Connecting Eligible Immigrant Families To Health Coverage Essay

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Connecting Eligible Immigrant Families to Health Coverage

Instructions:

Read the report Connecting Eligible Immigrant Families to Health Coverage and Care.
Write a one page post offering solutions to the problem from the nurse’s standpoint.Connecting Eligible Immigrant Families To Health Coverage Essay
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Beginning in 2014, the Patient Protection and Affordable Care Act (ACA) will significantly expand
coverage for low- and moderate-income families through an expansion in Medicaid eligibility and by
making tax credits available to help individuals purchase coverage through new Health Benefit
Exchanges. Given their high uninsured rate and limited access to private and public coverage, one group
who could significantly benefit from this coverage expansion is lawfully residing immigrant families.
However, in order for them to realize this potential benefit, it will be important to address the barriers
eligible immigrant families often face to enrolling in coverage and accessing needed care.
This report draws on the experience of outreach and enrollment workers who serve immigrant
communities to identify the role of Medicaid and CHIP for immigrant families, key barriers eligible
lawfully residing immigrant families face to enrolling in coverage and accessing care, successful
strategies to overcome these barriers, and considerations for health reform. It is based on findings from
four focus groups that were conducted during July and August 2011 with outreach workers who serve
immigrant communities in California, the District of Columbia, and Florida.
The Role of Medicaid and CHIP for Immigrant Families
Medicaid fulfills a number of roles for immigrant families. Focus group
participants stressed that Medicaid and CHIP coverage provide
immigrant families access to preventive and primary care, including
prenatal care, as well as care for chronic conditions. Several noted that,
without this coverage, obtaining health care would prove too financially
burdensome for low-income immigrant families and require them to
make difficult choices between paying for food or rent or health care.Connecting Eligible Immigrant Families To Health Coverage Essay
Participants also emphasized that, when families obtain Medicaid and
CHIP coverage, they often receive health education and connect to
other social services, which contribute to an overall increased
understanding of health and broad improvements in their quality of life.
Barriers to Coverage and Care for Eligible Immigrant Families
Fear was an overarching coverage barrier that emerged in all of the
focus group discussions. Participants identified two distinct fears that
deter eligible immigrant individuals and families from applying for
coverage. One is that receiving health care benefits will result in them
being considered a “public charge” and prevent them from obtaining
permanent residence. A second fear, often present among mixed status
families—such as U.S.-born children living with an undocumented
parent—is that applying for coverage for eligible family members may
expose other family members to risk of deportation.
“Not only do they get
medications and healthcare,
but they also get nutrition
advice, advice on raising
their kids to grow up
healthier and have less
medical problems when
they are adults. So I think
just having that access to
[Medicaid and CHIP]
increases their quality of life
immensely.”
Outreach Worker,
San Francisco
“…They have the fear, you
know, that they sign on
anything for any type of
resources, they won’t be
able to get permanent
status.”
Outreach Worker,
Los Angeles
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Burdensome and confusing application processes and difficulty
meeting documentation requirements were also consistently
identified as enrollment barriers. Participants said that applying for
coverage often requires long wait times on the phone or in-person, and
that it is difficult for families to take time away from work to complete
the application process. Moreover, participants felt that eligibility
workers in local offices are not always welcoming or helpful when
families do take the time to attempt to enroll. They identified
administrative challenges, such as applications not being received or
getting passed back and forth between programs. Moreover, they
highlighted difficulties immigrant families often face in meeting
documentation requirements, particularly since they often work in
seasonal jobs and/or are paid in cash and may be highly mobile.
Participants noted that many of these difficulties carry over to renewal
processes, often leading to losses in coverage at the point of renewal.
Language and literacy issues, as well as limited access to technology,
also were identified as key enrollment challenges. Participants noted
that individuals who do not speak English or who have low literacy
levels often have difficulty understanding forms and notices. Further,
they identified numerous instances of individuals encountering
problems obtaining translation assistance. Several participants also
noted that, as the enrollment process moves increasingly online,
enrollment may become more difficult for immigrant families because
of limited computer access and low levels of computer literacy.
After enrolling in coverage, immigrant families also face numerous challenges to accessing needed
care. Participants described how limited transportation options and language barriers can make it
difficult for families to navigate their way to appointments. Further, once an individual arrives for an
appointment, they may continue to face language barriers if there are no staff members available that
can provide medical interpretation services. Immigrant families may also experience fears and confusion
related to navigating an unfamiliar and complicated health care system.
Participants noted that many immigrant families require education on
how to obtain services under a managed care plan and assistance
identifying participating providers. It was further noted that, in some
cases, individuals are assigned to a primary care provider who may not
have an existing relationship with the family, may not be accessible to
the family, and/or may not have the capacity to provide culturally and
linguistically appropriate services. Challenges accessing specialty care
were also identified. In particular, participants described problems
finding participating specialists, as well as lengthy referral processes for
specialty care.Connecting Eligible Immigrant Families To Health Coverage Essay
“I think most of the barriers
we see with the people that
we serve is not only that
they don’t understand or
they don’t know, but also
the paperwork…. It is a lot
of paperwork, it is a lot of
proof they are requesting, a
lot of information that many
of them don’t have.”
Outreach Worker,
San Francisco
“I think it really is about just
leaving people behind and
kids that are more
vulnerable to not being
insured, whether they are
Hispanic or whether they
are rural, whether they are
Haitian immigrants…if they
don’t have computers in
their home or their parents,
for one reason or another,
can’t access it they are
going to be left behind. And
those are the kids that are
most vulnerable.”
Outreach Worker, Florida
“You can do really great
eligibility [work] and get
them the benefits, but if you
don’t do the teaching and
education on how you use
[the benefits]…you are not
actually getting anybody
access because they just
have no idea that that
doesn’t mean go to the ER.”
Outreach Worker,
District of Columbia
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Successful Strategies to Overcome Barriers to Coverage and Care
Participants identified a number of creative and successful strategies
they have developed to overcome barriers to coverage and care. In
particular, participants pointed to the effectiveness of conducting
outreach and application assistance through trusted organizations and
individuals with strong ties to the immigrant community. The
importance of educating families about their coverage options and the
enrollment process was stressed. Innovative ideas such as school
presentations that encourage youth to educate their community about
the availability of coverage were highlighted. Moreover, participants
heavily emphasized the value of direct, one-on-one enrollment
assistance from trusted individuals with a shared background or
experience. Across the focus groups, participants described taking a
very active and comprehensive role in helping families obtain and
maintain coverage and receive needed care. In addition, participants identified a variety of tools and
strategies they have developed to make the process easier for families, including providing families lists
of documents they will be required to provide, creating forms to make it easier for families to document
income, providing cards that families can present to request translation assistance, and encouraging
families to keep records and receipts of all application and paperwork submissions.

