IMMIGRANTS SPEAK OUT ABOUT THEIR EXPERIENCES ACCESSING MEDICAID AND HEALTH CARE SERVICES FINDINGS FROM BROWNSVILLE, TEXAS MAY 2000

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1 IMMIGRANTS SPEAK OUT ABOUT THEIR EXPERIENCES ACCESSING MEDICAID AND HEALTH CARE SERVICES FINDINGS FROM BROWNSVILLE, TEXAS MAY 2000 Kyle Anne Kenney, MPH

2 INTRODUCTION Background of Study The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) established new and complex eligibility rules for public benefits for legal immigrants, and made ineligible for most federal public benefits several categories of previously eligible legal immigrants. The Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA) of 1996 established certain procedures for determining the admissibility of immigrants and heightened fears that the use of public benefits, even the legitimate use of Medicaid, could jeopardize immigrants ability to become legal permanent residents or US citizens. It was anticipated that the combined effects of these two laws would result in a substantial reduction in the use of Medicaid as well as in the use of health care services by immigrants. This study, funded by The Robert Wood Johnson Foundation, was designed to examine the effects of the 1996 welfare and immigration reform laws on the ability and willingness of immigrants to access Medicaid and health care services. The primary research goals were: (1) to examine how state and local officials have implemented the new Medicaid eligibility requirements for immigrants; (2) to describe how the implementation of these requirements is affecting immigrants access to health services; and (3) to explore whether immigrants are discouraged from the legitimate use of Medicaid and other health services. The study used a case study approach and was conducted at four sites: Chicago, Illinois; Metropolitan Washington DC; San Diego, California; and Brownsville, Texas. Five research questions provide the analytic framework for conducting the research and data analysis: (1) How have the 1996 welfare and immigration laws affected immigrants ability to apply for Medicaid? (2) How have the 1996 welfare and immigration laws affected immigrants willingness to apply for Medicaid? (3) How have the 1996 welfare and immigration laws affected immigrants ability and willingness to seek primary health services? (4) How have the 1996 welfare and immigration laws affected immigrants ability and willingness to seek emergency health services? and (5) How have the 1996 welfare and immigration laws affected immigrants health-related quality of life (vis-à-vis their effects on immigrants ability and willingness to apply for Medicaid and/or seek health services)? A unique aspect of this research involved the extensive use of focus groups and individual interviews with immigrants. This approach allowed us to examine directly immigrant families : (1) experiences with changing eligibility criteria; (2) perceptions about and experiences with the process of applying for, and getting access to, Medicaid; (3) willingness and ability to seek health care services; (4) willingness and ability to seek Medicaid and health care services for their children; and (5) health-related quality of life associated with changes in access due to the 1996 welfare and immigration reform laws. Focus of this Report The purpose of this report is to present a separate overview of the issues discussed by immigrants in interviews and focus groups conducted during the site visit in Brownsville, Texas. 1

