1. www.healthpolicy.ucla.edu Health Coverage for Immigrants E. Richard Brown, PhD Director, UCLA Center for Health Policy Research Professor, UCLA School of Public Health Principal Investigator, California Health Interview Survey State Innovations in Health Coverage Chicago August 3-4, 2006

2. UCLA Center for Health Policy Research What I will cover  Health care coverage of citizens vs. noncitizens  Federal policies affecting noncitizens’ eligibility for Medicaid  State responses to the issue, with a special focus on California  Data sources  Kaiser Family Foundation publications on Medicaid and SCHIP eligibility for immigrants  Medicaid and SCHIP Eligibility for Immigrants, April 2006  New Requirements for Citizenship Documentation in Medicaid, July 2007  National Disability Rights Network  Factsheet, “Citizenship Documentation Interim Final Rule”  March 2005 Current Population Survey  2003 California Health Interview Survey

3. UCLA Center for Health Policy Research Noncitizens have far lower rates of employment-based insurance, resulting in far higher uninsured rates Insurance Coverage by Citizenship Status, Children and Adults, Ages 0-64, United States, 2004 US CitizenNoncitizen Employer-based66.9%40.0% Medicaid/SCHIP10.7%9.4% Other coverage7.2 %5.0% Uninsured15.3%45.6% Source: March 2005 Current Population Survey

4. UCLA Center for Health Policy Research Noncitizens—with or without green cards—have less access to employment-based insurance Access and Take-up Rates of Employer-based Coverage for California Adult Employees, Ages 18-64, 2003 % with Access to Employer-based Coverage % of Employees who Take-up Coverage Among Those Eligible US Born Citizen79.0%86.3% Naturalized Citizen81.4%86.0% Noncitizen with Green Card 64.4%81.9% Noncitizen without Green Card 45.4%76.2% Source: 2003 California Health Interview Survey

5. UCLA Center for Health Policy Research Noncitizens also have less access to Medicaid and SCHIP — Welfare reforms of 1996  Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996  Tied eligibility for Medicaid to an immigrant’s legal status and to length of residency in U.S., making it more difficult for them to obtain Medicaid coverage  Restrictions also applied to SCHIP, when it was enacted in 1997  Most immigrants are subject to a 5-year bar on eligibility  Legal permanent residents (immigrants with green cards) ineligible for Medicaid or SCHIP during first 5 years in U.S.  After 5 years, become eligible for Medicaid and SCHIP if meet other eligibility requirements  States can extend 5-year bar until person has worked for 40 quarters or become naturalized citizen  In 2004, 22 states and District of Columbia used state funds to provide coverage to some immigrants ineligible for Medicaid and SCHIP  Some immigrants exempt from this rule and are eligible for Medicaid and SCHIP regardless of length of residence  Refugees and most other humanitarian immigrants as well as active-duty members or veterans of U.S. Armed Forces and their families

6. UCLA Center for Health Policy Research Noncitizens also have less access to Medicaid and SCHIP — Welfare reforms of 1996  Sponsor “deeming” further restricts immigrants’ access to Medicaid  Many legal immigrants have “sponsors” who pledge to support them  Federal law requires part of sponsor’s income and resources to be counted in determining Medicaid eligibility — even if sponsor doesn’t share any income  Sponsor deeming can push immigrant over state’s income or asset limits for Medicaid — even for very poor and those without resources to pay for care  Seven-year limit on receipt of Social Security Income for refugees and asylees  Refugees and other humanitarian immigrants are eligible to receive SSI benefits for their first 7 years in U.S. and often lose Medicaid  After 7 years, they lose SSI unless they become naturalized citizens  Loss of SSI also often means loss of Medicaid coverage because SSI eligibility is vehicle to Medicaid eligibility  They can maintain Medicaid eligibility beyond 7 years if they qualify under different eligibility category

7. UCLA Center for Health Policy Research Noncitizens also have less access to Medicaid and SCHIP — Other immigrant policies  Undocumented immigrants and immigrants in U.S. on temporary basis (e.g., temporary work visa or student visa) generally ineligible for Medicaid and SCHIP  Regardless of their length of residence in U.S.  This restriction predates PRWORA  States can use SCHIP funds to provide prenatal care to pregnant women, regardless of their immigration status  In 2002, CMS amended SCHIP regulations to give states option of providing SCHIP-funded prenatal care without applying an immigration test  This rule extends SCHIP eligibility to pregnant woman’s fetus, which does not have an immigration status and is not subject to restrictions  Currently, 7 states provide SCHIP-funded prenatal care to pregnant immigrants  Emergency treatment is available to all immigrants, regardless of their status  Legal and undocumented immigrants who meet all eligibility requirements except for immigrant-related restrictions are eligible for emergency medical treatment  Emergency Medical Treatment and Labor Act (EMTALA) also requires hospitals to screen and stabilize all persons, including immigrants, who seek care in ER