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Looking Ahead to Health Reform
To fully realize the potential of the coverage expansions under health reform in 2014, it will be
important to assure eligible individuals successfully enroll in coverage. Given their high uninsured rate,Connecting Eligible Immigrant Families To Health Coverage Essay
reaching and enrolling eligible immigrant families will be key to achieving overall success with the
expansion. However, doing so will entail effectively addressing the numerous enrollment barriers they
face. At a broad level, assuring enrollment systems are transformed to provide the simple, high-quality
user experience that is envisioned under reform will be imperative for addressing many of the barriers
eligible immigrant families, as well as other individuals, currently face. Doing so will not only require
significant changes in processes and systems, but also an overall cultural shift among local eligibility
offices that is focused on promoting coverage. Moreover, successfully enrolling eligible immigrant
families will likely require targeted outreach efforts and enrollment assistance. As part of these efforts,
the findings from these focus groups, as well as other data, suggest the importance of assuring that
trusted community organizations and individuals have adequate training and resources to provide
outreach and assistance, conducting outreach through varied locations and methods to meet
immigrants where they are, adopting enrollment processes that meet the specific needs of immigrant
families, and strengthening messages to dispel fears among the immigrant community.
Strategies and Tools to Help Immigrant Families Overcome Barriers to Coverage and Care
 Utilizing trusted community organizations and individuals to provide outreach and enrollment assistance
 Direct one-on-one assistance from individuals with a shared background or experience
 Educating families about coverage options and the enrollment process
 Providing families with a list of required documents and identifying alternative options
 English and Spanish zero income and cash income form to document income
 Cards that families can present to request translation assistance
 Keeping records and receipts of all application and paperwork submissions
 Maintaining contact over time to assist families with renewal and accessing necessary services

