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Immigrants and Coverage
                           Affordable Care Act
Lynn A. Blewett, PhD
Professor and Director
State Health Access Data Assistance Center (SHADAC)
University of Minnesota

Safe Table Forum: Health Care Access for
Immigrants in Washington State
August 23, 2012


                  Funded by a grant from the Robert Wood Johnson Foundation   1
Overview

• Citizenship/Immigrant Definitions
• Estimates of foreign-born in the U.S. by type
  of immigration status – US and WA
• Impact of Affordable Care Act coverage
  expansions
• Implication for state policy and local safetynet
  programs


                                                     2
Some definitions
Immigrants

Immigrant                  Noncitizen, legally
                           admitted
Legal Permanent Resident   Noncitizen, legally         -Has authorization to work in
or Legal Alien             admitted                    U.S. (Green Card holders)
                                                       -Married to US citizen

Asylees/Refugees           Noncitizen, legally         -Admitted for fear of prosecution
                           admitted                    in home country

Non-Immigrants
Non-Citizen Temporary      Noncitizen, temporary       -Travelers, business people,
Immigrants                 visitor, legally admitted   students, others

Non-Legal Immigrants
Unauthorized (non-legal)   Noncitizen, no legal        -Entered with no or false
Alien                      authorization               documents
                                                       -0verstayed temp visa           3
A few more definitions…..
• Natural citizen: someone born in the U.S. or born to
  U.S. citizen parent (s) living in another country
• A naturalized citizen: someone born in a foreign country,
  but took a series of steps and was granted citizenship.
   – Has been a legal resident of the U.S. at least 5 yrs.
   – Is age 18 or older
   – Has knowledge of the English language and history of
     the U.S.
              naturalized citizens have all the
             rights and responsibilities of a U.S.
               citizen, except are barred from
                 serving as President or Vice
                          President

                                                              4
US Population by Citizenship Status and an ACA preview
     = Foreign Born
                              Citizens       Non-Citizens



                                                Legal         5 yr.
                                              Immigrants      Ban,
                                                              HIX
  Full                U.S.-Born citizens
 ACA
Benefits
                                                 Non-
                                               Immigrants

                                                              No
                                                            Benefits
                                               Non-Legal
                                              Immigrants
                      Naturalized citizens

                                                                      5
Foreign-Born Persons in the US
(2010, in millions)
                                            Naturalized
                                             Citizens
                                               14.9       Legal Alien
                                                             12.4

                                                          Temp Residents,
                                                               1.7

                                                               Non-Legal
                                                                 11.2

                                                 Foreign Born = 40.2 million




 US-Born Citizen = 264.1 million


                       Source: Pew-Hispanic Center Feb 2, 2011                 6
Percent of Non-Elderly Adults who were Foreign
Born, 2010




Source: SHADAC analysis of data from the ACS, 2012   7
Percent of Non-Elderly Adults who were Non-
 Citizens, 2010




Source: SHADAC analysis of data from the ACS, 2012   8
Washington State




                   9
Non-Elderly Adults (age 19-65) by Citizenship
                 Status, Washington State 2010
  Foreign                             Non-Citizen
  Born                                Immigrants
                           Naturalized   9.3%
                              Citizens
                               7.2%


                                                                 U.S.-Born
                                                                  Citizens
                                                                   83.5%




Source: American Community Survey as analyzed by SHADAC , 2010

                                                                             10
Characteristics of Non-Elderly Adults
                            (age19 to 64) State of Washington 2010
                                             U.S. Born Citizens                   Foreign Born   Non-Citizens
                                                                                    Citizens
      Total                                            3,504,939                     303,154        388,610
      Percent                                            83.5%                        7.2%           9.3%
      Age
             19 to 25                                    15.9%                        7.8%           17.0%
             26 to 34                                    18.9%                        16.6%          29.3%
             35 to 44                                    20.3%                        26.9%          28.6%
             45 to 54                                    23.8%                        27.1%          16.5%
             55 to 64                                    21.1%                        21.6%          8.5%
      Race/Ethnicity
             Hispanic                                    5.3%                         16.8%          46.6%
             White non-Hispanic                          84.3%                        24.8%          21.9%
             Black Alone
                non-Hispanic                             3.1%                         5.4%           3.9%
             Asian Alone
                non-Hispanic                             2.0%                         49.5%          25.8%
             Multiple/Other
                non-Hispanic                             5.3%                         3.4%           1.9%
Source: Estimates based on analysis of American Community Survey by SHADAC 2012

