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The Patchwork System of Public Insurance Coverage for Immigrants

The Patchwork System of Public Insurance Coverage for Immigrants. Leighton Ku, PhD, MPH ku@cbpp.org AcademyHealth, Orlando, June 2007. What Share of the Uninsured Are Immigrants?. Source: March 2006 CPS. Immigrants & Uninsured Immigrants Are Mostly Working Age Adults. 8.3 mil.

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The Patchwork System of Public Insurance Coverage for Immigrants

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  1. The Patchwork System of Public Insurance Coverage for Immigrants Leighton Ku, PhD, MPH ku@cbpp.org AcademyHealth, Orlando, June 2007

  2. What Share of the Uninsured Are Immigrants? Source: March 2006 CPS

  3. Immigrants & Uninsured Immigrants Are Mostly Working Age Adults 8.3 mil. Source: CPS, March 2006

  4. Almost Half of All Non-citizen Immigrants Are Uninsured Source: March 2005 Current Population Survey

  5. Public Programs Serve Small Fraction of Low-income Immigrants (Below 200% Poverty) Source: March 2005 Current Population Survey

  6. 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.

  7. 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.

  8. Immigrant Growth Among States, 1990-2005

  9. Substantial State Coverage of LPR Children, 2007

  10. Substantial State Coverage of LPR Parents, 2007 Source: Cox, forthcoming

  11. 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.

  12. 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.

  13. Average Annual Medical Expenditures for Non-Elderly Adults by Type, Los Angeles County $2,963 $2,340 52% $1,760 58% $1,341 46% 41% 28% 20% 23% 23% 20% 22% 30% 36% Source: Adapted from Goldman, Smith and Sood. Health Affairs 2006

  14. 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.

  15. 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.

  16. 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).

  17. 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?

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