“…What actually helps a
lot is to have examples of
people that have actually
gone through it. And our
own staff has been in
those situations and have
received the benefits. It
didn’t affect their Green
Card, they were able to get
healthcare taken care of….
So kind of hearing it from
community members has
been really helpful for us.”
Outreach Worker,
San Francisco
4 00
INTRODUCTION
One primary goal of the Patient Protection and Affordable Care Act (ACA) is to significantly reduce the
number of uninsured. To achieve this, beginning in 2014, the law will expand Medicaid eligibility and
provide tax credits to help individuals purchase coverage through new Health Benefit Exchanges. The
Medicaid expansion and new subsidized exchange coverage will significantly increase the coverage
options available to millions of low- and moderate-income families who lack access to affordable
coverage today. Given their high uninsured rate and limited access to private and public coverage, one
group who could significantly benefit from the coverage expansions in the ACA is lawfully residing
immigrant families. However, for eligible immigrant families to fully realize the potential opportunity of
the expansions, it will be important to address the myriad of barriers they face to enrolling in coverage
and accessing needed care.Connecting Eligible Immigrant Families To Health Coverage Essay
This brief draws on the experience of outreach workers serving immigrant families to identify the role of
Medicaid and CHIP for eligible immigrant families, key barriers eligible immigrant families currently face
to enrolling in coverage and accessing care, successful strategies to overcome these barriers, and
implications for implementation of health reform. It is based on findings from four focus groups
conducted with individuals who provide outreach and enrollment assistance in immigrant communities.
BACKGROUND
Overview of Immigrants and Health Coverage Today
Immigrants are a diverse group, ranging in immigration status, length of time in the country, country of
origin, race/ethnicity, family status and age. As of 2010, there were 38 million immigrants residing in the
United States, accounting for 12.5% of the population.1 This includes 17 million naturalized citizens and
21 million non-citizens, who include both lawfully present and undocumented individuals.2 Moreover,
there are many more individuals who live in families with mixed immigration status, such as U.S.-born
citizen children residing with non-citizen parents. As of 2009, there were 5.6 million citizen children in
the United States living with at least one non-citizen parent.3
Similar to native citizens, the majority of naturalized citizens have employer or other private coverage.
However, non-citizens are nearly three times as likely to be uninsured relative to U.S.-born citizens,
reflecting more limited access to both private and public coverage (Figure 1). Although non-citizens are
as likely as citizens to work, they are often
in jobs and industries that do not offer
coverage. Further, non-citizens are
subject to immigrant-specific eligibility
restrictions in Medicaid and CHIP. Since
1996, lawfully residing non-citizen
immigrants have been barred from
enrolling in Medicaid and CHIP during
their first five years in the United States.
States were recently provided the option
to eliminate this “five-year bar” for
pregnant women and children, but do not
have the option to waive the waiting
period for other adults. Undocumented
immigrants are prohibited from enrolling
in Medicaid and CHIP.4
Figure 1
Health Insurance Coverage for the Nonelderly,
by Citizenship Status, 2010
Medicaid/Other Public also includes CHIP, other state programs, Medicare, and military-related coverage. Data may not total 100% due to rounding.
SOURCE: KCMU/Urban Institute analysis of March 2011 Current Population Survey, Annual Social and Economic Supplement
64% 64%
39%
21% 12%
14%
16% 24%
47%
Native Citizens Naturalized Citizens Non-Citizens
Private Medicaid/Other Public Uninsured Connecting Eligible Immigrant Families To Health Coverage Essay
00 5
Coverage for Immigrants Under the ACA
As noted, the ACA will significantly expand coverage in 2014. Medicaid will expand to nearly all
individuals with incomes up to 133% of poverty ($14,484 for an individual or $24,645 for a family of
three in 2011). Moreover, individuals without employer or public coverage will be able to buy coverage
through new Health Benefit Exchanges, and those with incomes up to 400% of poverty ($43,560 for an
individual or $74,120 for a family of three in 2011) will be eligible for tax credits to help pay for the
coverage. However, as shown in Table 1, immigrants will continue to face specific eligibility restrictions.
Table 1:
Immigrant Eligibility for Medicaid and Exchange Coverage in 2014
Medicaid Exchange Coverage
Eligibility in 2014 Expands to nearly all individuals with
incomes up to 133% of poverty
Individuals without employer or public coverage
can buy coverage through exchanges
