The Patchwork System of Public Insurance Coverage

for ImmigrantsLeighton Ku, PhD, MPH

ku@cbpp.orgAcademyHealth, Orlando, June 2007

What Share of the Uninsured Are Immigrants?

Native-born Citizens

74%

Naturalized Citizens

5%

Non-citizen Immigrants

21%

Source: March 2006 CPS

Immigrants & Uninsured Immigrants Are Mostly Working Age Adults

28%12%

60% 83%

12% 5%

1.0 mil.

0.1 mil

0%

20%

40%

60%

80%

100%

Native-born Non-citizens Uninsured Non-citizens

ElderlyAdultsChildren

Source: CPS, March 2006

8.3mil.

Almost Half of All Non-citizen Immigrants Are Uninsured

0% 20% 40% 60% 80% 100%

Non-CitizenImmigrants

Native-bornCitizens

Uninsured Medicaid/SCHIP Other Public Employer-sponsored Other Private

Source: March 2005 Current Population Survey

Public Programs Serve Small Fraction of Low-income Immigrants (Below 200% Poverty)

0% 20% 40% 60% 80% 100%

Non-CitizenImmigrants

Native-bornCitizens

Uninsured Medicaid/SCHIP Other Public Employer-sponsored Other Private

Source: March 2005 Current Population Survey

Complex Medicaid/SCHIP Eligibility Rules

• Medicaid usually not available for childless adults.• Citizens fully eligible, including naturalized and US-

born citizen children.• Lawful permanent residents (LPRs) not fully eligible

during 1st five years in US, but:– Refugees and asylees eligible for 1st seven years in

US. Veterans, etc. eligible.– Many states use state funds to cover immigrants

during 5 year bar in Medicaid or SCHIP.• Undocumented and other immigrants eligible for

emergency Medicaid coverage, including child birth.

Barriers to Participation

• Participation low even among eligible immigrants (or citizen children of immigrants)

• Lack of knowledge• Lack of language assistance during enrollment• Confusion and fear about rules• Medicaid citizenship documentation• Community outreach can help, but outreach

funds have been limited in recent years.

Immigrant Growth Among States, 1990-2005

IL

AR

MS

LA

WA

MN

ND

WY

ID

UT

OR

IA

WI MI

NE

SD

ME

MOKS

OHIN

NY

KY

TNNC

NH

MA

VT

PA

VAWV

CTNJ

DE

MD

RI

HI

DC

AK

SCNM

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

Substantial State Coverage of LPR Children, 2007

IL*

WA*MN*

NE

ME*

NY* MA*

PA*

VA*

CT *NJ*

DE *MD*

RI*

HI *

DC *

TX *

FL*

27 New Growth States*Coverage (6)

No Coverage (21)

11 Traditional Migrant States *Coverage (10 + DC)No Coverage (1)

NE*

CA*

12 Other States*Coverage (2)No Coverage (10)

Source: Cox, forthcoming Kaiser Commission on Medicaid and the Uninsured report

Substantial State Coverage of LPR Parents, 2007

Source: Cox, forthcoming

WA*MN*

NE

ME*

NY* MA*

PA*CT *

NJ*DE *

DC *

27 New Growth States*Coverage (4)

No Coverage (23)

11 Traditional Migrant States *Coverage (5 + DC)No Coverage (6)

NE*

CA*

12 Other States*Coverage (2)No Coverage (10)

Source: Cox, forthcoming Kaiser Commission on Medicaid and the Uninsured report

Medicare Eligibility

• Non-citizens less likely to be elderly. Many immigrants return to home country when elderly.

• LPRs and refugees eligible for Medicare, same as citizens. – If have less than 40 quarters of work, may buy into

Part A. • Legally present “non-qualified” eligible if they had at

least 40 quarters of authorized work. • Undocumented ineligible.

Other Public Care

• Sec. 1011 – to cover costs of uncompensated emergency care for uninsured, undocumented aliens. Underused. EMTALA requires basic emergency treatment for all.

• Health centers – all immigrants eligible for free or subsidized care at federally-funded health centers.

• Public & nonprofit hospitals & clinics often offer free or subsidized charity care, but sometimes eligibility for undocumented is limited due to state or local rules.

Average Annual Medical Expenditures for Non-Elderly Adults by Type, Los Angeles County

$0

$500

$1,000

$1,500$2,000

$2,500

$3,000

$3,500

Native-bornCitizen

NaturalizedCitizen

Legal PermResident

Undocumented

Out of Pocket Public Private

Source: Adapted from Goldman, Smith and Sood. Health Affairs 2006

$2,963

$2,340

$1,760$1,341

20% 22% 30% 36%

28%20% 23% 23%

52%

58%46%

41%

Potential Federal Policies

• Could include option to cover LPR children and pregnant women during SCHIP reauthorization.

• Comprehensive immigration reform?? • May include a long pathway to earned legal status &

citizenship and stronger immigration enforcement. Effect on public coverage modest and slow.

• Legal status and reduced flow of immigrants may lead to better jobs and increased private coverage.

• Binational insurance could reduce private insurance costs in border areas for legally present immigrants.

Potential State Actions

• Immigration volatile issue in many states. Usually not a visible issue in state health reforms.

• Some expansions presented as “all kids” proposals, as in Illinois or California counties.

• Mixed story in broader health coverage expansions. • Proposals to expand coverage by diverting DSH or

UPL funds may impair safety net for immigrants.• State or local anti-immigrant laws could cause access

problems for undocumented and other immigrants.

But It’s Not Just Coverage…

• Even when insured, immigrants have less access to care and receive poorer quality care due to language barriers.

• Federal civil rights policies require free interpretation for LEP, but no funding stream and little enforcement.

• HRET: Only 3% of hospitals get any reimbursement for interpretation, from Medicaid.

• Potential for language reimbursement (Medicare, Medicaid, private insurance).

Questions for the Future

• What are costs of uncompensated care and of state-funded coverage for immigrants?

• How can we improve enrollment among eligible immigrants or access among insured immigrants?

• Quality of care for immigrants? More hospitalization for ambulatory-sensitive conditions?

• How do immigrants’ health coverage, utilization and cost change over time? What are effects of changes in immigration status?

• How can public perceptions of immigrants be improved?