                                                                                                                11
Characteristics of Non-Elderly Adults
                              (age19 to 64) Washington State 2010
                                              U.S. Born Citizens   Foreign Born   Non-Citizens
                                                                     Citizens
       Educational Attainment
             <High School                                 6.5%         15.2%          35.2%
             High School                                  24.1%        19.2%          22.0%
             Some College                                 39.8%        31.7%          17.9%
             College of More                              29.7%        33.8%          24.9%
       Income
             0-138 FPG                                    23.8%        19.5%          43.0%
             139-200 FPG                                  8.5%         10.0%          13.5%
             201-400 FPG                                  26.3%        29.3%          20.4%
             400+ FPG                                     41.4%        41.3%          23.1%
       Employment Status
           Full-Time                                      60.0%        64.4%          54.3%
           Part-Time                                      23.0%        22.8%          30.2%
           Not working                                    17.0%        12.8%          15.5%

Source: American Community Survey as analyzed by SHADAC, 2010.

                                                                                                 12
Characteristics of Non-Elderly Adults
                                (age19 to 64) Washington State 2010

                                            U.S. Born Citizens                      Foreign Born    Non-Citizens
                                                                                      Citizens
      Insurance Coverage

            Employer                                    66.8%                               64.5%       39.9%
            Direct Purchase                              7.3%                                7.5%       6.3%
            Public                                       9.2%                                8.1%       8.4%
            Uninsured                                   16.7%                               19.9%       45.4%
      Health Status*

          Poor/Fair Health                              11.1%                                9.0%       8.9%




Sources: American Community Survey as analyzed by SHADAC, 2010. (*) Current Population Survey as
analyzed by SHADAC, 2011.




                                                                                                                   13
Summary of differences between
U.S Born and Foreign Born non-elderly Adults - WA

• Non-Citizens are more likely to be
   –   Young
   –   Hispanic
   –   Working part-time
   –   Low income
   –   Less likely to have graduated from high school
   –   More likely to be uninsured
   –   Health status not significantly different


                                                        14
Federal policies on immigrant access to
coverage




                                          15
Federal policies on immigrants’ access to coverage


   Personal       CHIP Unborn      Children’s        Patient
 Responsibility    Child State       Health        Protection &
   and Work           Plan         Insurance        Affordable
  Opportunity     Amendment         Program          Care Act
 Reconciliation                  Reauthorization    (PPACA)
      Act                             Act
  (PRWORA)                         (CHIPRA)


    1996            2002            2009             2010




                                                                  16
PRWORA 1996 and the Infamous Five-year Ban
• PRWORA made legal immigrants ineligible for federal
  “means-tested” public benefits until having resided
  legally in U.S. for 5 years

• Also deemed undocumented immigrants ineligible for
  state and local benefits

• States needed to enact special legislation after 1996 in
  order to cover undocumented immigrants or those
  excluded under 5-year ban



                                                             17
CHIP Un-Born Child Option of 2002

• Provides federal match for funds to cover
  pregnant women regardless of immigration
  status

• This option essentially covers services for the
  un-born child which has no immigration status

• 14 states currently receive funds through the
  unborn child option

                                                    18
Immigration Children’s Health Improvement Act

• Included as part of CHIPRA- Children’s Health
  Insurance Program Reauthorization Act- 2009

• As of 2009, states now eligible to receive federal
  matching funds to cover income-eligible pregnant
  women and children previously under 5-year ban
   – 17 States and the District of Columbia have chosen to
     cover both pregnant women and children under this
     law
   – 5 States have chosen to cover children under this law
   – 1 State has chosen just to cover pregnant women
     under this law
                                                             19
Affordable Care Act




