IMMIGRANTS AND HEALTH CARE IN CALIFORNIA: ELIGIBILITY ENROLLMENT CHALLENGES COSTS OF BEING UNINSURED Gabrielle Lessard National Immigration Law Center

Who We Are National Immigration Law Center (NILC)  Our mission is to defend & advance the rights & opportunities of low-income immigrants and their family members.  We provide publications, offer technical assistance and training, and engage in advocacy and strategic litigation.

Eligibility 3

Major Health Coverage Options  Covered California  state health insurance marketplace/exchange  Medi-Cal  Full-scope  Limited-scope Emergency, pregnancy, etc.  Services open to all  Includes emergency Medi-Cal, community health centers, some county programs

Eligibility for Medi-Cal 5 Full scope:  Qualified immigrants  PRUCOLs  Lawfully present children Limited scope (most often emergency or pregnancy):  Others  All must meet income and residency requirements

Qualified Immigrants  Lawful permanent residents, or LPRs (persons with green cards).  Refugees, persons granted asylum or withholding of deportation/removal, and conditional entrants.  Persons granted parole by the Department of Homeland Security (DHS) for a period of at least one year.  Cuban and Haitian entrants.  Certain battered immigrants, their children, and/or their parents.  Certain victims of trafficking. 6 For the complete list see Overview of Immigrant Eligibility for Federal Programs at:

PRUCOL Permanently Residing Under Color of Law - not an immigration status, but a benefit eligibility category (see MC 13 Form – Statement of Citizenship, Alienage, and Immigration Status). May include persons:  with approved immediate relative visa petition  who filed application for adjustment to LPR status  granted deferred action (including DACA)  granted Family Unity status  granted a stay of deportation  who have lived in the US continuously since before Jan. 1, 1972  who are survivors of domestic violence (certain immigrants)  Other persons in the US with the knowledge of DHS whose departure that agency does not contemplate enforcing. 7

State Residency  Live in CA with intent to reside here, or  Live in CA and entered State with job commitment or to seek employment, whether or not currently employed. Children generally assume the residence of their parents, with an opportunity to establish state residence independently. 8

Eligibility for Covered California Lawfully Present Qualified lawfully present immigrants are eligible to purchase health coverage through state health care marketplaces exception: People who received deferred action through DACA are specifically excluded

Lawfully Present Noncitizens All “qualified” immigrants Others authorized to live and/or work in the U.S., e.g. temporary protected status (TPS) most with deferred action Applicants for: adjustment to LPR and certain other statuses Asylum applicants with employment authorization Family immigrants with available visa Individuals with valid nonimmigrant status Students, workers, etc. May not satisfy the residency requirement Complete list:

Enrollment Challenges 11

Barriers  Confusion about eligibility  Problems in application process  Language access issues  Lack of information/misinformation  Concern that receiving benefits or having medical debt will interfere with ability to naturalize or adjust status (“public charge”)  Fears about jeopardizing family members  Belief that benefits will need to be repaid by recipient or sponsor 12

Public Charge “ Public charge”: likely to become primarily dependent on government for subsistence, as demonstrated by:  receipt of public cash assistance for income maintenance or  institutionalization for long-term care at government expense “Totality of circumstances”: age, health/disability, income, education, job/skills, family situation and affidavit of support Can result in denial of:  Admission to U.S., or adjustment to Lawful permanent resident status  But not relevant for citizenship applicants, asylees, survivors of domestic violence, trafficking, serious crime, etc. Not relevant in public charge determinations:  Medical benefits other than long-term care  Non-cash benefits (e.g., SNAP, WIC)  “earned benefits” or cash for food, housing, child care, etc. 13

Immigration Enforcement Information provided on applications is confidential  Information about immigration status may be used only to determine an applicant’s eligibility for health care coverage. U.S. Immigration and Customs Enforcement (ICE) has released a notice stating that information provided in health insurance application process will not be used for civil immigration enforcement  On October 25, 2013, U.S. Immigration and Customs Enforcement (ICE) issued a memo titled “Clarification of Existing Practices Related to Certain Health Care Information,” confirming that immigrant parents can enroll their U.S. citizen children and other eligible family members in health insurance programs under the ACA without triggering immigration enforcement activity.Clarification of Existing Practices Related to Certain Health Care Information

Information Provided to Covered CA  People submitting application must provide basic information about all members of the tax household.  Subsidies are based on tax household income  Only individuals who are applying for coverage are required to provide their immigration/citizenship status.  The Social Security Number (SSN) of a non-applicant may be requested to electronically verify household income.  A non-applicant can be required to provide an SSN only if that person is:  a primary tax filer,  who has an SSN, and  is applying for tax credits. 15

Key Issues for Mixed-Status Families Undocumented people may apply for coverage on behalf of their dependent family members  Applications should distinguish between applicants (e.g., U.S. citizen child) & non-applicants (e.g., undocumented parent)  Non-applicants are not required to provide their immigration status  Non-applicants without SSNs cannot be required to provide one  Never provide an SSN unless officially issued by the Social Security Administration  Individual Taxpayer Identification Numbers (ITINs) should not be used  Information provided on an application may be used ONLY to determine eligibility for health insurance. 16

Costs of Being Uninsured 17

Individuals 18  Uninsured people live sicker and die younger  Diagnosed in later stages of disease cancer  More likely to die from accidents and acute conditions Heart attack, stroke  Less likely to know they have asymptomatic conditions HIV, diabetes, high blood pressure  More likely to have medical debt  More likely to miss work or retire early due to illness

Health Care System 19  Hospitals tend to terminate less profitable services  These are generally services used by the uninsured Emergency, maternity, psychiatric  Health and hospital systems invest in areas with more insured residents  Doctors generally prefer newer facilities and equipment  Hospitals with older facilities have more difficulty recruiting on-call specialists, resulting in longer wait times for everyone

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