1. Immigrants’ access to care under the Affordable Care Act: The role of states in addressing coverage gaps Lynn A. Blewett, PhD Professor and Director State Health Access Data Assistance Center University of Minnesota, School of Public Health University of Minnesota School of Public Health Roundtable Minneapolis, MN April 19 th, 2011 Funded by a grant from the Robert Wood Johnson Foundation

2. www.shadac.org 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 2 Funding by a grant from the RWJF Foundation to the State Health Access Data Assistance Center (SHADAC)

3. www.shadac.org 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 coverage 3

4. www.shadac.org Federal policies on immigrants’ access to coverage 4 Personal Responsibility and Work Opportunity Reconciliation Act PRWORA 1996 CHIP Unborn Child State Plan Amendment CHIP 2002 Children’s Health Insurance Program Reauthorization Act CHIPRA 2009 Patient Protection & Affordable Care Act PPACA 2010

5. www.shadac.org 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 5 Source: U.S. Dept. of Health and Human Services, Assistant Secretary for Planning & Evaluation, 2009

6. www.shadac.org 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 6 Source: Kaiser Commission on Medicaid and the Uninsured, 2009

7. www.shadac.org 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 7 Source: Kaiser Commission on Medicaid and the Uninsured, 2009

8. www.shadac.org 20102014 Bridge to Reform 133% Medicaid 200-400% Tax Credit Early Medicaid Small Employer Tax Credit High Risk Pool Dependent Care Coverage 55-64 Reinsurance Exchanges Indv Mandate Key Provisions of the ACA

9. www.shadac.org 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 - 9

10. www.shadac.org Coverage Expansion Categories 10 Medicaid Expansion 133% Premium Subsidy 400% Federal Poverty Level

11. www.shadac.org 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 11 And the Undocumented

12. www.shadac.org 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 status 12

13. www.shadac.org 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) 13

14. www.shadac.org State-level access to public coverage for excluded pregnant women (1) 14 Source: Kaiser Commission on Medicaid and the Uninsured, 2009

15. www.shadac.org 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 women 15

16. www.shadac.org 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 Care 16

17. www.shadac.org State initiatives to cover excluded immigrant children (1) 17 Source: Kaiser Commission on Medicaid and the Uninsured, 2009

18. www.shadac.org 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 children 18

19. www.shadac.org 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 counties 19

20. www.shadac.org 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 states 20

21. www.shadac.org 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 21 Source: SHADAC estimates, ACS, 2008

22. www.shadac.org Characteristics of Low-income Non-elderly Adults in U.S., by Assigned Legal Status 22 All non-elderly adults with family income <=138% FPG Citizens & “ Legally qualified” Immigrants † Likely Excluded Immigrants Total 30.0 Million4.1 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 years Source: SHADAC estimates, ACS, 2008

23. www.shadac.org Number of low-income excluded adults by state 23 Source: SHADAC estimates, ACS, 2008

24. www.shadac.org Proportion of low-income adults who are excluded within each state 24 Source: SHADAC estimates, ACS, 2008

25. www.shadac.org 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 CHCs 25

26. www.shadac.org How can states address coverage gaps? 26 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 gaps

27. www.shadac.org Role of the safety net & Local Access to Care Programs (LACPs) Nevada – Access to Healthcare Network Massachusetts – Health Safety Net Healthy San Francisco 27

28. www.shadac.org 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% FPL 28

29. www.shadac.org 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 cost 29

30. www.shadac.org Healthy San Francisco 30 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 fee

31. www.shadac.org 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 gaps 31

32. www.shadac.org 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 budgets 32

33. www.shadac.org 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. The University of Minnesota is an Equal Opportunity Employer