                      20
Key provision of the ACA

1. Medicaid expansion and uniform eligibility -
       now optional
2. Private insurance market
3. Temporary high-risk pool
4. Health insurance exchange
5. Individual and employer mandate with
   penalties
6. Delivery system and payment reform
                                                  21
U.S. Medicaid/CHIP Income
                                       Eligibility Thresholds-2012
       350%
                              250%
       300%
                                                                                ACA Medicaid Expansion to
       250%                                                                              138% FPL
                                                         185%                   $26,344 for family of 3 - 2012
       200%

       150%

       100%                                                                                                      22 million
                                                                                   63%
                                                                                                            37% Low-Income
         50%
                                                                                                                 Uninsured
                                                                                                                Adults 19-64
            0%                                                                                                              0
                           Children                  Pregnant                   Working                    Jobless      Childless
                                                     Women                      Parents                    Parents        Adults

Source: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the
Uninsured and the Georgetown University Center for Children and Families, 2012.
Exceptions to the Individual Mandate

• Financial hardship
• Religious objections
• American Indians and Alaska Natives
• Incarcerated individuals
• Those for whom the lowest cost plan option
  exceeds 8% of income, and
• Those whose income is below the tax filing
  threshold
                 And the Undocumented
                                               23
What does national health reform mean for
immigrants?
• Naturalized citizens
  – Same access as US-born citizens
• For legal immigrants:
  – Waiting period of five years for Medicaid/CHIP
    eligibility stands
  – Required to purchase coverage under individual
    mandate provisions with associated tax penalties
  – May participate in new federal or state or federal
    health insurance exchange and receive tax credits
  – Exchange application will require verification of legal
    status
                                                              24
For Non-Legal Immigrants

• Cannot participate in Health Insurance Exchange
  even if willing to purchase at full cost

• Exempt from the Individual Mandate (no penalties
  assessed for not having coverage)

• Not eligible for Medicare, Medicaid or CHIP

• Remain eligible for emergency Medicaid if low-
  income
                                                     25
Children born in U.S. to non-legal parent(s)
• Children are considered U.S. Citizen

• Eligible for Health Insurance Exchange with subsidies
  and tax credits
   – Verification of U.S. citizenship and income required

• May be eligible for Medicaid and CHIP for low-
  income
   – Verification of U.S. citizenship and income required

                                                            26
Subsidy Amount                                      Average 2011 US Premium for

    in the Exchange by FPL                                Single Coverage $5,429

     $6,000




     $5,000
                                                                        $1,184

     $4,000                                                   $2,246
                                                  $3,055
     $3,000
                                        $4,022
     $2,000

                            $4,759
     $1,000
                 $5,320

        $-


              133%        150%         200%           250%      300%       400%

Source: Employer Health Benefits 2011 Annual Survey                                   27
State initiatives to cover excluded immigrant
children
• Before 2009, all coverage extended to excluded
  immigrant children was state-funded (no federal match)

   – 17 states extended coverage to legal immigrant
     children residing in U.S. < 5 years

   – Only 4 of these states cover undocumented children
     (IL, MA, NY, DC)

   – Some counties in CA cover undocumented children


                                                           28
State initiatives to cover excluded immigrant
children




Source: Kaiser Commission on Medicaid and the Uninsured, 2009



                                                                29
Key Summary Points
• A substantial number of immigrants are excluded from ACA
  expansions and the five year ban lives on
• Legal immigrants are not eligible for Medicaid for five
  years, but will be mandated to purchase coverage and
  allowed to participate in exchanges
• Some states have made efforts to cover children regardless
  of immigration status
• Remaining uninsured immigrants are likely to continue to
  seek care at CHCs and in community hospitals as
  uncompensated charity care
   – Remember EMTALA


                                                          30
How can states address coverage gaps?
• Understanding the estimated scope of the population
  without coverage will help states and safety-net providers
  develop strategies on how to cover the gaps
   -Who are they, where do they live, where do they get care
   now?
   -Use data/information to better target new safetynet
   programs

• Leverage new FQHC/CHC funding

• As federal Medicare and Medicaid Disproportionate Share
  Payments (DSP) are reduced over time – continue to
  assess financial needs of public safety net hospitals
                                                               31
Consider alternative safetynet programs e.g.
Local Access to Care Programs (LACPs)

