Steven P. Wallace, PhD UCLA Center for Health Policy Research & UCLA School of Public Health

1. The impact of health care reform
on immigrants
Steven P. Wallace, PhD
UCLA Center for Health Policy Research &
UCLA School of Public Health
swallace@ucla.edu

2. Percent Residents Born Abroad
36.4
LA 36.1 35.6
24.8
CA 22.7 27.3 26.9
19.6 22.1 26.3
15 15.3 21.7
18.4 13.5 10.7
19
8.9 15.1
13.4
10.4 10.8 11.7 12.8 10.9 11 12.4 12.5
8.8 7.5
6.6 7.4 US 6.2
8
4.8
1900 1910 1920 1930 1940 1950 1970 1980 1990 2000 2005 2009
Source: U.S. Census and ACS

3. Age-adjusted total per capita
health spending, 2008 dollars
Stimpson, Wilson, Eschbach, Health Affairs 2010.
doi: 10.1377/hlthaff.2009.0400

4. Odds ratios*, health care access vs.
U.S.-born Mexican Americas, CA
1.28
1.00 1.00 1.00 1.06
1.00
0.82 0.83 0.83
0.70 0.75 0.700.73
0.52 0.50
US Born Naturalized Green card Undocumented US Born NL
MexicanAm white
Usual source of care MD visit ED visit
* Adjusted for sex, marital status, health insurance, age, education, employment,
federal poverty level, location of residence, and self-reported health status.
Source: CHIS 2003 in Arch Intern Med, Vol 167, Nov 26, 2007, p 2354

5. No Usual Source of Care,
California, 2009
47.4%
43.4% Insured Uninsured
36.4%
21.6%
7.7% 9.0%
US Born Naturalized citizen Noncitizen
Source: California Health Interview Survey, 2009

6. Percent Uninsured Ages 0-64,
Calif. 2009
41.9%
Mexican
31.3%
All others 25.2%
14.8% 12.9%
11.9%
US Born Naturalized citizen Noncitizen
Source: California Health Interview Survey, 2009

7. Uninsured in CA by
Documentation Status, 2005
21.0%
3.0% Undoc adults
Undoc kids
Citizens/LPR
76.0%

8. Most insurance from work,
California 2009
61.8%
58.5% Employment
Private purchased
32.3%
6.7% 7.8%
3.4%
US Born Naturalized citizen Noncitizen
Source: California Health Interview Survey, 2009

9. Calif. any insurance 2008:
Employed Mexican-born noncitizens ages 25-49
73.9
288,449
65.3 % insured
# employed
198,821
47.7 48.6
45.7 151,963
143,157
43.3 125,120
41.8
83,291 34.6
73,336 68,407 32.8 33.6
63,344
51,339
Prof-Exec Sales Admin Priv HH-Prot Sgv Farm Repair Mach opr Trans Labor
Overall 42.7% have
Source: Current Population Survey, 2009
any coverage

10. Work coverage has declined:
Employed all noncitizens in U.S. ages 25-49
Percent with health insurance from job
52.7
51.4
49.8
Percent
46.8 46.9 46.9
45.3 46.1 44.8
2000 2002 2003 2004 2005 2006 2007 2008 2009
Source: Current Population Survey

11. Work coverage has declined:
Employed Mexican-born noncitizens in U.S., 25-49
37.5 37.9 36.5
Percent
32.3
31.2 31.7 30.4
28.9 29.3
2000 2002 2003 2004 2005 2006 2007 2008 2009
Source: Current Population Survey

12. CA work coverage declined:
Employed all noncitizens ages 25-49
51.3
Percent
48.6
45.9 45.8
43.4
42 41.9 42.8
38.5
2000 2002 2003 2004 2005 2006 2007 2008 2009
Source: Current Population Survey

13. CA work coverage declined:
Employed Mexican-born noncitizens ages 25-49
40.4 40.5
percent
37.2 36.3
33.2 32.2 32.8
31.8
30
2000 2002 2003 2004 2005 2006 2007 2008 2009
Source: Current Population Survey

14. Main Elements of the
Reform Legislation affecting
Working-Age Population*
*Most go into effect in 2014

15. Insurance Coverage
Will reduce uninsured from 48 million to
21 million through :
• Employer mandate
• Individual mandate
• Medicaid (Medi-Cal) expansion
• + Community health center expansion

