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Pres sph2011 apr19_blewett

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  • 1. Immigrants’ access to care underthe Affordable Care Act: The role ofstates in addressing coverage gapsLynn A. Blewett, PhDProfessor and DirectorState Health Access Data Assistance CenterUniversity of Minnesota, School of Public HealthUniversity of Minnesota School of Public Health RoundtableMinneapolis, MNApril 19th, 2011Funded by a grant from the Robert Wood Johnson Foundation
  • 2. Acknowledgments • SHADAC Co-Authors Sharon Long Senior Health Economist Jessie Kemmick Pintor Doctoral Student, RA Michel Boudreaux Doctoral Student, RA Peter Graven ABD, Doctoral Student, RA Funding by a grant from the RWJF Foundation to the State Health Access Data Assistance Center (SHADAC)www.shadac.org 2
  • 3. Overview • Federal policies on immigrant access to coverage • State-level policies and initiatives to cover immigrant pregnant women and children • Non-elderly immigrant adults excluded in ACA expansions • State safety net programs to address gaps in coveragewww.shadac.org 3
  • 4. Federal policies on immigrants’ access to coverage Personal CHIP Unborn Children’s Patient Responsibility Child State Health Protection and Work Plan Insurance Opportunity Amendment Program & Reconciliation Reauthorization Affordable Act Act Care Act CHIP PPACA PRWORA CHIPRA 2010 1996 2009 2002www.shadac.org 4
  • 5. Welfare Reform 1996 • PRWORA made legal residents 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 to in order to cover undocumented immigrants or those excluded under 5-year ban Source: U.S. Dept. of Health and Human Services, Assistant Secretary for Planning & Evaluation , 2009www.shadac.org 5
  • 6. Unborn child option of 2002 • Provides federal match for funds to cover pregnant women regardless of immigration status-CHIP • This option essentially covers services for the unborn child which has no immigration status • 14 states currently receive federal matching funds through unborn child option for pregnant women Source: Kaiser Commission on Medicaid and the Uninsured, 2009www.shadac.org 6
  • 7. Children’s Health Insurance Program Reauthorization Act - 2009 • Immigration Children’s Health Improvement Act (ICHIA) included in CHIPRA • States now eligible to receive federal matching funds to cover -income-eligible pregnant women, and -children previously under 5-year ban • Number of states participating unknown Source: Kaiser Commission on Medicaid and the Uninsured, 2009www.shadac.org 7
  • 8. Key Provisions of the ACA Dependent High Risk Care Coverage 55-64 Pool Reinsurance Early Medicaid Exchanges SmallEmployer Indv MandateTax Credit Bridge to Reform 133% Medicaid 200-400% 2010 2014 Tax Creditwww.shadac.org
  • 9. Key provision of the ACA 1. Medicaid expansion and uniform eligibility 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 -www.shadac.org 9
  • 10. Coverage Expansion Categories Medicaid Premium Expansion Subsidy 133% 400% Medicaid Subsidy $29,326 $88,000 Family Family of Of Four Four 0 100 200 300 400 500 Federal Poverty Levelwww.shadac.org 10
  • 11. 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 Undocumentedwww.shadac.org 11
  • 12. What does national health reform mean for immigrants? • For permanent legal residents: – Waiting period of five years for Medicaid/CHIP eligibility – Required to purchase coverage under individual mandate provisions – Participation in new federal or state insurance exchanges will require verification of legal statuswww.shadac.org 12
  • 13. What are states doing to address coverage gaps? • Several states provide federal- or state- funded public coverage to immigrant pregnant women and children – Most of these states cover permanent residents subject to 5-year ban, some cover undocumented pregnant women and children • Access to care available for other excluded immigrants through safety nets and local access to care programs (LACP)www.shadac.org 13
  • 14. State-level access to public coverage for excluded pregnant women (1) Source: Kaiser Commission on Medicaid and the Uninsured, 2009www.shadac.org 14
  • 15. Access to public coverage for excluded pregnant women (2) • States offering coverage to excluded pregnant women rely on a variety of funding mechanisms • 17 states provide coverage to pregnant women regardless of immigration status • 8 states offer coverage only to legally qualified immigrant pregnant womenwww.shadac.org 15
  • 16. Access to public coverage for excluded pregnant women (3) • Of the 17 states providing coverage to pregnant women regardless of status • 15 finance this coverage through CHIP unborn child option (matching federal $) • 2 additional states rely on state funded-programs or state-funded Medicaid • e.g. DC Health Care Alliance, MA Commonwealth Carewww.shadac.org 16