3 The Brownsville site visit report includes data gathered from immigrants as well as from several types of informants including state and local officials, safety net providers (SNPs), and representatives of community-based organizations (CBOs). Data gathered from immigrant interviews and focus groups in Metropolitan DC were incorporated into the larger report as they were relevant to the impact of the 1996 welfare and immigration reform laws; 1 however, in this separate report, we provide a more detailed presentation of the immigrants personal experiences and opinions concerning their ability and willingness to access Medicaid and health care services. While this report includes issues not directly linked to the changes in the laws, presenting the concerns of immigrants in greater breadth and depth contributes to a richer understanding of the context for immigrants experiences with Medicaid and health care. Policy and Research Context The 1996 Welfare Reform and Immigration Reform Laws For immigrants, the passage of federal welfare reform meant much more than ending the entitlement to cash assistance. The law restricted noncitizen eligibility for a wide range of public means-tested benefits, including TANF, Food Stamps, Supplemental Security Income, and Medicaid, and gave states broad new authority to set social welfare policy for immigrants. PRWORA essentially bars legal immigrants from means-tested benefits for which they were previously eligible for at least five years. For the first time since welfare was created, legal immigrants are now eligible for significantly fewer benefits than citizens. These reforms thus represent a turning point in the history of US immigration policy. 2 Essentially the law created a fundamental distinction between legal immigrants who were lawfully present in the US before the law passed (immigrants arriving before August 22, 1996 or pre-enactment immigrants) and those immigrants arriving on or after August 22, 1996 (postenactment immigrants). States were given the option to bar most pre-enactment immigrants from TANF and nonemergency Medicaid programs; only two states chose to enact this option. 3 States are required to bar most post-enactment immigrants from federal means-tested benefits (i.e., nonemergency Medicaid, SSI, Food Stamps, TANF, and the state Children s Health Insurance Program (CHIP)) for their first five years in the United States. PRWORA also introduced changes in terminology in that legal immigrants are now categorized as qualified, and certain groups of PRUCOLs (persons residing under color of law) and undocumented immigrants are now categorized as not qualified (the term unqualified is also used). With the notable exception of certain PRUCOLs who were, in effect, moved from legal to not qualified, all immigrant groups that were formerly legal became qualified. 4 The term 1 The Brownsville site visit report as well as all other site visit reports and the overall synthesis report of the study are available at 2 Zimmerman and Tumlin, (1999). Patchwork Policies: State Assistance for Immigrants Under Welfare Reform, Urban Institute, May, p Alabama opted not to provide TANF benefits to pre-enactment eligible immigrants and Wyoming opted not to provide preenactment eligible immigrants nonemergency Medicaid. See Zimmerman and Tumlin, (1999). Patchwork Policies: State Assistance for Immigrants Under Welfare Reform, Urban Institute, May, p Certain PRUCOLs represent a striking example of a group of individuals who lost the most as a result of PRWORA as they were legally residing in the US yet are now in the unqualified category with illegal/undocumented immigrants and are eligible for only emergency Medicaid. The categories of PRUCOLs so affected by these provisions of PRWORA include: indefinite stay of deportation, indefinite voluntary departure, deferred action status, residing under supervision of INS, and suspension of deportation. Little information is available about these PRUCOLs and, to our knowledge, we did not interview any of these 2

4 qualified is used in the law to distinguish among categories of immigrants for the purpose of eligibility for public benefits. However, being a member of a qualified immigrant category does not necessarily mean that eligibility for public benefits is available. PRWORA essentially created three groups of qualified immigrants in terms of eligibility for public benefits. For pre-enactment legal permanent residents (LPRs) with fewer than 40 qualifying work quarters, states can decide whether to provide federal benefits; they will receive federal matching funds for these benefits; states must provide benefits to pre-enactment LPRs with 40 qualifying work quarters. Most, but not all (e.g., veterans), post-enactment LPRs are barred from receipt of federal public benefits for the first five years after their arrival. All other categories of qualified immigrants (e.g., refugees, parolees, LPRs with more than 40 work qualifying quarters) are eligible for federal public benefits for five to seven years depending upon the program. After the five-year bar, states may opt to provide federally-funded public benefits to post-enactment LPRs although they must provide benefits to those with 40 work quarters. In dealing with these new groups of immigrants, the distinction between being a qualified immigrant and being eligible for public benefits must be clearly understood (i.e., a qualified immigrant is not necessarily an eligible immigrant). PRWORA represents a substantial and unprecedented shift in (i.e., devolution of) immigration policy from the federal to the state level. State officials now have substantial discretion to determine which types of immigrants will receive which kinds of public benefits. The law also imposes greater financial responsibility on states choosing to extend benefits to noncitizens/legal immigrants who have been barred from receiving federal public benefits by PRWORA. These provisions mean that: (1) there will be variability by state in terms of coverage and access for immigrants/noncitizens arriving in the US on or after August 22, 1996; and (2) assessing the experiences of immigrants will require knowledge about particular choices made by states with respect to eligibility for public benefits. The provisions of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), enacted by Congress subsequent to the passage of PRWORA, also have implications for access to Medicaid. Briefly, this law, designed to codify practices of the Immigration and Naturalization Services (INS) concerning the admissibility of immigrants, increased the reporting and verification requirements for federal and state agencies that administer public benefits and focused attention on the issue of public charge. 5 In addition, IIRIRA changed the deeming law to hold immigrant sponsors legally responsible for new immigrants at a higher income level. This law has heightened concerns among immigrants that PRUCOL immigrants. These immigrants represent a very small group, albeit a group quite adversely affected by the changes created by PRWORA. The majority of PRUCOLs, however, were unaffected. 5 An alien who is likely at any time to become a "public charge" is ineligible for admission to the U.S. and is ineligible to adjust status to become a legal permanent resident. An alien who has become a public charge can also be deported from the US. "Public charge" means an alien who has become (for deportation purposes) or who is likely to become (for admission/adjustment purposes) primarily dependent on the government for subsistence. The INS will consider the receipt of cash benefits for income maintenance purposes and institutionalization for long-term care at government expense in determining dependence on the government for subsistence. In deciding whether an alien is likely to become a public charge, the law requires the INS to take certain factors into account, including the alien's age, health, family status, assets, resources, financial status, education and skills. Government officials examine all of these factors, looking at the "totality of the circumstances" concerning the alien. No single factor will be used as the sole basis for finding that someone is likely to become a public charge. [accessed ]. 3

