28-05-2025
Bowser budget proposal would scale back health care for immigrants, others
Mayor Muriel E. Bowser's budget proposal would make changes to health-care programs that insure undocumented immigrants and low-income adults, as city grapples with financial pressure and the impacts of President Donald Trump's spending and tax cut bill.
Starting Aug. 1, the budget proposal calls for the city to begin phasing adults age 21 and older out of the Healthcare Alliance Program, which uses local dollars to cover 27,000 adults regardless of immigration status; and in March impose limits such as requiring people to reenroll in-person every six months. The 6,000 children in the program would be unaffected, city officials say.
The city would also save money by paying for care as participants use services, instead of per person enrolled. The changes would save the city $457 million over four years, budget documents released Tuesday show, though some advocates worry the cuts would cost thousands of residents their health care and hospitals would rack up more uncompensated care costs.
In addition, about 25,000 parents or caregivers and childless adults covered under the expansion of the Affordable Care Act who earn more than 133 percent of the federal poverty level would lose Medicaid coverage under the proposal. Instead, many of them would be eligible for a new basic plan on the exchange with similar coverage, city officials said.
The mayor's proposal, which the D.C. Council must now consider, reflects the competing interests the Bowser (D) administration has weighed when crafting a budget that is financially responsible and anticipates federal changes without abandoning the city's most vulnerable residents.
Unlike other cities, the District is subject to the whims of the Republican-controlled Congress, which must sign off on its laws and budget and can tinker with specific line items lawmakers don't like. The House last week narrowly passed a budget bill that includes additional limits on Medicaid eligibility and would cut federal Medicaid payments to a handful of states and D.C. that currently use local dollars to cover adults regardless of immigration status.
'We are not unmindful of the fact that if the Senate passes what the House did, and the president signs it, [that] to continue Alliance in any form or any size at any cost would have attracted a $100 million penalty, by our rough estimate,' Wayne Turnage, deputy director for health and human services, said in an interview Wednesday.
But Turnage stressed the changes under Bowser's proposal 'are driven solely by the spending pressure that the Medicaid program and the Alliance program created going into fiscal year '26 and then somewhat exacerbated by the declining revenue picture.'
The budget documents released Tuesday included a $120 million Indigent Care fund for uninsured people. But Turnage said that was in error.
D.C.'s chief financial officer has predicted the city could endure a more than $1 billion revenue downturn over the next four years, largely due to the Trump (R) administration's moves to shrink the federal government. Bowser officials warn that the city could lose 40,000 jobs as a result of those efforts, a reality they say necessitates more fiscal discipline and a push to diversify the city's economy.
Overall, Bowser's budget proposal would invest in pro-business policies in an attempt to attract and grow nonfederal industries at the same time as it makes significant cuts to government programs. Among the $250 million in cuts and policy changes that could save another $500 million are reductions in emergency rental assistance and pauses to planned cost-of-living adjustments in a cash assistance program for poorer families.
Patients, providers and advocates led by the D.C. Primary Care Association rallied last week on the steps of the John A. Wilson District Building to highlight the risk to health care on multiple fronts. The Senate is taking up Trump's 'big beautiful bill' in June and D.C. Council will begin holding hearings Thursday and with a vote scheduled for the end of July.
The proposed D.C. changes would mean 'vulnerable residents will not have health care and will end up using emergency rooms more frequently and illnesses will not be diagnosed in a timely manner,' said Kate Coventry, deputy director of legislative strategy at the DC Fiscal Policy Institute.
'D. C. has always taken pride in the fact that almost every resident has access to health care coverage,' she said. 'Health care is a human right and that shouldn't be dependent on immigration status.'
Andrew Patterson, senior counsel with Legal Aid DC, said he was concerned that the organization's clients who rely on the Alliance program could lose their insurance — and wants D.C. officials to stay committed to insuring undocumented residents regardless of congressional pressure and financial challenges.
'We want to see them maintain that dedication even in challenging budget times,' Patterson said. 'We don't think all of the hardship should fall on the most vulnerable people in our city.'
Although the city's Alliance program does not use federal funds, the Trump administration has been explicit about increasing oversight on jurisdictions that use federal Medicaid funding for undocumented immigrants, including reviews to close loopholes and strengthen enforcement.
'Medicaid is not, and cannot be, a backdoor pathway to subsidize open borders,' Centers for Medicare & Medicaid Services Administrator Mehmet Oz said in a statement Tuesday. 'States have a duty to uphold the law and protect taxpayer funds. We are putting them on notice — CMS will not allow federal dollars to be diverted to cover those who are not lawfully eligible.'
California Gov. Gavin Newsom (D) recently asked state lawmakers to scale back the health benefits that the state offers to undocumented immigrants in part because maintaining it would cost the state $30 billion if federal changes go through, data from KFF, a nonprofit group that conducts health policy research, show. New York, Illinois, New Jersey and Oregon are among the states with similar programs.
Congress has previously taken action to limit rights for noncitizens in recent years — with some Democratic support.
The House Committee on Oversight and Government Reform last month advanced a bill repeal a 2022 law that allows noncitizens to vote in local elections. The same bill passed the GOP-controlled House with 52 Democrats.
The committee in March also advanced the District of Columbia Federal Immigration Compliance Act, requiring the city to comply with federal immigration laws, including detainers of individuals. In the last Congress, a lawmaker offered an amendment to block D.C. from using local funds to house undocumented immigrants.
D.C. currently limits how much its local authorities can collaborate with federal immigration enforcement, but Bowser's budget proposal would repeal that policy and start allowing local law enforcement to provide federal immigration agencies with information and access to D.C.'s jails.
Abel Nuñez, executive director of the immigrant-serving Central American Resource Center, said he was not surprised to see Bowser propose adjustments to the Alliance program, which he said was a large expense for a city now facing increased financial pressures. 'We knew changes were coming,' he said.
Plus, Nuñez added, 'At the end, when this budget is done, it still needs to go before the U.S. Congress, controlled by a Republican Party that has already targeted the District.'
'We're in a very weak position at the moment,' he said.
Nuñez said he hoped to work with Bowser and the council to find a way for the city to continue providing adults with health coverage regardless of immigration status.
Because, Nuñez said, no matter what happens with the budget, 'the mayor is still going to have to deal with sick people in her jurisdiction … they're still going to need access to health care.'