  • 17. State initiatives to cover excluded immigrant children (1) Source: Kaiser Commission on Medicaid and the Uninsured, 2009www.shadac.org 17
  • 18. State Initiatives to cover excluded immigrant children (2) • 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 childrenwww.shadac.org 18
  • 19. Access to public coverage for excluded immigrant children (3) • Illinois All Kids • MA Children’s Medical Security Plan • NY Child Health Plus • DC Health Care Alliance • Restricted MediCal in several CA countieswww.shadac.org 19
  • 20. Additional coverage gaps for immigrants under ACA • Using 2008 American Community Survey (ACS) data, SHADAC estimates: 1) The number of low-income (FPG<=138%) immigrants excluded from 2014 Medicaid expansions (undocumented and immigrants subject to 5-year ban) 2) Characteristics of excluded immigrants 3) Distribution of excluded immigrants across stateswww.shadac.org 20
  • 21. How many excluded non-elderly adults? • Of the 33.6 million low-income non-elderly adults eligible for Medicaid under 2014 Medicaid expansions: – About 400,000 are likely to be legal residents in the U.S. for less than 5 years – 3.7 million are likely to be undocumented immigrants Source: SHADAC estimates, ACS, 2008www.shadac.org 21
  • 22. Characteristics of Low-income Non-elderly Adults in U.S., by Assigned Legal Status All non-elderly adults with family income <=138% FPG Citizens & “ Legally Likely Excluded qualified” Immigrants† Immigrants Total 30.0 Million 4.1 Million Female 58% 52% Age 18 to 44 69% 86% 45 to 64 31% 14% Married 28% 56% Children under 19 in household 49% 71% Anyone in family worked last year 69% 84% Insurance Public 32% 12% Private 33% 20% Uninsured 35% 69% Lives in metropolitan area 71% 89% †Includes those who report birth/naturalized citizenship, permanent residents, and immigrants assigned “likely legal” status who have resided in the U.S. for more than 5 yearswww.shadac.org Source: SHADAC estimates, ACS, 2008 22
  • 23. Number of low-income excluded adults by state Source: SHADAC estimates, ACS, 2008www.shadac.org 23
  • 24. Proportion of low-income adults who are excluded within each statewww.shadac.org Source: SHADAC estimates, ACS, 2008 24
  • 25. Policy Implications • A substantial number of immigrants are excluded from ACA expansions • Excluded legal immigrants are not eligible for Medicaid, but will be mandated to purchase coverage and allowed to participate in exchanges • Remaining uninsured immigrants are likely to continue to seek care at CHCswww.shadac.org 25
  • 26. How can states address coverage gaps? • Need for safety net care will not be evenly distributed across states – In CA, NV, AZ, and TX, 1 in 5 low-income non-elderly adults will not be eligible for Medicaid due to legal status • Understanding the likely scope of the population without coverage will help states and safety-net providers cover the gapswww.shadac.org 26
  • 27. Role of the safety net & Local Access to Care Programs (LACPs) • Nevada – Access to Healthcare Network • Massachusetts – Health Safety Net • Healthy San Franciscowww.shadac.org 27
  • 28. Nevada Access to Healthcare Network • 1 in 5 low-income Nevadans will not be eligible for Medicaid – In addition, NV does not provide coverage to excluded pregnant women and children • However, Nevada has a far-reaching, network of safety net providers • Available regardless of immigration status • Discounted rates for individuals up to 250% FPLwww.shadac.org 28
  • 29. Massachusetts Health Safety Net • Program for MA residents who are uninsured, underinsured, or without access to affordable coverage • Does not consider immigration status • Covers “medically necessary” services at CHCs and hospitals • Safety net pool pays part or all of costwww.shadac.org 29
  • 30. Healthy San Francisco • Provides accessible, affordable services for uninsured residents • Available regardless of immigration status, employment status, or pre-existing conditions • Covers individuals with family incomes up to 500% FPL • Sliding scale participant feewww.shadac.org 30
  • 31. Conclusions • Many restrictions at federal level maintained under health reform • States have flexibility to provide coverage for excluded pregnant women under CHIPRA • Local Access to Care Programs also play important role in addressing coverage gapswww.shadac.org 31
  • 32. Conclusions • Concern over increasing link between uninsurance and undocumented status and connection to the federally-funded saftey net providers – Community Health Centers – Public Hospitals – Community Hospitals • Future of state initiatives directed toward immigrants unclear under tight state budgetswww.shadac.org 32
  • 33. Contact Information Lynn A. Blewett, PhD blewe001@umn.edu State Health Access Data Assistance Center University of Minnesota, Minneapolis, MN www.shadac.org ©2002-2009 Regents of the University of Minnesota. All rights reserved.www.shadac.org The University of Minnesota is an Equal Opportunity Employer 33