5 any use of public assistance, even a legitimate use of Medicaid, could interfere with an immigrant s ability to become an LPR or petition to bring relatives to the U.S. 6 Just as we began our site visits in the Spring 1999, the INS issued regulations clarifying the grounds for public charge and specifically noting that any use of the Medicaid (except long-term care) and CHIP programs would not by itself subject an immigrant to the risk of being labeled a public charge. Medicaid Coverage for Immigrants in Texas Post-PRWORA As discussed above, PRWORA transferred the substantial authority to states to determine the public benefits for which immigrant groups are eligible. In Texas, Medicaid benefits were continued for pre-enactment LPRs or those immigrants who arrived to the US before August 22, Texas did not opt to provide coverage for post-enactment immigrants, however, and these immigrants who arrived after August 22, 1996 are barred from receiving Medicaid benefits for five years. This situation may be improving for post-enactment LPR children, however. The Texas state legislature voted in 1999 to provide state-funded health insurance for citizen children as well as legal immigrant children (pre and post-enactment) who do not qualify for Medicaid or CHIP. This program will be implemented in April of 2000 and will cover children 0-18 years old and in families with incomes up to 200 percent FPL with benefits that are similar to the CHIP benefits. Most categories of immigrants including post-enactment LPRs and undocumented immigrants remain eligible to apply for emergency Medicaid. METHODS FOR COLLECTING DATA FROM IMMIGRANTS Design of Data Collection Five members of the project team conducted the Brownsville, Texas site visit from July 26 to July 28, The focus groups and interviews took place at different locations in Brownsville including four CBOs, one community health center, and the Texas Department of Human Services office. To recruit immigrants, we worked with members of the community whom the immigrants trusted. Community contacts at the site visit locations recruited immigrants to participate in the study either by posting flyers or by approaching clients they believed would be interested in participating. The contacts scheduled the interviews, found private settings for the interviews to take place, and arranged for refreshments. The focus groups and interviews involved at least two project team members. Most immigrants interviewed in Brownsville were most comfortable speaking Spanish. Three members of the project team speak Spanish and either conducted the interviews in Spanish or translated between English and Spanish. 6 Brady, S. (1998) One in Ten: Protecting Children s Access to Federal Public Benefits Under the New Welfare and Immigration Laws, National Association of Child Advocates, Issue Brief, April. 4

