Covering Immigrant Children: Where do we stand?

1. Covering Immigrant Children: Where do we stand? Joan Alker Deputy Executive Director Georgetown Center for Children and Families http://ccf.georgetown.edu

2. Children’s Coverage, 2007 Children = 78.6 million Uninsured 11% Employer-Sponsored Insurance 55% Medicaid/Other Public 29% Individual Coverage 4% Source: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of 2008 ASEC Supplement to the CPS.

3. Non-Citizen Children’s Coverage, 2007 Children = 2.8 million Employer-Sponsored Insurance 32% Uninsured 34% Individual Coverage 3% Medicaid/Other Public 27% Source: K. Schwartz, et al., “Health Insurance Coverage of America’s Children,” Kaiser Commission on Medicaid and the Uninsured (January 2009).

4. Uninsured Children vs. All Children,by Race and Ethnicity, 2007 Multiracial (3%) Multiracial (2%) Am. Indian(1%) Am. Indian (1%) Asian Asian Black Black Hispanic Hispanic White White 8.9 Million 78.6 Million NOTES: Children includes all individuals under age 19. American Indian category includes Aleutian Eskimos. Asian includes South Pacific Islander. Data may not total 100% due to rounding.SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of 2008 ASEC Supplement to the CPS.

5. Children’s Coverage, by Citizenship Status, 2007 Number 1.1 M 1.6 M 76.0 M Source: K. Schwartz, et al., “Health Insurance Coverage of America’s Children,” Kaiser Commission on Medicaid and the Uninsured (January 2009).

6. A closer look at public programs and children

7. Medicaid and CHIP Enrollment, 2007 36.5 million 7.1 million CHIP 29.3 million Medicaid Source: Center for Children and Families analysis of the Statistical Enrollment Data System (SEDS) FY 2007 Master File (February 11, 2008). Note: Data represent children ever enrolled in Medicaid or CHIP.

8. Key differences in Medicaid v. CHIP • Medicaid is an entitlement. This guarantees coverage and funding. • CHIP is not, though recent reauthorization makes financing more secure. Generally serves higher income children. • Medicaid benefits are more comprehensive (EPSDT v. CHIP benchmarks). • Cost-sharing protections are tighter.

9. States that Currently Cover Lawfully Residing Immigrant Children and Pregnant Women with State-Only Funds WA NH VT MT ME ND OR MN MA ID WI SD NY WY MI RI CT IA PA NV NE NJ OH IL UT IN DE CO CA WV KS VA MD MO KY NC DC TN AZ OK NM AR SC MS AL GA TX LA AK FL HI Source: National Immigration Law Center, “State-Funded Medical Assistance Programs” (Updated September 2008) and National Immigration Law Center, “State-Funded SCHIP Programs” (Updated September 2008). Note: The following states also offer coverage to some immigrant children and/or pregnant women, but are not included in the map due to the small number of people actually covered: AK, CO, FL, OH, NM, WY

10. States that Cover All Children, Regardless of Immigration Status with State-Only Funds WA NH VT MT ME ND OR MN MA ID WI SD NY WY MI RI CT IA PA NV NE NJ OH IL UT IN DE CO CA WV KS VA MD MO KY NC DC TN AZ OK NM AR SC MS AL GA TX LA AK FL HI Note: Some California counties offer coverage to all children regardless of status, but it is not offered statewide. Source: National Immigration Law Center, “State-Funded Medical Assistance Programs” (Updated September 2008) and National Immigration Law Center, “State-Funded SCHIP Programs” (Updated September 2008).

11. Children with at Least One Unauthorized Immigrant Parent, by Status, 2003-2008 (in millions) Note: Children are persons under age 18 who are not married. Source: Pew Hispanic Center tabulations from augmented March Current Population Surveys

12. CHIPRA: Key Features Was signed into law on Feb. 4th – one of the first bills in this Congress. President Obama described it as a downpayment on health care reform New funding levels and formula New incentives to enroll Medicaid children Eligibility changes (ICHIA being one of them!) Significant new emphasis on quality, access

13. “In a decent society, there are certain obligations that are not subject to tradeoffs or negotiation – health care for our children is one of those obligations. That is why we have passed this legislation to continue coverage for seven million children, cover an additional four million children in need, and finally lift the ban on states providing insurance to legal immigrant children if they choose to do so.” President Barack Obama at CHIPRA bill signing

14. New Coverage for Immigrants in CHIPRA • As of 4/1/09, states have option to obtain federal matching dollars for covering “lawfully residing” children and pregnant women regardless of date of entry and without any waiting period. • Can cover them through Medicaid and CHIP but must start with lowest income kids • No federal funding to cover undocumented immigrants • States could now use state funds to cover other immigrants (e.g., lawfully residing adults, undocumented children)

15. What Does “Lawfully Residing” Mean? • Lawfully Residing is broader than “qualified” immigrant; includes green-card holders (lawful permanent residents) as well as other immigrants • Certain battered immigrants and dependents, U visa holders, residents of “compact of free association states,” persons with deferred action status, and other lawfully present immigrants should be included • SSA defines “lawfully residing” as lawfully present and residing in the U.S. • CMS will have to issue guidance on this.

16. What Does “Lawfully Residing” Mean? (cont.) • Could include or not include many categories • Example #1: Massachusetts covers PRUCOLS as well as visiting foreign students • Example #2: New Mexico: Battered Legally Permanent Residents (LPRs) • Issue for CMS guidance: strike a balance between more covered groups or making it too broad (and politically unfeasible)

17. Which states will pick up the option? • States with “replacement” programs are expected to – • States without – UT had a bill that moved through the legislature but died in the final hours.

18. Prospects for Health Care Reform In his FY 2010 budget, President Obama establishes a reserve fund of $634 billion as a down payment on health reform. The President laid out eight broad principles for reform, but is leaving the details to Congress.

19. Congress on fast track • House process: Three Committees are developing a joint bill (Ways and Means, Energy and Commerce, and Education and Labor) • Senate process: Finance Committee and HELP Committee are both developing products.

20. Baucus “November White Paper” “Currently, legal immigrant children and pregnant women are subject to a five-year waiting period before they can become eligible for Medicaid or CHIP. Not only does this exacerbate health disparities, but it increases the number of uninsured. The waiting period should be eliminated and eligible legal immigrants should have access to Medicaid and CHIP. Source: M. Baucus, “Call to Action: Health Reform 2009,” U.S. Senator Max Baucus (D-Mont.), (November, 2008).