8. UCLA Center for Health Policy Research Deficit Reduction Act of 2005 affects citizens, not noncitizens  Deficit Reduction Act of 2005 attempts to ensure enforcement of eligibility provisions against certain noncitizens by requiring documentation of citizenship  Previously states could simply allow applicants, under penalty of perjury, to attest to their citizenship in writing  DRA requires U.S. citizens to submit documents verifying citizenship to apply for or renew Medicaid coverage  Levels of acceptable documentation  Primary evidence includes passport, certificate of naturalization, or certificate of U.S. citizenship  Secondary evidence (only if primary evidence not available) includes a birth certificate and other specified documentation, accompanied by specified identity documentation  Other (less acceptable) evidence includes certain types of non-governmental documents (e.g., hospital record extract, health insurance & medical records, written affidavits, etc.)  SSI eligibles and Medicare beneficiaries are exempted from citizenship documentation requirements for Medicaid eligibility  For other eligibles, states can do cross matches with federal or state agency data  Citizens unable to produce required documentation will lose Medicaid coverage

9. UCLA Center for Health Policy Research Impact of immigrant-related provisions on access to Medicaid and SCHIP  1996 PRWORA restrictions on Medicaid and SCHIP eligibility for immigrants contributed to increasing uninsured rates among noncitizen immigrants  Clarification that for most immigrants, Medicaid or SCHIP would not be used against them in visa or citizenship procedures reduced, but did not erase, concerns  Other barriers continue to keep immigrants out of Medicaid and SCHIP  Immigrants in first 5 years, refugees and asylees in SSI after 7 years, and immigrants excluded by sponsor deeming  Shifted burden of their health care to states (only some of which provide state-funded coverage) and local safety net providers  2005 DRA exempts noncitizens from citizenship verification requirements, although must continue to provide proof they are legal U.S. residents  DRA will create procedural barriers for many citizens applying for or retaining Medicaid, despite intent to use documentation enforcement to keep out noncitizens

10. UCLA Center for Health Policy Research States are acting to cover uninsured children, regardless of immigration status  U.S.-born children are eligible for Medicaid and SCHIP regardless of their parents’ immigration status  But child’s immigration status may prevent eligibility  Many communities have health care safety net that provides care for all persons regardless of immigration status  But access varies tremendously across communities  Health care heavily subsidized by charity and local tax dollars as well as federal grants  Some states and communities are expanding public health care coverage programs to include children regardless of immigration status  Illinois  Nearly 900,000 noncitizen adults and children — about 4% of all noncitizens in U.S.  Enacted “All Kids” to ensure that nearly all children in the state would have health insurance coverage — regardless of immigration status  California  6 million noncitizen adults and children — 28% of all noncitizens in U.S.  Grappling with legislation to cover all children — regardless of immigration status

11. UCLA Center for Health Policy Research California — from local coalitions to statewide legislation  California local public-private health insurance expansion programs for children  Local public-private coalitions created locally funded health insurance expansion programs for children — called Children’s Health Initiatives  Led way in providing coverage to children who do not qualify for Medi-Cal or Healthy Families (SCHIP) due to their immigration status  19 county-level Children’s Health Initiatives  Together cover 88,000 children — out of estimated 534,000 uninsured children in those counties  18 are single-county programs and 1 program covers five rural counties  First program in Santa Clara County  Currently 13,000 enrolled — out of about 19,000 uninsured children in county  Largest program in Los Angeles County  Nearly 42,000 enrollees — out of about 235,000 uninsured children in county  Most county programs have enrolled uninsured children up to maximum available funding  Most of these programs are capped and closed

12. UCLA Center for Health Policy Research California — from local coalitions to statewide legislation  Of about 800,000 uninsured children in California in 2003:  55% were eligible for Medi-Cal or Healthy Families  Another 6% (44,000) were eligible for county programs  20% (159,000) were not eligible due to income limits of the programs  19% (148,000) were not eligible due to immigration restrictions  Legislation for universal coverage for children passed State Legislature but vetoed by Governor Schwarzenegger in 2005  Governor Schwarzenegger now has indicated his support for such legislation  His 2006-07 budget proposal included $22 million for county health insurance programs that cover all children, including those who are undocumented  Successfully opposed by Republican members of Legislature due to requirement for 2/3 majority vote for state budget  Funding for universal coverage for children is included in tobacco tax initiative on Nov. 2006 election ballot  With enabling legislation, would create universal coverage for children in California

13. UCLA Center for Health Policy Research A long way to go…  California may be more receptive than most states to covering uninsured regardless of citizenship or immigration…  But California has long way to go  Of 4.1 million adults who were uninsured in 2003:  6% (244,000) were eligible for Medi-Cal  Another 0.1% (4,000) were eligible for county programs  68% (2.8 million) were citizens or legal immigrants with green card  26% (1.1) million were noncitizens without a green card  Health care coverage expansion and controlling health care costs are now high on political and policy agenda  San Francisco just enacted new health insurance expansion program with mandated employer pay-or-play participation  Legislative bills are focal point for statewide policy action  Single-payer and other proposals  Candidates for Governor are developing own proposals