Because of a quirk in the Affordable Care Act, there’s been an odd little story circulating this week about Arizona Governor Jan Brewer’s decision to support Medicaid expansion. In states that don’t expand, legal immigrants below the poverty line would end up with more insurance options than native-born citizens below the poverty line—some have speculated that may have pushed Brewer, a staunch anti-Obamacare conservative, toward expansion. Charlie Frago had a good roundup (paywall) this morning on the impact here in Arkansas.

This sounds to me like much ado about nothing, but here’s the deal. If a state does not expand Medicaid, as we’ve explained, folks without coverage below 100 percent of the federal poverty level (FPL) would be out of luck. But there’s an exception: The way the law is constructed, legal immigrants will be eligible for subsidies to buy private health insurance on the exchange no matter what. (See the p.p.s. below for a detailed explanation of why and how this came to be).

The Associated Press noted on Wednesday that state officials had pointed this out to Brewer and an item in the Washington Post yesterday speculated that Brewer may have been swayed by the optics of foreigners getting new coverage while poor folks born in the USA don’t.

Color me skeptical. If you read the relevant budget memo, the gist is what we already knew: given the amount of federal dollars coming in to the state, it’s just too good of a deal to pass up. I think it’s the billions of dollars that got Brewer’s attention, not the short graph about “legal aliens.” As for the legal immigrants (and we should stress legal—the Affodable Care Act has no prevision for people in the country illegally), they’re eligible for the subsidies regardless, so it’s not as if they are somehow getting a bonus if Arizona doesn’t expand. The idea is just that, while Brewer didn’t feel sorry for poor Arizonans who would be denied coverage without expansion, now she feels sorry for them because someone pointed out that some other poor Arizonans—legal immigrants—wouldn’t be denied. (Or more to the point, that this would look bad.)


There’s a fairness issue here, I suppose, but the real scandal if we don’t expand Medicaid has nothing to do with where you were born, it has to do with income. Without expansion, people between 100 and 400 percent of the FPL will get government subsidies to buy health insurance. People below 100 will not. So an individual making $40,000 or a family of four with an income of $90,000 could get help; a single parent with two kids making $16,000 or an individual making less than $11,000 would be left out in the cold. That is, as Surgeon General Joe Thompson ethically upside down. Or as expansion skeptic Sen. Michael Lamoureux admitted, “that’s not a good situation.”