6 Interview and Focus Group Topics The questions posed to immigrants in interviews and focus groups were designed to reveal their level of awareness about the 1996 welfare and immigration reform laws by asking them about their experiences with, and opinions about, health care, Medicaid, and health insurance in the US in the years prior to and since the changes in the laws in In addition, demographic information was collected from each immigrant about their age, country of origin, length of time in the United States, immigration status, and Medicaid history so as to allow us to put the immigrants comments into the context of their personal background. While most immigrants were not knowledgeable about the 1996 laws specifically, in many instances they were able to identify changes in their health care seeking behavior or access that had occurred in the years following implementation of the 1996 laws. Immigrant accounts about changes in health care seeking behavior or access coupled with the demographic data collected during the interviews illustrated the effects of the 1996 laws and provided real-life examples of how changes due to welfare and immigration laws affected individuals in the community. Limitations The results of focus groups are rarely generalizeable and our findings based on these immigrant interviews are not presented as representative of the entire San Diego immigrant population. Also noteworthy is the particular selection bias of our immigrant sample. These immigrants self-selected for participation and thus were probably less likely to be fearful about immigrant-related repercussions, but they were also connected to resources such as communitybased organizations or clinics and therefore probably more likely to have knowledge about Medicaid, and about how and where to access health care in the site visit locations. Despite these limitations, however, the findings provide a rich and detailed picture of these immigrants personal experiences with respect to accessing Medicaid and health care services prior to and since the immigration and welfare reform laws, and suggest valuable insights regarding the factors affecting immigrants ability and willingness to access Medicaid and health care services. CHARACTERISTICS OF IMMIGRANTS A total of 73 immigrants were interviewed in Brownsville 65 immigrants were interviewed in groups ranging from two to eight participants while the remaining eight immigrants were interviewed individually (see table of demographics below). At one of the community-based organizations where focus groups were held, the immigrants recruited had not been in the US longer than a few days and were not able to inform us about immigrants access to health care or Medicaid in the US. These 19 immigrants were interviewed about their expectations for seeking health care and public benefits in the US, and while their comments were interesting, they are not relevant to this study and are not included in this report. Findings presented here are based on reports of 54 immigrants. They were 46 females and eight males. All immigrants came to the United States from Mexico. Most immigrants had been in the US over ten years and only two been in the US less than three years. Nearly half of 5

7 Table 1. Demographic Profile of Immigrants Interviewed BROWNSVILLE TEXAS Total Number of Participants 54 Region of Origin Africa 0 Asia 0 Latin America 54 (Mexico) Eastern Europe 0 Language Preference 8 English 46 Spanish Residence (ave. length) 11.7 years Immigration Staus At Entry 26% pre-enactment LPRs 0% post-enactment LPRs 0% refugees/asylees 45% undocumented 28% other Current 7% naturalized citizen 38% pre-enactment LPRs 9% post-enactment LPRs 26% undocumented 20% other Gender 46 Female ( 85%) Age (ave.) 36.8 years Currently Employed 35% Insured Status, Adults Medicaid 24% Private 0% Uninsured 76% Children U.S. Born 71% Insured Status, All Children Medicaid 64% CHIP 0% Uninsured 36% Private 0% 6

8 the immigrants interviewed are pre-enactment legal permanent residents who obtained their residency before the 1996 laws were implemented. Close to half of the participants originally entered the US without documents, and more than one quarter of all the immigrants are currently undocumented. Four of the remaining immigrants are now US citizens. Thirty-four of the 54 immigrants had received Medicaid in the past, primarily for child delivery and labor under the emergency Medicaid assistance program. Seven immigrants currently have Medicaid and six are covered by Medicaid and SSI; the remaining 41 immigrants are uninsured. The children of 24 immigrants are covered by Medicaid while the Medicaid status of the children for 19 immigrants is mixed at least one child in these 19 families has Medicaid, while others are not eligible due to immigration or age requirements. Of the remaining 11 immigrants, two do not have children and the children in nine immigrants families are uninsured. Nineteen of the 54 immigrants reported being currently employed, and many females mentioned that their husbands were working. FINDINGS Immigrants Ability to Access Medicaid Changes in Medicaid Eligibility Policies Immigrants in Brownsville are aware that changes in Medicaid eligibility have occurred since Immigrants reportedly learn most about their eligibility and about the changes in welfare and immigration laws by going through the application process themselves, through word of mouth, and from the experiences others have in applying for and using Medicaid. Immigrant adults and children in Texas who entered the US after August 22, 1996 are not eligible for Medicaid because of the welfare reform laws. The lack of Medicaid eligibility and other public benefits has resulted in a lack of access to regular health care and assistance for many post-enactment LPRs. One woman and her eldest daughter are post-enactment LPRs while her husband and other children are US citizens. She is frustrated that she and her daughter cannot access Medicaid and are not counted with the other members of her family for receipt of food stamps and cash assistance because of welfare reform. She works part-time and believes the distinction between pre and post-enactment LPRs is unfair since she is still a legal and employed resident. She stated, I am counted and taxed if employed, but they don t count me otherwise. [Mexican woman, post-enactment LPR] Another immigrant had lived in the US in the past but went back to Mexico in He returned to the US in late 1996 as a post-enactment LPR. He was eligible for Medicaid in the past but because he returned to the US and acquired his LPR status after the new welfare and immigration laws were enacted, he is no longer able to access Medicaid. The immigrant is very 7