• Nevada – Access to Healthcare Network

• Massachusetts – Health Safety Net

• Healthy San Francisco

       Local Non-Profit organization to develop
        network of providers who contractually
               agree to provider free or
           reduced cost care to an enrolled
                      population

                                                  32
Concluding thoughts
• Even with full ACA implementation and before Medicaid
  expansions were ruled as optional by the Supreme Court
  – there were still going to be 20 Million uninsured

• Still a significant need for safetynet services, providers,
  systems

• Non-legal immigrants are here and have health care
  needs – do we continue to ignore their needs?
• We still pay for their care in inefficient and costly ways
   – Uncompensated care in community hospitals, state/local funding
     of public hospitals

                                                                      33
Lynn A. Blewett, PhD
                 State Health Access Data Assistance Center
                             blewe001@umn.edu
                                @lynnblewett




                        Sign up to receive our newsletter and updates at
                                       www.shadac.org
                                             @shadac

www.shadac.org

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Pres safe tableforumwa_stateaug23_blewett

  • 1. Immigrants and Coverage Affordable Care Act Lynn A. Blewett, PhD Professor and Director State Health Access Data Assistance Center (SHADAC) University of Minnesota Safe Table Forum: Health Care Access for Immigrants in Washington State August 23, 2012 Funded by a grant from the Robert Wood Johnson Foundation 1
  • 2. Overview • Citizenship/Immigrant Definitions • Estimates of foreign-born in the U.S. by type of immigration status – US and WA • Impact of Affordable Care Act coverage expansions • Implication for state policy and local safetynet programs 2
  • 3. Some definitions Immigrants Immigrant Noncitizen, legally admitted Legal Permanent Resident Noncitizen, legally -Has authorization to work in or Legal Alien admitted U.S. (Green Card holders) -Married to US citizen Asylees/Refugees Noncitizen, legally -Admitted for fear of prosecution admitted in home country Non-Immigrants Non-Citizen Temporary Noncitizen, temporary -Travelers, business people, Immigrants visitor, legally admitted students, others Non-Legal Immigrants Unauthorized (non-legal) Noncitizen, no legal -Entered with no or false Alien authorization documents -0verstayed temp visa 3
  • 4. A few more definitions….. • Natural citizen: someone born in the U.S. or born to U.S. citizen parent (s) living in another country • A naturalized citizen: someone born in a foreign country, but took a series of steps and was granted citizenship. – Has been a legal resident of the U.S. at least 5 yrs. – Is age 18 or older – Has knowledge of the English language and history of the U.S. naturalized citizens have all the rights and responsibilities of a U.S. citizen, except are barred from serving as President or Vice President 4
  • 5. US Population by Citizenship Status and an ACA preview = Foreign Born Citizens Non-Citizens Legal 5 yr. Immigrants Ban, HIX Full U.S.-Born citizens ACA Benefits Non- Immigrants No Benefits Non-Legal Immigrants Naturalized citizens 5
  • 6. Foreign-Born Persons in the US (2010, in millions) Naturalized Citizens 14.9 Legal Alien 12.4 Temp Residents, 1.7 Non-Legal 11.2 Foreign Born = 40.2 million US-Born Citizen = 264.1 million Source: Pew-Hispanic Center Feb 2, 2011 6
  • 7. Percent of Non-Elderly Adults who were Foreign Born, 2010 Source: SHADAC analysis of data from the ACS, 2012 7
  • 8. Percent of Non-Elderly Adults who were Non- Citizens, 2010 Source: SHADAC analysis of data from the ACS, 2012 8
  • 10. Non-Elderly Adults (age 19-65) by Citizenship Status, Washington State 2010 Foreign Non-Citizen Born Immigrants Naturalized 9.3% Citizens 7.2% U.S.-Born Citizens 83.5% Source: American Community Survey as analyzed by SHADAC , 2010 10