Tax credits available to those with incomes up to
400% of poverty
Naturalized
Citizens
Eligible on the same basis as U.S.-born
citizens
May purchase exchange coverage and receive tax
credits on the same basis as U.S.-born citizens
Lawfully Residing
Immigrants
Most lawfully residing immigrants are
subject to a five-year wait before they may
qualify
States may choose to waive the five-year
wait for lawfully residing children and
pregnant women (but not for other adults)
May purchase coverage and receive tax credits
without a five-year wait
Undocumented
Immigrants
Prohibited from enrolling in Medicaid Prohibited from purchasing coverage through
exchanges
METHODOLOGY
To gain increased insight into barriers to coverage and care facing eligible immigrants and successful
strategies to overcome these barriers, Health Outreach Partners (HOP) and the Kaiser Commission on
Medicaid and the Uninsured (KCMU) hosted focus group discussions with outreach and enrollment
professionals that serve immigrant communities. A total of 35 professionals participated in one of four
focus groups held in San Francisco, CA; Los Angeles, CA; Washington, DC; and Parrish, FL in July and
August 2011. The majority of participants were employed by community health centers who serve
immigrant populations; however, some worked with other types of organizations serving immigrants.
The responsibilities of participants ranged from providing outreach and education to providing direct
enrollment assistance and supporting individuals in accessing needed services.Connecting Eligible Immigrant Families To Health Coverage Essay
Using a structured interview guide, participants were asked about the role of Medicaid and CHIP for the
immigrant families they serve, current barriers to coverage and care facing eligible immigrants,
strategies they employ to overcome these barriers, and perceptions of the potential impact of the
coverage expansions under reform on immigrant communities. With consent of the participants, all
focus groups were recorded and transcribed. Data were analyzed using ATLAS.Ti version 5.5, a
qualitative data analysis software program. Findings from the focus groups were supplemented with
review of other relevant research and data, including HOP’s national needs assessment on farmworker
health outreach (Breaking Down Barriers: A National Needs Assessment on Farmworker Health
Outreach, available at http://www.outreach-partners.org/resources/nna).
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KEY FINDINGS
The Role of Medicaid and CHIP for Immigrant Families
Participants stressed that Medicaid and CHIP coverage provide
immigrant families access to preventive and primary care, including
prenatal care, as well as to care for chronic conditions. Several
participants noted the importance of Medicaid and CHIP coverage for
enabling immigrants to access prenatal care. It was noted that, without
the coverage, many pregnant women would likely go without care,
which could lead to increased birth complications and infant mortality.
Moreover, it was recognized that Medicaid and CHIP coverage are key for supporting families in
obtaining immunizations and well-child check-ups for children. Participants also indicated that Medicaid
and CHIP coverage allow individuals to obtain care for chronic conditions such as diabetes and
hypertension, which have a high prevalence among the low-income immigrant population.
Several participants noted that, without Medicaid and CHIP coverage,
obtaining health care would prove too financially burdensome for
low-income immigrant families. They felt that, in the absence of this
coverage, families would be required to make difficult choices between
paying for groceries or rent versus seeking medical care or purchasing
prescription medication for chronic conditions like diabetes or
hypertension. Further, some participants suggested that if Medicaid
and CHIP were not available, individuals would be likely to seek home
remedies or care from informal resources, rely on over the counter
medications, stretch prescription medications, and forgo needed
services.Connecting Eligible Immigrant Families To Health Coverage Essay
Participants also emphasized that Medicaid and CHIP coverage contribute to an overall increased
understanding of health and broader improvements in quality of life among immigrant families. It was
noted that, as a result of obtaining Medicaid or CHIP coverage, immigrant families often gain a new
understanding of the importance of preventive health care and how to utilize care within the U.S. health
care system. Participants said that they often provide health education to families when they enroll in
Medicaid and CHIP coverage, including education on the importance of immunizations and preventive
health as well as nutrition counseling. Moreover, participants pointed out that, when families seek and
connect to health care coverage, they often are connected to other important social services and
supports that lead to improvements in their overall family well-being.

