Provisions in the new tax and spending bill passed by the U.S. Senate early Tuesday would go even further than the House bill in removing health care and other benefits from immigrants with legal status.

The House version of the massive tax and spending bill penalized states providing health care for some immigrants with legal status as well as those that chose to spend state money to enroll immigrants without legal status in Medicaid.

But the Senate bill is even tougher on immigrants here legally and illegally, reducing benefits for most refugees and immigrants on humanitarian parole, including Afghans and Ukrainians who helped the United States in wars overseas and in return were promised safe haven and a safety net in the United States.

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The Senate bill also cuts state reimbursement for emergency care in the states that expanded Medicaid under the Affordable Care Act. That would force those states to pay more for emergency care for immigrants, cut back services or drop out of Medicaid expansion, a potentially catastrophic move for low-income U.S. citizens as well as new immigrants.

The bill passed with three dissenting Republican votes, from U.S. Sens. Rand Paul of Kentucky, Susan Collins of Maine and Thom Tillis of North Carolina. Vice President JD Vance broke the tie. The bill, officially the “One Big Beautiful Bill Act,” now returns to the House for final passage before going to President Donald Trump to be signed.

Advocates and experts see repercussions as refugees and other legal immigrants lose health insurance and turn to already-stressed hospitals and charities for help. It could be a nail in the coffin for some rural hospitals that are in financial trouble and scaling back services. Hospitals are required to serve anyone who arrives for emergency care, regardless of their ability to pay.

“In our state, it’s going to be absolutely devastating for rural hospitals,” said Kate Woomer-Deters, a senior attorney at the North Carolina Justice Center’s Immigrant & Refugee Rights Project. “Refugees are not going to go home just because they lost their health care coverage. They’re still going to be showing up at the door of hospitals and clinics needing care.”

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Some groups, such as Afghans, Ukrainians and Iraqis, were often brought here after helping the U.S. in war efforts, putting their lives in danger and making life in their home country untenable.

“In the case of the Afghans, this is pretty much a knife in the back to those folks who helped the United States when the United States needed help in their country,” said David Meyer, a board member of the Bloomington Refugee Support Network in Indiana, where he personally helps seven refugee families from Afghanistan, Honduras, Iraq, Nicaragua and Syria.

The Senate bill takes Medicaid, the Affordable Care Act and even food stamps off the table for most refugees. There are a few narrow exceptions for people with green cards, some Cuban migrants waiting for citizenship, and some Micronesians and Marshall Islands natives with treaty rights, said Shelby Gonzales, vice president for immigration policy at the progressive Center on Budget and Policy Priorities.

That also applies to immigrants with legal status who don’t have green cards: people with asylum, immigrant victims of domestic violence, immigrant victims of sex trafficking and parolees — such as Afghans — admitted due to urgent humanitarian reasons, as well as to refugees.

It’s not going to help hospitals. It’s not going to help individuals. It’s not going to help states. There’s going to be some cost-eating by all of them.

– Shelby Gonzales, Center on Budget and Policy Priorities

“There’s going to be more emergency health care needs because uninsured people will be delaying care,” Gonzales said. “It’s not going to help hospitals. It’s not going to help individuals. It’s not going to help states. There’s going to be some cost-eating by all of them.”

The bill also cuts funding for expansion states to pay for emergency care in hospitals. Increased costs could force some states to drop Medicaid expansion altogether, spreading the pain to low-income U.S. citizens as well, Gonzales said.

“It’s one more reason states are looking at their budgets and they’re having to make decisions about their Medicaid expansion program,” Gonzales said.

In Indiana, Meyer said, Afghan women especially often need food stamps, formally known as the Supplemental Nutrition Assistance Program, to get by at first. It takes them a long time to learn to read and write since they were not allowed to attend any school under the Taliban.

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“They arrived in our community totally illiterate in their native language and starting from scratch learning English, so that’s a huge impediment to being gainfully employed,” Meyer said. Even once they’ve become self-sufficient enough to get off food stamps and Medicaid, many still need the support of the Affordable Care Act to get health care.

Removing all subsidized health care “would have a devastating effect on those families, and not just Afghans but Syrians, people from the Democratic Republic of Congo and others that have been relocated to south-central Indiana,” Meyer said.

Indiana hosted more than 10,500 of the nearly 460,000 refugees who arrived in the United States between 2013 and 2023, according to a 2023 report from the nonprofit Immigration Research Initiative. In fiscal 2024, another 1,380 arrived in Indiana, mostly from Congo and Burma, but including 90 people from Afghanistan, according to State Department records.

In North Carolina, there were 276 new Afghan refugees in fiscal 2024 among 2,730 total new refugees. Even professional Afghans such as doctors and lawyers struggle at first in low-wage jobs, said Woomer-Deters, of the North Carolina Justice Center. It takes time for them to get accreditation and language skills to practice their professions here, she said.

“A lot of these folks need their food stamps, Medicaid — they need these programs for an adjustment period when they get here. And these are people we’ve invited to come and have vetted,” she said.

A Congressional Budget Office report June 29 estimated that almost 12 million people, including 1.4 million immigrants covered by state-only programs, would lose health insurance under the Senate plan.

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A Republican response to an earlier CBO report emphasized that the bill would save states $13.1 billion in Medicaid spending over 10 years, “freeing up resources they can choose to reinvest to further strengthen care for the most vulnerable Americans.”

The Center on Budget and Policy Priorities, however, called that conclusion misleading in its own response in turn.

“These savings would largely result from millions of people losing health coverage — hardly an outcome worth celebrating,” the response said.

Leonardo Cuello, a research professor at Georgetown University’s McCourt School of Public Policy’s Center for Children and Families, said there was one small positive change in the Senate version compared to the House version.

States will no longer be penalized for using the option to cover some immigrant children and pregnant women.

And the Senate version would not penalize expansion states for offering Medicaid to immigrants on humanitarian parole, but only because that help for parolees was ended in entirely, along with help for refugees and other kind of immigrants with legal status who lack green cards, Cuello said.

“In other words, they are blocking all paths to health care,” Cuello said in an emailed statement. “This is not an attack on the undocumented. It’s an attack on lawfully present immigrants.”