  • 11. Characteristics of Non-Elderly Adults (age19 to 64) State of Washington 2010 U.S. Born Citizens Foreign Born Non-Citizens Citizens Total 3,504,939 303,154 388,610 Percent 83.5% 7.2% 9.3% Age 19 to 25 15.9% 7.8% 17.0% 26 to 34 18.9% 16.6% 29.3% 35 to 44 20.3% 26.9% 28.6% 45 to 54 23.8% 27.1% 16.5% 55 to 64 21.1% 21.6% 8.5% Race/Ethnicity Hispanic 5.3% 16.8% 46.6% White non-Hispanic 84.3% 24.8% 21.9% Black Alone non-Hispanic 3.1% 5.4% 3.9% Asian Alone non-Hispanic 2.0% 49.5% 25.8% Multiple/Other non-Hispanic 5.3% 3.4% 1.9% Source: Estimates based on analysis of American Community Survey by SHADAC 2012 11
  • 12. Characteristics of Non-Elderly Adults (age19 to 64) Washington State 2010 U.S. Born Citizens Foreign Born Non-Citizens Citizens Educational Attainment <High School 6.5% 15.2% 35.2% High School 24.1% 19.2% 22.0% Some College 39.8% 31.7% 17.9% College of More 29.7% 33.8% 24.9% Income 0-138 FPG 23.8% 19.5% 43.0% 139-200 FPG 8.5% 10.0% 13.5% 201-400 FPG 26.3% 29.3% 20.4% 400+ FPG 41.4% 41.3% 23.1% Employment Status Full-Time 60.0% 64.4% 54.3% Part-Time 23.0% 22.8% 30.2% Not working 17.0% 12.8% 15.5% Source: American Community Survey as analyzed by SHADAC, 2010. 12
  • 13. Characteristics of Non-Elderly Adults (age19 to 64) Washington State 2010 U.S. Born Citizens Foreign Born Non-Citizens Citizens Insurance Coverage Employer 66.8% 64.5% 39.9% Direct Purchase 7.3% 7.5% 6.3% Public 9.2% 8.1% 8.4% Uninsured 16.7% 19.9% 45.4% Health Status* Poor/Fair Health 11.1% 9.0% 8.9% Sources: American Community Survey as analyzed by SHADAC, 2010. (*) Current Population Survey as analyzed by SHADAC, 2011. 13
  • 14. Summary of differences between U.S Born and Foreign Born non-elderly Adults - WA • Non-Citizens are more likely to be – Young – Hispanic – Working part-time – Low income – Less likely to have graduated from high school – More likely to be uninsured – Health status not significantly different 14
  • 15. Federal policies on immigrant access to coverage 15
  • 16. Federal policies on immigrants’ access to coverage Personal CHIP Unborn Children’s Patient Responsibility Child State Health Protection & and Work Plan Insurance Affordable Opportunity Amendment Program Care Act Reconciliation Reauthorization (PPACA) Act Act (PRWORA) (CHIPRA) 1996 2002 2009 2010 16
  • 17. PRWORA 1996 and the Infamous Five-year Ban • PRWORA made legal immigrants ineligible for federal “means-tested” public benefits until having resided legally in U.S. for 5 years • Also deemed undocumented immigrants ineligible for state and local benefits • States needed to enact special legislation after 1996 in order to cover undocumented immigrants or those excluded under 5-year ban 17
  • 18. CHIP Un-Born Child Option of 2002 • Provides federal match for funds to cover pregnant women regardless of immigration status • This option essentially covers services for the un-born child which has no immigration status • 14 states currently receive funds through the unborn child option 18
  • 19. Immigration Children’s Health Improvement Act • Included as part of CHIPRA- Children’s Health Insurance Program Reauthorization Act- 2009 • As of 2009, states now eligible to receive federal matching funds to cover income-eligible pregnant women and children previously under 5-year ban – 17 States and the District of Columbia have chosen to cover both pregnant women and children under this law – 5 States have chosen to cover children under this law – 1 State has chosen just to cover pregnant women under this law 19
  • 21. Key provision of the ACA 1. Medicaid expansion and uniform eligibility - now optional 2. Private insurance market 3. Temporary high-risk pool 4. Health insurance exchange 5. Individual and employer mandate with penalties 6. Delivery system and payment reform 21
  • 22. U.S. Medicaid/CHIP Income Eligibility Thresholds-2012 350% 250% 300% ACA Medicaid Expansion to 250% 138% FPL 185% $26,344 for family of 3 - 2012 200% 150% 100% 22 million 63% 37% Low-Income 50% Uninsured Adults 19-64 0% 0 Children Pregnant Working Jobless Childless Women Parents Parents Adults Source: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2012.