Over 11.3 million undocumented immigrants in the United States, and between 1.9 million and 3.8 million in the European Union currently face barriers to health care access. Numerous legal issues and the current political climate regarding immigration policies present the complex reality of ensuring their basic right to health care. The lack of viable health care options is at its core a human rights issue, but it also prevents undocumented parents and their children from successful assimilation and integration into society. This essay will focus on the U.S. and examine the existing barriers to and possible solutions for the limited access to health care for undocumented immigrants.Connecting Eligible Immigrant Families To Health Coverage Essay

Under the Affordable Care Act (ACA), undocumented immigrants in the U.S. are not eligible for Medicaid, Medicare, lower copayment or premium tax credits. Furthermore, they cannot purchase coverage through an exchange even at full cost. Lacking access to federal and private coverage, undocumented immigrants currently have three options: emergency care at any Emergency Department (ED), state-funded Medicaid coverage for emergency care, and safety-net hospitals or Federally Qualified Health Centers (FQHCs) for non-emergency care.

However, not only do the above-mentioned options provide only limited access to chronic disease management or preventive care services, but the ACA also cut funding to safety-net hospitals, leading undocumented immigrants to develop medical complications and depend on costly ED visits. Lack of health care access is also a generational challenge since non-citizen children and citizen children in mixed citizenship status families are more likely to be uninsured compared to children with naturalized or U.S. parents.

Unfortunately, current U.S. immigration policies do not provide concrete solutions. President Barack Obama’s current executive actions to offer 5.2 million undocumented immigrants work authorization and temporary relief from deportation do not grant lawful status to undocumented immigrants, and therefore do not guarantee access to financially feasible healthcare options. The immigration reform bill (H.R.15) introduced by House Democrats, which has not been brought to the floor, outlines a pathway to citizenship; however, undocumented immigrants would have to wait at least ten years for health insurance exchanges and 15 years in total to have access to federal coverage.Connecting Eligible Immigrant Families To Health Coverage Essay

Lack of access to health care for undocumented immigrants is first and foremost an ethical issue grounded in the humanist view that all human beings have a basic right to health care. At the same time, it is also a policy issue regarding comprehensive immigration reform, which aims to incorporate undocumented immigrants into society as fully functioning and productive members. Undocumented immigrants are already contributing significantly to state and local taxes—an estimated $10.6 billion in 2010, and if the reform bill is passed, they are subject to more federally assessed tax liabilities, fees and penalties on their way to full citizenship. Granting access to health care will not only empower immigrant parents and children, but it will give them incentives to go to the back of the line.

It is noteworthy that several states with higher immigrant populations have made efforts to work around the system by expanding Children’s Health Insurance Program (CHIP) coverage and other state-funded programs. Many advocates also argue that the current reform bill should contain provisions to reduce the waiting period for health benefits. More importantly, both in the U.S. and the EU, civil society and non-profit organizations are playing an important role in filling the gap in the existing health systems by providing primary care, culturally appropriate services through community health workers, and undertaking research and advocacy activities. In the future, more comprehensive and collaborative approaches are needed to ensure undocumented immigrants’ basic rights to healthcare access.Connecting Eligible Immigrant Families To Health Coverage Essay

The high costs of health care and the erosion of health insurance coverage are two important long-term challenges that confront all Americans. These problems are especially acute for immigrants to the United States, who have extremely low rates of health insurance coverage and poor access to health care services.

In fact, almost half of all immigrants — here defined as noncitizen immigrants — are uninsured, a level that is about three times higher than for native-born citizens. Because so many immigrants lack insurance, they face serious barriers to medical care and pay more out-of-pocket when they receive care.

In addition to the obvious health and humanitarian concerns associated with poor health care access, other economic and social reasons cause concern. Unresolved health problems can limit immigrants’ ability to maintain productive employment, particularly given that many work in physically strenuous jobs or in jobs in which there is a high incidence of occupational injuries.Connecting Eligible Immigrant Families To Health Coverage Essay

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Because so many immigrants lack the protections of health insurance, the cost of even a single hospitalization can drive many into debt and financial insolvency. The Institute of Medicine, a component of the National Academy of Sciences, has estimated that lack of health insurance in the United States costs between $65 and $130 billion per year, due to health impairments and years of productive life lost of all uninsured, not just immigrants.

Immigrants, both legal and unauthorized, often rely on a patchwork system of safety-net clinics and hospitals for free or reduced-price medical care, including state- and county-owned facilities, as well as charitable and religiously affiliated facilities. Their reliance on this system has led many states and communities to be concerned about uncompensated health care costs for uninsured immigrants and the state and local fiscal burdens that result.

This paper summarizes key issues and research concerning immigrants’ access to private health insurance, public health insurance, and to health care in general.

Data on Immigrants’ Access to Health Insurance

U.S. census data show that immigrants are more likely to be uninsured than native-born citizens (see Table 1). Overall, noncitizen immigrants are more than three times as likely to be uninsured (44 percent) as native-born citizens (13 percent). The percent of naturalized citizens who are uninsured (17 percent) is between that of noncitizens and native citizens.Connecting Eligible Immigrant Families To Health Coverage Essay

