Health Coverage for Immigrants

1
Health Coverage for Immigrants

• E. Richard Brown, PhDDirector, UCLA Center for
  Health Policy ResearchProfessor, UCLA School of
  Public HealthPrincipal Investigator, California
  Health Interview Survey
• State Innovations in Health CoverageChicagoAugus
  t 3-4, 2006

2
What I will cover

• Health care coverage of citizens vs. noncitizens
• Federal policies affecting noncitizens
  eligibility for Medicaid
• State responses to the issue, with a special
  focus on California
• Data sources
• Kaiser Family Foundation publications on Medicaid
  and SCHIP eligibility for immigrants
• Medicaid and SCHIP Eligibility for Immigrants,
  April 2006
• New Requirements for Citizenship Documentation in
  Medicaid, July 2007
• National Disability Rights Network
• Factsheet, Citizenship Documentation Interim
  Final Rule
• March 2005 Current Population Survey
• 2003 California Health Interview Survey

3
Noncitizens have far lower rates of
employment-based insurance, resulting in far
higher uninsured rates
Insurance Coverage by Citizenship Status, Children and Adults, Ages 0-64, United States, 2004 Insurance Coverage by Citizenship Status, Children and Adults, Ages 0-64, United States, 2004 Insurance Coverage by Citizenship Status, Children and Adults, Ages 0-64, United States, 2004
US Citizen Noncitizen
Employer-based 66.9 40.0
Medicaid/SCHIP 10.7 9.4
Other coverage 7.2 5.0
Uninsured 15.3 45.6
Source March 2005 Current Population Survey Source March 2005 Current Population Survey Source March 2005 Current Population Survey
4
Noncitizenswith or without green cardshave less
access to employment-based insurance
Access and Take-up Rates of Employer-based Coverage for California Adult Employees, Ages 18-64, 2003 Access and Take-up Rates of Employer-based Coverage for California Adult Employees, Ages 18-64, 2003 Access and Take-up Rates of Employer-based Coverage for California Adult Employees, Ages 18-64, 2003
with Access to Employer-based Coverage of Employees who Take-up Coverage Among Those Eligible
US Born Citizen 79.0 86.3
Naturalized Citizen 81.4 86.0
Noncitizen with Green Card 64.4 81.9
Noncitizen without Green Card 45.4 76.2
Source 2003 California Health Interview Survey Source 2003 California Health Interview Survey Source 2003 California Health Interview Survey
5
Noncitizens also have less access to Medicaid
and SCHIP Welfare reforms of 1996

• Personal Responsibility and Work Opportunity
  Reconciliation Act (PRWORA) of 1996
• Tied eligibility for Medicaid to an immigrants
  legal status and to length of residency in U.S.,
  making it more difficult for them to obtain
  Medicaid coverage
• Restrictions also applied to SCHIP, when it was
  enacted in 1997
• Most immigrants are subject to a 5-year bar on
  eligibility
• Legal permanent residents (immigrants with green
  cards) ineligible for Medicaid or SCHIP during
  first 5 years in U.S.
• After 5 years, become eligible for Medicaid and
  SCHIP if meet other eligibility requirements
• States can extend 5-year bar until person has
  worked for 40 quarters or become naturalized
  citizen
• In 2004, 22 states and District of Columbia used
  state funds to provide coverage to some
  immigrants ineligible for Medicaid and SCHIP
• Some immigrants exempt from this rule and are
  eligible for Medicaid and SCHIP regardless of
  length of residence
• Refugees and most other humanitarian immigrants
  as well as active-duty members or veterans of
  U.S. Armed Forces and their families

6
Noncitizens also have less access to Medicaid
and SCHIP Welfare reforms of 1996

• Sponsor deeming further restricts immigrants
  access to Medicaid
• Many legal immigrants have sponsors who pledge
  to support them
• Federal law requires part of sponsors income and
  resources to be counted in determining Medicaid
  eligibility even if sponsor doesnt share any
  income
• Sponsor deeming can push immigrant over states
  income or asset limits for Medicaid even for
  very poor and those without resources to pay for
  care
• Seven-year limit on receipt of Social Security
  Income for refugees and asylees
• Refugees and other humanitarian immigrants are
  eligible to receive SSI benefits for their first
  7 years in U.S. and often lose Medicaid
• After 7 years, they lose SSI unless they become
  naturalized citizens
• Loss of SSI also often means loss of Medicaid
  coverage because SSI eligibility is vehicle to
  Medicaid eligibility
• They can maintain Medicaid eligibility beyond 7
  years if they qualify under different eligibility
  category

7
Noncitizens also have less access to Medicaid
and SCHIP Other immigrant policies

• Undocumented immigrants and immigrants in U.S. on
  temporary basis (e.g., temporary work visa or
  student visa) generally ineligible for Medicaid
  and SCHIP
• Regardless of their length of residence in U.S.
• This restriction predates PRWORA
• States can use SCHIP funds to provide prenatal
  care to pregnant women, regardless of their
  immigration status
• In 2002, CMS amended SCHIP regulations to give
  states option of providing SCHIP-funded prenatal
  care without applying an immigration test
• This rule extends SCHIP eligibility to pregnant
  womans fetus, which does not have an immigration
  status and is not subject to restrictions
• Currently, 7 states provide SCHIP-funded prenatal
  care to pregnant immigrants
• Emergency treatment is available to all
  immigrants, regardless of their status
• Legal and undocumented immigrants who meet all
  eligibility requirements except for
  immigrant-related restrictions are eligible for
  emergency medical treatment
• Emergency Medical Treatment and Labor Act
  (EMTALA) also requires hospitals to screen and
  stabilize all persons, including immigrants, who
  seek care in ER

