1 Health Care and Health Reform for Immigrants In Colorado Elisabeth Arenales, Esq. Colorado Center on Law and Policy 789 Sherman, Suite 300 | Denver, CO (303) x December 2009

2 Immigrant Statistics 31 million or 11% population US (2000) 14% US Workforce 20% low wage workers (200% FPL) will contribute $500 billion to Social Security 83% are in working families Colorado population: 443, % (2005) − Undocumented 225, ,000 Source: Pew Hispanic Center

3 Immigrant Barriers to Health Care Lack of access to public and private insurance Language and cultural barriers Fragmented Lack of understanding Low-income Federal law (5-year waiting period) Documentation requirements

4 Immigrant Barriers to Health Care Non-citizens are more likely to be employed in small firms or self- employed Non-citizens are often employed in low paying jobs that do not offer insurance Colorado survey: 80% did not receive health insurance benefits 80% did not get paid for sick days

5 Immigrant Lack of insurance 50% of non-citizens who have been in the US <5 years are uninsured 43% of non-citizens who have been in the US 5+ years are uninsured Conclusion: non-citizens are much more likely to be uninsured than their counterparts

6 Immigrant Lack of insurance 21.3% (about 167,000) of non- citizens in Colorado are uninsured Compare to 15% of Coloradans are uninsured 800,000) 8.2% have been in the US less than 5 years 13.1% have been in the US for more than 5 years

7 Immigrant Facts about Access to Health Care 13% of adult non-citizens rely on emergency room visits compared to 20% of uninsured citizens Low-income uninsured non-citizens rely on clinics and health centers for care more than their citizen counterparts

8 Immigrant Facts about Access to Health Care Uninsured non-citizens are two times more likely than citizen counterparts to go without preventive care. Drops significantly for those with insurance. 51% uninsured immigrant children lack a usual source of care (compared to 30% uninsured citizens)

9 Immigrant Facts about Access to Health Care 48% of uninsured immigrant children go a year without seeing a health care professional (compared to 38% citizen children) Per capita expenditures for non-citizens were $1,797 compared to $3,702 for citizens Only one-fourth of health care expenditures for immigrants are reimbursed by public programs

10 Health Care Access Undocumented and nonpermanent Undocumented immigrants and nonpermanent immigrants (student or temporary work visas) not eligible for public programs except emergency Medicaid Migrant health centers Some community health centers Fee for service

11 Non-citizen Health Care Access Points Public Programs Clinics (FQHC’s and others) Public Hospitals Health Departments Community Outreach Programs

12 Asylees and Refugees Get Medical Assistance for first 8 months. Then eligible if low income for 7 years. Important to get LPR status because of 5 year bar.

13 Medicaid: Eligibility Children (assets test): % FPL % FPL ($20,650 for a family of 4) 0-21 EPSDT Adults with children 37% FPL Pregnant women up to 133% FPL Disabled up to 225% FPL or on or would have qualified for SSI

14 Emergency Medicaid Available to lawful and undocumented immigrants who meet all Medicaid requirements aside from immigration restrictions “emergency medical condition” means a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in (A) placing the patient’s health in serious jeopardy, (B) serious impairment to bodily functions, or (C) serious dysfunction of any bodily organ or part. 42 USC 1396b(v)(3)(v)

15 Children’s Basic Health Plan or CHP+ Eligible up to 205% FPL (Federal Poverty Level is $20,650 for a family of 4) Children to 19 and pregnant women Modeled after private health insurance Immigrant eligibility Must be a qualified alien Subject to five year waiting period

16 Access for Pregnant Women Presumptive Eligibility PE – allows coverage while eligibility is being determined Studies show $3-$4 saved for every $1 spent State prenatal program for legal immigrant women No five year waiting period Not necessarily permanent funding through tobacco money

17 Colorado Indigent Care Program (CICP) Reimbursement for providers for uncompensated care to indigent population (not health insurance) Legal immigrants and migrant workers eligible Limited $ program Applies at certain hospitals and clinics Eligible at 250% FPL and cannot qualify for Medicaid or SCHIP Copay requirements based on income

18 Old Age Pension Health and Medical Care Program Established by state Constitution provides up to $699 per month to participants Provides limited health assistance for those receiving OAP grants Age 60 and above Not eligible for SSI or Medicaid Limited funding, $10 million/year Legal immigrants eligible

19 Public Program Immigrant Eligibility 5 year waiting period Five year bar applies (must be in the US legally at least 5 years) Exceptions to five year bar include: refugees, asylees, deportation withheld and certain other categories Must otherwise meet eligibility requirements for a program Applies to SCHIP, Medicaid

20 Update 5 Year Waiting Period CHIP Reauthorization Act 2009 allows states to eliminate the five year waiting period for pregnant women and children in CHIP and Medicaid Colorado has committed to doing this when funds are available

21 Health Reform: What’s it About?

22 Background: Our Healthcare System (CO 57%) (CO 19%) (CO 7%) (CO 17%) Sources: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2007 and 2008 Current Population Survey (CPS: Annual Social and Economic Supplements).

23 Health Reform: Why now? Too many are uninsured 48 million uninsured in US More than 800,000 in Colorado 25% of Colorado children under 200% FPL a year) are uninsured 45,000 Americans die each year because of lack of medical care (Journal American Medicine) 1 Coloradan dies a day because uninsured (IOM)

24 Cumulative Changes in Health Insurance Premiums and Workers’ Earnings, Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, ; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, (April to April).

25 The Cost of Doing Nothing The cost of an individual insurance policy in Colorado will increase by 9% a year, between 2008 and 2016, faster than anywhere else in the country. (New American Foundation “Cost of Doing Nothing”.) That means If we do nothing, by 2016 Colorado families will a year on health insurance (that’s 40% of median income)

26 The Economy is Suffering Health care is more than 16% of GDP today, 17.7% by 2012 (CBO) Colorado’s economy lost as much as $3.9 Billion in 2007, because of the poor health and shorter lifespan of the uninsured. (New American Foundation, “Cost of Doing Nothing”)

27 Goals for National Reform Access to quality, affordable health care Stable coverage Stable costs Choice of providers and coverage Control over decision making Reduce the number of uninsured Improve health outcomes

28 Health Insurance Reform- Risk Pooling Risk Pooling vs. Risk Rating

29 How Reform Increases Risk Pooling Individual mandate Insurer’s required to issue No more health status rating No more gender rating Limits on age rating No pre-existing condition exclusions No caps

30 What’s Affordable? Families under 200% FPL have almost nothing to spend on health care 25% of families are in debt at end of the month Families spending more than 5% of income make tradeoffs including on education/savings/childcare See: The Cost of Care: Can Coloradans Afford Health Care (Colorado Center on Law and Policy; 2009)

31 What will it look like? Everyone has to have insurance (but not undocumenteds) Medicaid is the base After that: subsidies for private insurance up to 400% FPL ($88,000 family of four) Public option?

32 Issues for Immigrants Undocumenteds not included 5 year bar: how hard will it be to get help? Refugees and asylee rules likely to stay the same