1. Facts & Issues Concerning Health Coverage for Immigrants Leighton Ku, PhD, MPH Professor of Health Policy George Washington University Presented to Health Action Conference January 29, 2009

2. IL Immigrant Growth Across States, 1990-2005 AR MS LA WA MN ND WY ID UT OR IA WI MI NE SD ME MOKS OH IN NY KY TN NC NH MA VT PA VA WV CT NJ DE MD RI HI DC AK SC NM OK GA TX FL AL Traditional High Migrant States (11 + DC) (above US avg in 1990) New Growth States (27) (# immigrants at least doubled 1990-2005) NE CA NV AZ CO MT

3. The Struggle in Progress: Legal Immigrant Children & Pregnant Women

4. Figure 1: Two-thirds of Immigrants Who Enter as Children Become Citizens as Adults Naturalized Citizens Not Yet Citizens Source: Analyses of March 2008 Current Population Survey data about citizenship status of those 30 years or older who entered as immigrants before the age of 18.

5. Figure 2: Low-income Citizen Children Gained Health Coverage, While Immigrant Children Lost Ground Citizen Children in Native-born Families Noncitizen Immigrant Children Source: Analyses of Current Population Survey

6. Figure 3: When Insured, Immigrant Children Use More Preventive & Primary Care, Less ER Care Percent of Noncitizen Immigrant Children Who Received This Type of Care in Last 12 Months ** significance greater than 95%, * significance greater than 90%* Source: Analyses of 2007 National Health Interview Survey

7. Figure 4: Immigrant Patients at Community Health Centers Are Disproportionately Uninsured Source: 2002 Community Health Center User Survey Percent of Patients Who Are Uninsured -----Immigrants-----

8. State Supplemental Programs for Legal Immigrant Children Alaska* California Connecticut Delaware District of Columbia Florida* Hawaii Illinois Maine Maryland Massachusetts Minnesota Nebraska New Jersey New York Ohio* Pennsylvania Texas Virginia Washington Wyoming * Limited scope of coverage

9. State Supplemental Programs for Legal Immigrant Pregnant Women Alaska* California# Colorado Connecticut Delaware District of Columbia Hawaii Illinois# Louisiana# Maine Maryland Massachusetts Michigan# Minnesota# Nebraska# New Jersey New York New Mexico Ohio* Pennsylvania Rhode Island# Tennessee# Texas# Washington Wisconsin# Wyoming* * State provides limited coverage # State uses SCHIP funds and already receives federal match

10. Issues After ICHIA Passes How to keep states that now cover legal immigrants from dropping coverage? How to get states that do not currently cover legal immigrant children and pregnant women to exercise the new option?

11. Coverage for Adults: the Next Struggle

12. About 90% of Uninsured Low- income Immigrants Are Adults Children Under 18: 5.0 million uninsured Native-born, 4.3 million Naturalized, 50,000 Non-citizen, 612,000 Adults 18-65: 19.5 million uninsured Native-born, 12.7 million Naturalized, 1.2 million Non-citizen, 5.6 million Uninsured Adults & Children Below 200% of Poverty, 2007 Analysis of March 2008 Current Population Survey

13. Low-income Immigrants Are More Uninsured: Less Public & Less Private Coverage Source: Analyses of March 2007 Current Population Survey for those with incomes below 200% of poverty ($41,000 for family of four)

14. Immigrants Less Likely to Be Offered Insurance at Work Source: Comparisons among Latinos in California, 1999-2001. Enrico Marcelli (Harvard Univ.) Migraciones Internacionales, 2(4):5-36, Jul-Dec. 2004

15. Immigrants Are Sparing Users of Medical Care: Per Capita Expenditures Far Below Native-born Adults Source: preliminary analyses of 2003 MEPS Average Annual Per Capita Medical Expenditures, Based on Full-Year Insurance Status, for Adults

16. Breakdown of Estimated Public Medical Spending for Non-elderly Adults, U.S., 2000 Native-born Citizen Temp Legal Immigrant Undocumented Permanent Resident Naturalized Citizen Source: Analyses based on Goldman, Smith and Sood, 2006 Non-citizen immigrants are 9.5% of non-elderly adults, but incur only 3.7% of public medical expenses.

17. Coverage & Access for Adults: What Next? Legal adult immigrants? Seniors? Undocumented immigrants? Undocumented children? Public coverage? Private coverage? Enhanced safety net access? Immigration reform – path to citizenship? Better services, e.g., language access?