for undocumented migrants is a minuscule portion of emergency Medicaid spending – only about 0.4% in Fiscal Year 2023, according to KFF.

And beyond that, it’s worth noting that this is not just a matter of federal law, but a federal law signed by a Republican president, Ronald Reagan. Republicans in their agenda bill earlier this year sought to reduce federal Emergency Medicaid funding; their argument is essentially that the move reduced a possible incentive hospitals might have to prioritize care for undocumented immigrants. But Democrats point out that just shifts costs to states and hospitals themselves, given they are still legally required to provide the care. That’s unless and until EMTALA is repealed.

That also raises some perhaps uncomfortable questions for the administration.

For one, the next logical question is whether Vance and Republicans would prefer that hospitals not provide potentially life-saving care to undocumented migrants who are severely ill, perhaps just allowing them to die.

An answer Thursday from White House press secretary Karoline Leavitt showed how difficult these questions become. She was asked if hospitals should ask for proof of citizenship before treating a dying patient, and she responded, “That’s probably not a question for me to answer.”

And secondly, it reinforces that even Trump’s agenda bill still allowed for federal money to flow to giving undocumented migrants emergency health care. It was just a more restricted amount that shifted the burden to states and hospitals.

Republicans have also increasingly argued that some blue states are moving money around in such a way that they’re effectively using federal Medicaid funds under the guise of state funding for undocumented health care. Leavitt on Friday accused California of “a gimmick that funds its Medicaid for illegals program.”

But as Luhby noted, a provision that would have penalized states that purportedly do this was stripped from Trump’s agenda bill. The law does eliminate states’ ability to get a certain waiver related to the taxes that states can charge certain providers to help pay for Medicaid, but the provision isn’t specifically about undocumented immigrants.

As these claims have been fact-checked, Republicans have increasingly turned to another, separate argument.

They’ve noted that, during the 2020 Democratic presidential primaries, most of the top candidates supported covering undocumented immigrants with government health care. Vance, Leavitt and many other Republicans have pointed to a clip from a debate, in which the candidates all raised their hands in support of such a policy.

And this is true. It’s one of a number of positions Democrats staked out during that campaign to appeal to the political left that they probably wish they hadn’t. (Many such answers came back to bite Kamala Harris in the 2024 presidential campaign.)

“Don’t let the Democrats lie to you,” Republicans Rep. Pete Stauber of Minnesota said Thursday on X. “In a 2019 debate, every Democrat candidate raised their hand in support of taxpayer-funded healthcare for illegal immigrants. Now, they have shut down the government over it.”

Johnson added Thursday: “Those hands included Joe Biden and Kamala Harris. Now, what did they do? Did they follow through on that promise? Yeah, they absolutely did.”

He clarified that he meant Biden expanded those who were eligible for such coverage by allowing them to obtain at least temporary legal status. So again, the argument seems to be more that these people shouldn’t have been given legal status rather than that they are currently undocumented in a legal sense.

And just because those Democrats expressed that view back then doesn’t mean it has any impact on the current debate. Republicans would argue that this betrays Democrats’ long-term intentions. But it’s not what Democrats are currently asking for out of a shutdown deal; they are primarily pushing for more generous federal subsidies to help Americans afford Obamacare policies. (And indeed, it seems highly unlikely that Democrats would view any move to shut down the government over undocumented immigrants’ health care as smart or practical politics today.)

Democratic Sen. Ruben Gallego of Arizona has even said Democrats would support language making doubly sure that any coverage wouldn’t be extended to the undocumented.

“We are willing to pass anything in law that says people in this country illegally should not be receiving any benefits, subsidies, anything,” Gallego told Semafor.

It’s not uncommon for politicians to try to spin debates in terms that are more favorable to their side. To a certain degree, it’s politics as usual.

But what we’ve increasingly seen in the Trump-era GOP is a more shameless and almost unflinching willingness to say whatever is most advantageous in the moment, no matter if it misleads Americans about the very real issues in an important debate.

The party has increasingly warmed to the tactics of a president who not only uttered more than 30,000 false and misleading claims in his first term, according to the Washington Post, but actually got significantly more counterfactual as time went on.

Perhaps the epitome of this approach came in 2024. The Trump campaign not only spread unfounded claims about Haitian migrants in Ohio eating people’s pets that even local Republicans rejected; Vance effectively acknowledged willingly spreading misinformation – while arguing that the ends justified the means.

“If I have to create stories so that the American media actually pays attention to the suffering of the American people,” Vance told CNN’s Dana Bash, “then that’s what I’m going to do, Dana. Because you guys are completely letting Kamala Harris coast.”

You could understand why Republicans feel the need to adjust the terms of the debate here, given the enhanced Obamacare subsidy extensions Democrats are pushing for are overwhelmingly popular.

A KFF poll released Friday showed 78% of Americans and even 57% of MAGA Republicans supported extending them. A Washington Post poll released a day earlier showed 47% of Americans believed Trump and the Republicans were “mainly responsible” for the shutdown, compared to 30% who blamed Democrats. That’s somewhat counterintuitive, given Democrats are the ones who won’t sign on to a clean bill to keep the government open.