Table 1. Health Insurance Coverage of United States Population, by Immigration Status and Income, 2004
Uninsured Employer-sponsored insurance Medicaid/SCHIP Nongroup & other private Medicare & other public Total
ALL INCOMES
U.S.-born citizens 13.3% 59.1% 13.0% 5.5% 9.1% 100.0%
Naturalized citizens 17.2% 54.9% 10.3% 5.4% 12.2% 100.0%
Noncitizen immigrants 44.1% 36.5% 12.6% 4.0% 2.9% 100.0%
LOW-INCOME (below 200 percent of poverty line)
U.S.-born citizens 22.6% 24.9% 32.5% 6.4% 13.5% 100.0%
Naturalized citizens 26.2% 26.4% 23.2% 5.6% 18.7% 100.0%
Noncitizen immigrants 56.1% 18.1% 19.3% 3.6% 2.9% 100.0%
Source: Author’s analyses of March 2005 Current Population Survey
Recent immigrants are more likely to be uninsured. Over time, their rates of insurance improve and their incomes grow. This is partly because immigrants tend to find better-quality jobs with time, and partly because both citizens’ and immigrants’ incomes increase with age and greater job experience. The main reason immigrants are less insured than native-born citizens is that, despite their high rates of employment, fewer immigrants have employer-sponsored health insurance.

The discrepancy between immigrants and native-born citizens persists among those with incomes below 200 percent of the poverty line (about $33,000 per year for a family of three in 2006). Among the low-income category, 56 percent of noncitizen immigrants are uninsured versus 23 percent of native-born citizens (see Table 1 and Figure 1).Connecting Eligible Immigrant Families To Health Coverage Essay

However, reasons for the insurance gap change when considering the low-income population. The primary reason for the difference in coverage between low-income immigrants and citizens is that fewer immigrants have public coverage, including Medicaid (which serves the poor) and Medicare (which serves the elderly). Low-income immigrants are also less likely to have employer-sponsored coverage and other private coverage, but the gaps are somewhat narrower.

Figure 1. Distribution of Health Insurance for Noncitizen Immigrants and Native-Born Citizens with Incomes Below 200 Percent of Poverty, 2004

Source: Author’s analyses of March 2005 Current Population Survey
Although census data do not reveal whether immigrants are legal or not, it is important to recognize that these profiles are affected by the types of immigrants living and working in the United States. Analyses by the Pew Hispanic Center indicate that annually, the proportion of immigrants who are unauthorized has grown in recent years, causing the proportion of those legally admitted to fall. Unauthorized immigrants are ineligible for public benefits (except for limited Medicaid coverage for treatment of emergency medical conditions) and have greater difficulty securing private health insurance as well.

Access to Private Health Insurance

Employer-sponsored insurance is the mainstay of health coverage for most Americans, but not for immigrants. Analyses of census data have found that a key reason for this lack of coverage is that immigrant workers, particularly Latino immigrants, are less likely to be offered insurance at work than citizen workers.Connecting Eligible Immigrant Families To Health Coverage Essay

Job-based health insurance is offered to 87 percent of non-Hispanic white citizen workers, but only to 50 percent of Latino immigrant workers. However, when they are offered health insurance, comparable numbers of white citizens and Latino immigrants accept the offer and take employer-sponsored insurance (87 percent of white citizen workers and 81 percent of Latino immigrant workers).

In most cases, accepting the insurance offer means immigrant employees are also willing to bear a portion of the costs in the form of employee premiums and other cost-sharing mechanisms. The offer and acceptance rates for Latino citizen workers are about the same as those for non-Hispanic white citizens.

Part of the reason immigrants are offered insurance at lower rates is that they frequently work in the types of industries that are less likely to offer health insurance, such as agriculture, construction, food processing, restaurant, hotel, and other service jobs. But more detailed analyses have shown that even after statistically adjusting for differences in job type, salary level, and other factors, immigrants are still less likely to be offered insurance.Connecting Eligible Immigrant Families To Health Coverage Essay

In some cases, employers may be able to effectively treat immigrants — even legal immigrants — differently by classifying them as contract, temporary, or part-time workers, so they are not required to offer benefits.

Moreover, rather than directly hiring workers (e.g., farm workers, janitorial staff, etc.), some firms instead pay contractors for labor, knowing that contractors lower their costs by not offering benefits to their employees. A recent report found that, regardless of citizenship, 21 percent of contract, temporary, and part-time workers had health insurance compared with 74 percent of full-time regular workers.

It is not clear whether discrimination is a cause, meaning that within the same company, immigrants are not offered health insurance offered to citizen workers, or whether immigrants tend to work in firms that generally do not offer insurance.

Under federal law, employers are supposed to offer health insurance on equivalent terms to all their workers, but it is plausible that immigrants, particularly unauthorized workers or temporary visa holders, are often not offered health benefits on terms equivalent to other workers.