  • 23. Exceptions to the Individual Mandate • Financial hardship • Religious objections • American Indians and Alaska Natives • Incarcerated individuals • Those for whom the lowest cost plan option exceeds 8% of income, and • Those whose income is below the tax filing threshold And the Undocumented 23
  • 24. What does national health reform mean for immigrants? • Naturalized citizens – Same access as US-born citizens • For legal immigrants: – Waiting period of five years for Medicaid/CHIP eligibility stands – Required to purchase coverage under individual mandate provisions with associated tax penalties – May participate in new federal or state or federal health insurance exchange and receive tax credits – Exchange application will require verification of legal status 24
  • 25. For Non-Legal Immigrants • Cannot participate in Health Insurance Exchange even if willing to purchase at full cost • Exempt from the Individual Mandate (no penalties assessed for not having coverage) • Not eligible for Medicare, Medicaid or CHIP • Remain eligible for emergency Medicaid if low- income 25
  • 26. Children born in U.S. to non-legal parent(s) • Children are considered U.S. Citizen • Eligible for Health Insurance Exchange with subsidies and tax credits – Verification of U.S. citizenship and income required • May be eligible for Medicaid and CHIP for low- income – Verification of U.S. citizenship and income required 26
  • 27. Subsidy Amount Average 2011 US Premium for in the Exchange by FPL Single Coverage $5,429 $6,000 $5,000 $1,184 $4,000 $2,246 $3,055 $3,000 $4,022 $2,000 $4,759 $1,000 $5,320 $- 133% 150% 200% 250% 300% 400% Source: Employer Health Benefits 2011 Annual Survey 27
  • 28. State initiatives to cover excluded immigrant children • Before 2009, all coverage extended to excluded immigrant children was state-funded (no federal match) – 17 states extended coverage to legal immigrant children residing in U.S. < 5 years – Only 4 of these states cover undocumented children (IL, MA, NY, DC) – Some counties in CA cover undocumented children 28
  • 29. State initiatives to cover excluded immigrant children Source: Kaiser Commission on Medicaid and the Uninsured, 2009 29
  • 30. Key Summary Points • A substantial number of immigrants are excluded from ACA expansions and the five year ban lives on • Legal immigrants are not eligible for Medicaid for five years, but will be mandated to purchase coverage and allowed to participate in exchanges • Some states have made efforts to cover children regardless of immigration status • Remaining uninsured immigrants are likely to continue to seek care at CHCs and in community hospitals as uncompensated charity care – Remember EMTALA 30
  • 31. How can states address coverage gaps? • Understanding the estimated scope of the population without coverage will help states and safety-net providers develop strategies on how to cover the gaps -Who are they, where do they live, where do they get care now? -Use data/information to better target new safetynet programs • Leverage new FQHC/CHC funding • As federal Medicare and Medicaid Disproportionate Share Payments (DSP) are reduced over time – continue to assess financial needs of public safety net hospitals 31
  • 32. Consider alternative safetynet programs e.g. Local Access to Care Programs (LACPs) • Nevada – Access to Healthcare Network • Massachusetts – Health Safety Net • Healthy San Francisco Local Non-Profit organization to develop network of providers who contractually agree to provider free or reduced cost care to an enrolled population 32
  • 33. Concluding thoughts • Even with full ACA implementation and before Medicaid expansions were ruled as optional by the Supreme Court – there were still going to be 20 Million uninsured • Still a significant need for safetynet services, providers, systems • Non-legal immigrants are here and have health care needs – do we continue to ignore their needs? • We still pay for their care in inefficient and costly ways – Uncompensated care in community hospitals, state/local funding of public hospitals 33
  • 34. Lynn A. Blewett, PhD State Health Access Data Assistance Center blewe001@umn.edu @lynnblewett Sign up to receive our newsletter and updates at www.shadac.org @shadac www.shadac.org