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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 19th, 2011
Funded by a grant from the Robert Wood Johnson Foundation
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)
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
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
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
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
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
www.shadac.org
2010 2014
Bridge to Reform 133%
Medicaid
200-400%
Tax
Credit
Early
Medicaid
Small
Employer
Tax Credit
High Risk
Pool
Dependent
Care Coverage55-64
Reinsurance
Exchanges
Indv Mandate
Key Provisions of the ACA
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
www.shadac.org
Coverage Expansion Categories
0 100 200 300 400 500
Medicaid
Subsidy
$88,000 Family of
Four
$29,326 Family Of Four
10
Medicaid
Expansion
133%
Premium
Subsidy
400%
Federal Poverty Level
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
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
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
www.shadac.org
State-level access to public coverage
for excluded pregnant women (1)
14
Source: Kaiser Commission on Medicaid and the Uninsured, 2009
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
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
www.shadac.org
State initiatives to cover excluded
immigrant children (1)
17
Source: Kaiser Commission on Medicaid and the Uninsured, 2009
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
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
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
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
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 Million 4.1 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
www.shadac.org
Number of low-income excluded
adults by state
23
Source: SHADAC estimates, ACS, 2008
www.shadac.org
Proportion of low-income adults who
are excluded within each state
24Source: SHADAC estimates, ACS, 2008
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
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
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
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
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
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
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
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
www.shadac.org 33
Contact Information
Lynn A. Blewett, PhD
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