Access to Public Health Insurance

For most low-income people in the United States, Medicaid is the mainstay of health insurance coverage. But not all immigrants are eligible for Medicaid and its counterpart, the State Children’s Health Insurance Program (SCHIP).Connecting Eligible Immigrant Families To Health Coverage Essay

The 1996 welfare reform law prohibited most lawful permanent residents admitted after the law’s enactment from receiving federal Medicaid or SCHIP coverage during their first five years in the United States; similar prohibitions also barred eligibility for other benefits such as food stamps, welfare, and supplemental security income. About 40 percent of all lawful permanent residents in the United States today entered after 1996 and have been subject to this prohibition.

Unauthorized immigrants and temporary visa holders (e.g., those with student or temporary work visas) are not eligible for Medicaid, except for Medicaid coverage of emergency room services. Elderly immigrants, though often ineligible for Medicare because they did not work in the United States for a sufficient number of years to qualify for it or Social Security, may still be eligible for Medicaid if they are poor enough and meet other criteria.Connecting Eligible Immigrant Families To Health Coverage Essay

Beginning in the late 1990s, the federal eligibility prohibition — combined with fears in the immigrant community that getting Medicaid or SCHIP could harm an immigrant’s chance of getting lawful residence, remaining in the United States, or becoming naturalized — discouraged participation even among those eligible for public benefits. The federal government subsequently clarified that getting Medicaid or SCHIP benefits would not make an immigrant ineligible for permanent residency.

Nonetheless, since welfare reform’s 1996 enactment, low-income immigrants have lost Medicaid coverage and are more likely to be uninsured. A number of states opted to cover some of these immigrants, particularly children or pregnant women, using state funds.

Federal legislation that passed in early February 2006 adds a new requirement that American citizens applying for or already enrolled in Medicaid must submit proof of citizenship, such as a U.S. passport or birth certificate. This provision would not apply to immigrants applying for Medicaid, who must already submit documentation of their legal status. Although the legislation is aimed at citizens, it could have repercussions for immigrants as well if it leads many in the immigrant community (and some caseworkers) to believe they must also show proof of citizenship to obtain coverage.Connecting Eligible Immigrant Families To Health Coverage Essay

Beyond the adult immigrant population, gaps in insurance coverage between immigrant children and citizen children widened over the past decade (see Figure 2). After the 1996 immigrant prohibitions, more immigrant children became uninsured.

Figure 2. Changes in Percentage of Low-Income Children (Below 200 Percent of Poverty) Who Are Uninsured, 1995 to 2004

Source: Author’s analyses of March 1996 and 2005 Current Population Surveys
In contrast, the enactment of SCHIP in 1997 and subsequent state efforts to expand children’s coverage with SCHIP and Medicaid led to higher insurance coverage of citizen children. As a result, the percentage of low-income children in native-born families who were uninsured fell from 19 percent in 1995 to 16 percent in 2004. Immigrant children did not benefit from these expansions, however, largely because they could not participate in them; the percent of low-income immigrant children who were uninsured climbed from 44 percent in 1995 to 49 percent in 2004.Connecting Eligible Immigrant Families To Health Coverage Essay

Initially, even though U.S.-born children were eligible, families with such children dropped out of Medicaid and SCHIP due to their fears about welfare reform. But as Figure 2 shows, this problem has eased thanks in large measure to substantial outreach and educational efforts on the part of state and local governments and community-based organizations. Consequently, the coverage of children in mixed-status families has improved, even though they are still more likely to be uninsured than children with native-born parents.

The Role of Immigrant Sponsors

The 1996 prohibition on Medicaid and SCHIP coverage was based on some legislators’ belief that sponsors of immigrants ought to be responsible for their health insurance coverage. Since 1997, those who sponsor immigrants must agree to be responsible for them and are informed that they may be held liable for the costs of public assistance, like Medicaid or SCHIP, if the sponsored immigrants receive benefits. Expectations that most recent immigrants could get private insurance from employers or that their sponsors would step in to provide other private coverage have proven to be unrealistic.Connecting Eligible Immigrant Families To Health Coverage Essay

While sponsors may be able to provide financial support in some areas, it can be quite difficult for sponsors to afford health insurance for the immigrants they have sponsored. In 2005, the price of an average, employer-sponsored health insurance policy for a family was over $10,000; for an individual, the cost of such a policy was over $4,000. The prices can be even higher when insurance must be purchased on a nongroup basis, as would be required for those who are not in the sponsors’ immediate families.

Many Americans are themselves uninsured, and sponsors with low- and middle-incomes usually cannot afford the health insurance of those they sponsor. The prohibition on Medicaid coverage for legal immigrants during their first several years in the United States effectively means that a large number of immigrants are uninsured, even if they are working and have serious health needs.