8
Deficit Reduction Act of 2005 affects citizens,
not noncitizens

• Deficit Reduction Act of 2005 attempts to ensure
  enforcement of eligibility provisions against
  certain noncitizens by requiring documentation of
  citizenship
• Previously states could simply allow applicants,
  under penalty of perjury, to attest to their
  citizenship in writing
• DRA requires U.S. citizens to submit documents
  verifying citizenship to apply for or renew
  Medicaid coverage
• Levels of acceptable documentation
• Primary evidence includes passport, certificate
  of naturalization, or certificate of U.S.
  citizenship
• Secondary evidence (only if primary evidence not
  available) includes a birth certificate and other
  specified documentation, accompanied by specified
  identity documentation
• Other (less acceptable) evidence includes certain
  types of non-governmental documents (e.g.,
  hospital record extract, health insurance
  medical records, written affidavits, etc.)
• SSI eligibles and Medicare beneficiaries are
  exempted from citizenship documentation
  requirements for Medicaid eligibility
• For other eligibles, states can do cross matches
  with federal or state agency data
• Citizens unable to produce required documentation
  will lose Medicaid coverage

9
Impact of immigrant-related provisions on access
to Medicaid and SCHIP

• 1996 PRWORA restrictions on Medicaid and SCHIP
  eligibility for immigrants contributed to
  increasing uninsured rates among noncitizen
  immigrants
• Clarification that for most immigrants, Medicaid
  or SCHIP would not be used against them in visa
  or citizenship procedures reduced, but did not
  erase, concerns
• Other barriers continue to keep immigrants out of
  Medicaid and SCHIP
• Immigrants in first 5 years, refugees and asylees
  in SSI after 7 years, and immigrants excluded by
  sponsor deeming
• Shifted burden of their health care to states
  (only some of which provide state-funded
  coverage) and local safety net providers
• 2005 DRA exempts noncitizens from citizenship
  verification requirements, although must continue
  to provide proof they are legal U.S. residents
• DRA will create procedural barriers for many
  citizens applying for or retaining Medicaid,
  despite intent to use documentation enforcement
  to keep out noncitizens

10
States are acting to cover uninsured children,
regardless of immigration status

• U.S.-born children are eligible for Medicaid and
  SCHIP regardless of their parents immigration
  status
• But childs immigration status may prevent
  eligibility
• Many communities have health care safety net that
  provides care for all persons regardless of
  immigration status
• But access varies tremendously across communities
• Health care heavily subsidized by charity and
  local tax dollars as well as federal grants
• Some states and communities are expanding public
  health care coverage programs to include children
  regardless of immigration status
• Illinois
• Nearly 900,000 noncitizen adults and children
  about 4 of all noncitizens in U.S.
• Enacted All Kids to ensure that nearly all
  children in the state would have health insurance
  coverage regardless of immigration status
• California
• 6 million noncitizen adults and children 28 of
  all noncitizens in U.S.
• Grappling with legislation to cover all children
  regardless of immigration status

11
California from local coalitions to statewide
legislation

• California local public-private health insurance
  expansion programs for children
• Local public-private coalitions created locally
  funded health insurance expansion programs for
  children called Childrens Health Initiatives
• Led way in providing coverage to children who do
  not qualify for Medi-Cal or Healthy Families
  (SCHIP) due to their immigration status
• 19 county-level Childrens Health Initiatives
• Together cover 88,000 children out of estimated
  534,000 uninsured children in those counties
• 18 are single-county programs and 1 program
  covers five rural counties
• First program in Santa Clara County
• Currently 13,000 enrolled out of about 19,000
  uninsured children in county
• Largest program in Los Angeles County
• Nearly 42,000 enrollees out of about 235,000
  uninsured children in county
• Most county programs have enrolled uninsured
  children up to maximum available funding
• Most of these programs are capped and closed

12
California from local coalitions to statewide
legislation

• Of about 800,000 uninsured children in California
  in 2003
• 55 were eligible for Medi-Cal or Healthy
  Families
• Another 6 (44,000) were eligible for county
  programs
• 20 (159,000) were not eligible due to income
  limits of the programs
• 19 (148,000) were not eligible due to
  immigration restrictions
• Legislation for universal coverage for children
  passed State Legislature but vetoed by Governor
  Schwarzenegger in 2005
• Governor Schwarzenegger now has indicated his
  support for such legislation
• His 2006-07 budget proposal included 22 million
  for county health insurance programs that cover
  all children, including those who are
  undocumented
• Successfully opposed by Republican members of
  Legislature due to requirement for 2/3 majority
  vote for state budget
• Funding for universal coverage for children is
  included in tobacco tax initiative on Nov. 2006
  election ballot
• With enabling legislation, would create universal
  coverage for children in California

13
A long way to go

• California may be more receptive than most states
  to covering uninsured regardless of citizenship
  or immigration
• But California has long way to go
• Of 4.1 million adults who were uninsured in 2003
• 6 (244,000) were eligible for Medi-Cal
• Another 0.1 (4,000) were eligible for county
  programs
• 68 (2.8 million) were citizens or legal
  immigrants with green card
• 26 (1.1) million were noncitizens without a
  green card
• Health care coverage expansion and controlling
  health care costs are now high on political and
  policy agenda
• San Francisco just enacted new health insurance
  expansion program with mandated employer
  pay-or-play participation
• Legislative bills are focal point for statewide
  policy action
• Single-payer and other proposals
• Candidates for Governor are developing own
  proposals