9 disappointed that he cannot access Medicaid. Since returning to the US, he has developed a chronic heart condition and is unable to access consistent primary care to maintain his health. Although this immigrant s story is atypical because he has first-hand experience with Medicaid eligibility both before and after the 1996 welfare and immigration reform laws, his situation effectively illustrates the consequences of lack of access to Medicaid for all post-enactment LPRs. He noted, This new law that came in 96, it kept me from well, I have a bad heart and it kept me from having regular Medicaid monthly. They have told me that I can apply for the emergency, but [my heart problem] is never an emergency. Those are the changes I ve seen from 96 to this moment: it wasn t the normal Medicaid I could get. [Mexican man, post-enactment LPR] Perceived Difficulty Obtaining Medicaid for Immigrants and their Citizen Children Most immigrants in Brownsville had experience applying for Medicaid for their citizen children. Immigrants reported that the application process is fairly simple but that more information is required now from immigrant parents compared to three or more years ago. Many felt their immigration status was a hindrance to getting assistance for their citizen children because there is more paperwork involved when parents are not citizens. Even though my children are citizens, my applying for them and my being a resident makes it more difficult. If I were a citizen, the treatment would be different, it would be direct. [Mexican man, pre-enactment LPR] There s discrimination once they know your [immigration] status. We were never asked our status before [when applying for Medicaid for our citizen children]. [Mexican woman, undocumented] The treatment we receive in programs like Medicaid and welfare shows to us that our residency isn t a residency to them. In other words, our residency is permanent, but by the way they treat us, they don t take us like that they treat us like visitors. Like visitors, at the time they want, they can close the door on you. It s a contradiction: I m not a resident but I am a resident. [Mexican man, post-enactment LPR] Many immigrants reported that undocumented immigrants have an easier experience accessing government assistance and health care than legal immigrants because, unlike legal immigrants, undocumented immigrants are not asked about their income and are not required to produce any documentation. Some LPRs reported that they lied as often as possible about their immigration status in situations such as applying for Medicaid for a citizen child where they felt they would be offered more public support with no strings attached. Legal immigrants perceived a greater commitment from the Texan community to protect the rights of the undocumented as opposed to helping the legal immigrants; this perception is reportedly stronger because of the 8