Access to Health Care

Because immigrants are so often uninsured, out-of-pocket health care costs are higher than those paid by the insured, making immigrants less able to pay for the care they need. Other factors, like language barriers, also impair immigrants’ access to and the quality of medical care they receive. The net result is that immigrants are much less likely to use primary and preventive medical services, hospital services, emergency medical services, and dental care than are citizens, even after controlling for the effects of race/ethnicity, income, insurance status, and health status.Connecting Eligible Immigrant Families To Health Coverage Essay

Low-income immigrant adults are twice as likely as low-income, native-born citizen adults to report that they have no regular source of health care according to a study published in 2001 by Leighton Ku and Sheetal Matani. Similarly, low-income immigrant children are four times more likely to lack a usual source of care as low-income children with native-born citizen parents.

A report by the U.S. Department of Health and Human Services recently concluded that racial/ethnic disparities in health care are gradually narrowing between African Americans and white Americans but are widening between Latinos and non-Hispanic white Americans. The poor health care access of immigrant Latinos is a major reason for this widening gap in medical care.

What little is known about the health care access of unauthorized immigrants suggests that it is particularly poor. One broad survey of California farm workers by researcher Don Villarejo and published in 2000 found that only one-sixth were offered employer-sponsored health insurance, and one-third of those receiving offers of coverage said they could not afford the insurance offered. Half of the males and one-third of the females had not seen a physician in the past two years, even though many had occupational illnesses or chronic health problems like high blood pressure and anemia.Connecting Eligible Immigrant Families To Health Coverage Essay

Sociologist Abel Valenzuela and a team of researchers found a high level of occupational injuries in their 2003-2004 national survey of day laborers, who are predominantly unauthorized. One-fifth of day laborers had suffered a work-related injury, but less than half received medical care for that injury.

Because some public health care facilities inquire about immigration status, immigrants believe that seeking treatment at such facilities could lead to problems with immigration officials. Thus, some immigrants turn to black-market sources of health care, such as unlicensed health care providers (e.g., immigrant doctors not licensed to practice in the United States), and may purchase prescription drugs that have been smuggled into the United States.

Some worry that the costs of medical care, especially emergency care, for immigrants is creating excessive financial strain on the nation’s health care system. Yet, a recent study by Dr. Sarita Mohanty, which was based on data from the late 1990s, found that, per capita, medical expenditures for immigrants were about 55 percent lower than those of U.S.-born individuals (see Figure 3). Expenditures for uninsured and publicly insured immigrants were also approximately half those of their U.S.-born counterparts.Connecting Eligible Immigrant Families To Health Coverage Essay

Other research, conducted by the Urban Institute and the Center for Studying Health Systems Change and published in 2006, has shown that immigrants are much less likely to use emergency rooms than native-born citizens. Indeed, border areas with high concentrations of immigrants may sustain high uncompensated care costs because so many immigrants are uninsured.

Figure 3. Average Per Capita Annual Medical Expenditures, 1998

Note:Estimates are adjusted for differences in race, insurance, income, etc.
Source: Mohanty, et al., 2005, based on Medical Expenditure Panel Survey.

The federal government recently began to reimburse hospitals for uncompensated emergency care costs incurred by uninsured, unauthorized immigrants. In 2005, its first year of operation, the federal government paid $58 million to assist these providers.Connecting Eligible Immigrant Families To Health Coverage Essay

A large share of other, uncompensated health care costs is borne by state and local governments or charitable or religious organizations that operate the facilities. And some costs are also indirectly transferred to those with private insurance, who bear somewhat higher health care costs when hospitals or other facilities cross-subsidize their losses from uncompensated care for uninsured people by charging private health insurers more.

Potential for Change

The present congressional debate over immigration reform offers the opportunity to improve immigrants’ access to health care, both because it could change the legal status of large numbers of immigrants and because it affords a window for Congress, advocates, and analysts to review other policies concerning the status of immigrants in the United States.Connecting Eligible Immigrant Families To Health Coverage Essay

Of course, it is not yet clear what direction immigration reform will take. It is conceivable that a new policy could make health care access more difficult for many immigrants, for example, by further restricting access to public benefits, limiting access to safety-net facilities, or making it illegal for health or social service providers to offer assistance to unauthorized immigrants.

On the other hand, if a new policy provides options for legalized status, it could improve immigrant workers’ employment prospects and thereby raise their opportunities to secure private, employer-sponsored insurance. Connecting Eligible Immigrant Families To Health Coverage Essay