16. Coverage (Employer
Mandate)
• Employers with more than 50 employees
must provide coverage or pay penalty of
$2000/employee.
• Tax credit to small employers that pay
at least 50% of health insurance costs;
<25full-time workers
• average annual wage < $50,000

17. Uninsured employees by company
size & citizenship, Calif. 2009
50.9%
US-born
Naturalized
Noncitizen
26.7%
20.5% 20.9% 21.6%
14.6% 12.9% 14.9%
11.2%
7.4% 8.3%
4.3%
1-49 50-99 100-999 1000+
Firm Size
Source: California Health Interview Survey, 2009

18. Coverage (2)
Individual mandate
• Everyone w/o employer insurance must
buy coverage or pay a penalty
($700/individual, $2100/family), unless
insurance cost exceeds 8% of income
• Income-based subsidies to uninsured
• sliding scale up to 400% poverty level

19. % uninsured among Californians
<age 65 with incomes133-400% FPL
39.6%
19.0%
15.4%
8.7 million 1.7 million 1.3 million
US-born Naturalized Noncitizen
Source: California Health Interview Survey, 2009

20. Coverage (3)
• Medicaid (low-income coverage)
expansion
• everyone covered whose income is less
than 133% of poverty level
• eliminates link to families with
children, i.e. singles & couples w/o
kids will qualify

21. % uninsured among Californians
<age 65 with incomes <133% FPL
43.8%
30.8%
20.8%
1 million 273,000 1.1 million
US-born Naturalized Noncitizen
Source: California Health Interview Survey, 2009

22. Health Insurers…
• Cannot turn away those w/a history of illness
• Cannot charge more to those w/a history of
illness (older people can be charged maximum
of 3 times that of younger person)
• Cannot terminate coverage
• Must renew coverage
• Return at least 80% of premiums in the form
of health service benefits
24

23. Other access issues
• Significant increase in funding for community
health centers (primary care)
25

24. 8.5 Million in CA Use Clinics
as Usual Source of Care, 2009
1717,
20%
US-born
1241, Naturalized
15% Non-citizen
5,506,
65%

25. % using clinics among those with a usual
source of medical care, Calif.
79.2%
insured uninsured
59.5% 60.4% 57.6%
45.4% 41.9%
35.4%
12.9%
Imm MexAm, in US Immg MexAm, in US Born US Born NL White
<10 yrs US 10+ yrs MexicanAm
Source: California Health Interview Survey, 2009

26. Other issues?
• Undocumented residents
• Mixed status families
• Definition of “emergency” for Medicaid

27. Senate bill p. 292
• (d) NO FEDERAL PAYMENTS FOR
INDIVIDUALS NOT LAWFULLY
PRESENT.—Nothing in this subtitle or the
amendments made by this subtitle allows
Federal payments, credits, or cost-sharing
reductions for individuals who are not lawfully
present in the United States.

28. Undocumented Immigrants,
U.S. = 11.2 million, 2010
State Estimated #
California 2,550,000
Texas 1,650,000
Florida 825,000
New York 625,000
New Jersey 550,000
Illinois 525,000
Georgia 425,000
Arizona 400,000
North Carolina 325,000
Maryland 275,000
Washington 230,000
Source: http://pewhispanic.org/files/reports/133.pdf

29. Mixed status families complicate
equitable health care, U.S.
Children of Mexican immigrants Children of NonLatino immigrants
14.9%
25.7%
47.1%
25.3%
59.8%
27.3%
Citizen parents Citizen parents
1-citizen parent 1-citizen parent
Noncitizen parents Noncitizen parents

30. Senate bill p. 126
• (c) APPLICATION OF EMERGENCY
SERVICES LAWS.— Nothing in this Act shall
be construed to relieve any health care
provider from providing emergency services as
required by State or Federal law, including
section 1867 of the Social Security Act
(popularly known as ‘‘EMTALA’’).

31. But each state defines “emergency” -
Georgia does not cover dialysis

32. Adequate use of health care
• Availability – are services located in the
community where immigrants live
• Accessibility – can immigrants afford the
care; are the hours of service appropriate
• Acceptability – do the immigrants have
confidence in the provider, can they
communicate

33. Summary
• Health Care Reform (ACA) will greatly
improve access to care to immigrants
• More insured @ work, subsidies, Medicaid
• Improved access to community health
centers
• Availability & acceptability changes
unclear
• Undocumented immigrants remain vulnerable

34. To get your OWN data on immigrant health go
to www.chis.ucla.edu