Governors who reject health insurance for the poor under the federal health care overhaul could wind up in a politically awkward position on immigration: A quirk in the law means some U.S. citizens would be forced to go without coverage, while legal immigrants residing in the same state could still get it.It's an unintended consequence of how last year's Supreme Court decision changed the Medicaid provisions of President Barack Obama's health care law.

The overhaul expanded the federal-state program for low-income and disabled people. The Supreme Court made the Medicaid expansion optional for states, which complicated things. Arizona officials called attention to the problem last week, when Republican Gov. Jan Brewer opted to accept the Medicaid expansion.

Brewer had been a leading opponent of the overhaul, and her decision got widespread attention. State budget documents cited the immigration glitch as one of her reasons.

"If Arizona does not expand, for poor Arizonans below (the federal poverty line), only legal immigrants, but not citizens, would be eligible for subsidies," the documents said.
That's because the immigrants would be eligible for government-subsidized private insurance, while low-income citizens would not. The Obama administration confirmed Arizona's interpretation.

The gist of what Brewer was saying is that "by rejecting the expansion, you are essentially rewarding the immigrant population at the expense of full citizens," said Matt Salo, executive director of the National Association of Medicaid Directors, a nonpartisan group that represents the states in Washington.

"The political optics of that could be crushing," he added. The Supreme court in it's ruling said states were free to accept or reject the Medicaid expansion the court did not touch the issue of coverage for legal immigrants in the health insurance exchanges. That provision remained in place.

And that's how the immigration glitch came to be. Poor people in a state that turns down Obama's Medicaid expansion can only get government subsidized coverage if they are legal immigrants. U.S. citizens are out of luck.

So far 11 states have said they're not interested in the Medicaid expansion. Meanwhile, while 17 states and Washington, DC, say they are taking it. The rest are weighing their options. The immigration glitch is now one of those considerations