Immigrants and Coverage                           Affordable Care ActLynn A. Blewett, PhDProfessor and DirectorState Healt...
Overview• Citizenship/Immigrant Definitions• Estimates of foreign-born in the U.S. by type  of immigration status – US and...
Some definitionsLegally-Resident ImmigrantsLegal Permanent Resident      Noncitizen, legally         -Has authorization to...
A few more definitions…..• Natural-born citizen: someone born in the U.S. or born  to U.S. citizen parent (s) living in an...
US Population by Citizenship Status and an ACA preview     = Foreign Born                              Citizens       Non-...
Foreign-Born Persons in the US(2010, in millions)                                            Naturalized                  ...
Percent of Non-Elderly Adults who were ForeignBorn, 2010Source: SHADAC analysis of data from the ACS, 2012   7
Percent of Non-Elderly Adults who were Non- Citizens, 2010Source: 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                      ...
Characteristics of Non-Elderly Adults                            (age19 to 64) State of Washington 2010                   ...
Characteristics of Non-Elderly Adults                              (age19 to 64) Washington State 2010                    ...
Characteristics of Non-Elderly Adults                                (age19 to 64) Washington State 2010                  ...
Summary of differences betweenU.S Born and Foreign Born non-elderly Adults - WA• Non-Citizens are more likely to be   –   ...
Federal policies on immigrant access tocoverage                                          15
Federal policies on immigrants’ access to coverage   Personal       CHIP Unborn      Children’s        Patient Responsibil...
PRWORA 1996 and the Infamous Five-year Ban• PRWORA made legal immigrants ineligible for federal  “means-tested” public ben...
CHIP Un-Born Child Option of 2002• Provides federal match for funds to cover  pregnant women regardless of immigration  st...
Immigration Children’s Health Improvement Act• Included as part of CHIPRA- Children’s Health  Insurance Program Reauthoriz...
Affordable Care Act                      20
Key provision of the ACA1. Medicaid expansion and uniform eligibility -       now optional2. Private insurance market3. Te...
U.S. Medicaid/CHIP Income                                       Eligibility Thresholds-2012       350%                    ...
Exceptions to the Individual Mandate• Financial hardship• Religious objections• American Indians and Alaska Natives• Incar...
What does national health reform mean forimmigrants?• Naturalized citizens  – Same access as US-born citizens• For legal i...
For Non-Legal Immigrants• Cannot participate in Health Insurance Exchange  even if willing to purchase at full cost• Exemp...
Children born in U.S. to non-legal parent(s)• Children are considered U.S. Citizen• Eligible for Health Insurance Exchange...
Subsidy Amount                                      Average 2011 US Premium for    in the Exchange by FPL                 ...
State initiatives to cover excluded immigrantchildren• Before 2009, all coverage extended to excluded  immigrant children ...
State initiatives to cover excluded immigrantchildrenSource: Kaiser Commission on Medicaid and the Uninsured, 2009        ...
Key Summary Points• A substantial number of immigrants are excluded from ACA  expansions and the five year ban lives on• L...
How can states address coverage gaps?• Understanding the estimated scope of the population  without coverage will help sta...
Consider alternative safetynet programs e.g.Local Access to Care Programs (LACPs)• Nevada – Access to Healthcare Network• ...
Concluding thoughts• Even with full ACA implementation and before Medicaid  expansions were ruled as optional by the Supre...
Lynn A. Blewett, PhD                 State Health Access Data Assistance Center                             blewe001@umn.e...
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Pres safe tableforumwa_stateaug23_blewett

  1. 1. Immigrants and Coverage Affordable Care ActLynn A. Blewett, PhDProfessor and DirectorState Health Access Data Assistance Center (SHADAC)University of MinnesotaSafe Table Forum: Health Care Access forImmigrants in Washington StateAugust 23, 2012 Funded by a grant from the Robert Wood Johnson Foundation 1
  2. 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. 3. Some definitionsLegally-Resident ImmigrantsLegal Permanent Resident Noncitizen, legally -Has authorization to work inor Legal Alien admitted U.S. (Green Card holders) -Married to US citizenAsylees/Refugees Noncitizen, legally -Admitted for fear of prosecution admitted in home countryNon-ImmigrantsNon-Citizen Temporary Noncitizen, temporary -Travelers, business people,Immigrants visitor, legally admitted students, othersNon-Legal ImmigrantsUnauthorized (non-legal) Noncitizen, no legal -Entered with no or falseAlien authorization documents -0verstayed temp visa 3
  4. 4. A few more definitions…..• Natural-born 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. 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 ACABenefits Non- Immigrants No Benefits Non-Legal Immigrants Naturalized citizens 5
  6. 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 = 265.8 million Source: Pew-Hispanic Center Feb 1, 2011 6
  7. 7. Percent of Non-Elderly Adults who were ForeignBorn, 2010Source: SHADAC analysis of data from the ACS, 2012 7
  8. 8. Percent of Non-Elderly Adults who were Non- Citizens, 2010Source: SHADAC analysis of data from the ACS, 2012 8
  9. 9. Washington State 9
  10. 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. 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. 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. 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 asanalyzed by SHADAC, 2011. 13
  14. 14. Summary of differences betweenU.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. 15. Federal policies on immigrant access tocoverage 15
  16. 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. 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. 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. 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
  20. 20. Affordable Care Act 20
  21. 21. Key provision of the ACA1. Medicaid expansion and uniform eligibility - now optional2. Private insurance market3. Temporary high-risk pool4. Health insurance exchange5. Individual and employer mandate with penalties6. Delivery system and payment reform 21
  22. 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 AdultsSource: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and theUninsured and the Georgetown University Center for Children and Families, 2012.
  23. 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. 24. What does national health reform mean forimmigrants?• 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. 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. 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. 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. 28. State initiatives to cover excluded immigrantchildren• 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. 29. State initiatives to cover excluded immigrantchildrenSource: Kaiser Commission on Medicaid and the Uninsured, 2009 29
  30. 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. 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. 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. 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. 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 @shadacwww.shadac.org
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