10 welfare policy restrictions against post-enactment LPRs that have made accessing health care so difficult for them. Sometimes you have to lie [and say you re undocumented] just so that they can leave you alone and give you the Medicaid for the children. It s not for me, it s for the children. They do that a lot now, they ask too many questions. It s easier if you just say you re illegal, they know there s nothing else to know. [Mexican man, pre-enactment LPR] The government should give more money to the residents paying taxes and not support illegals so much. [Mexican woman, pre-enactment LPR] Interaction with Medicaid Caseworkers Overwhelmingly, immigrants in Brownsville reported that caseworkers are unfriendly and unaccommodating in general, but this is something that existed before welfare and immigration reform. Many immigrants reported that caseworkers are not forthcoming with information and act as if the money for public benefits comes out of their own pockets. Immigrants also believed that caseworkers discriminated against immigrants and were especially unhelpful to immigrant applicants. People [at the Medicaid office] are not agreeable. They ask you thousands of questions that you have to answer but they don t explain anything to you and in the end they don t give you the Medicaid [They] make you waste the day. [Mexican man, undocumented] [Caseworkers] act like they own all the programs and the money comes out of their pockets. [Mexican woman, pre-enactment LPR] If you let them, the [caseworkers] will treat you bad. [Mexican woman, undocumented] [The caseworkers] come to your house to verify claims and act like my house is theirs it makes me feel bad, as if I am telling a lie. [Mexican woman, undocumented] While Medicaid application forms and assistance are available in Spanish, immigrants stated that English-speaking applicants receive better treatment from caseworkers while non- English speaking applicants were frowned upon. Immigrants reported that mistreatment against non-english speaking applicants came mainly from Hispanic caseworkers. It matters that you speak English. The person that comes and can speak English is treated better. [Mexican woman, undocumented] Immigrants Willingness to Apply for Medicaid The majority of immigrants in Brownsville, whether undocumented or legal immigrants, reported that they are very knowledgeable about their US-born children s rights to apply for 9

11 public benefits and that these citizen children are accessing Medicaid easily; although, immigrant parents reported that they must endure more paperwork in the Medicaid application process now than before, as discussed above. Families with members of mixed Medicaid eligibility reported being quite willing to access Medicaid for eligible family members. Immigrants also reported being quite willing to apply for emergency Medicaid for childbirth and emergencies. Most immigrants believed that their use of Medicaid for themselves or their children could affect them if they tried to change their immigration status; however, in most cases, immigrants reported that they were not interested in changing their immigration status anyway. A few immigrants reported that fears about public charge or about problems adjusting immigration status were deterrents to applying for Medicaid. One man expressed hesitation about his children s receipt of Medicaid: I don t know if it s going to affect me when I get my [citizenship]. That s what I always have in the back of my mind if it s going to affect me later. [Mexican male, preenactment LPR] Immigrants Ability and Willingness to Seek Primary Care Services Immigrants in Brownsville reported being willing to seek primary care services for their children even for those children who are undocumented or otherwise ineligible for Medicaid. Adult immigrants are not usually willing to seek primary care for themselves, however, because of the barriers they face when attempting to access care. Adults reported that long waits at primary care centers, inability to pay for care, and a general disinterest in seeking primary care services are all deterrents to seeking health care for adult immigrants. If you go to the clinic, you have to bring your children and plenty of food because you have to wait so long. [Mexican woman, pre-enactment LPR] I can t pay for health care services here. It s too expensive just the consultation let alone the medicine. I cross over to Matamoros with my kids. [Mexican woman, preenactment LPR] Undocumented immigrants reportedly go without care more frequently because they do not have the ability to cross the border into Mexico in order to get care that is more affordable or more accessible. I only go to the doctor when I m sick. When it s something small, we know what to take so we don t have to be paying a doctor or risk crossing the border The children go for routine care like physicals and dentists. Medicaid pays. [Mexican woman, undocumented] Families with mixed eligibility status reported that seeking primary care has become more difficult in recent years because of changed Medicaid policies. Prior to the change in laws in 1996, children who were citizens as well as children who were LPRs could both qualify for Medicaid whereas now members of the same family can easily have different eligibility status 10

12 because eligibility is determined, in part, by date of entry into the US. Immigrants reported that because of Brownsville s close proximity to Mexico, many families cross back and forth between the US and Mexico and therefore it is easy for children in the same family to have a differing immigration status. The immigrants explained that often families must see different providers and receive different standards of care, depending on which child or family member needs care. Long wait times exacerbate this problem. For example, one post-enactment LPR has five children, the oldest and the two youngest of whom were born in the US while the two middle children were born in Mexico and became LPRs after August 22, This woman reported having to go to different providers for her citizen children who had Medicaid than for her two children who are not eligible for Medicaid as post-enactment LPRs. This situation for families with mixed eligibility may improve with the implementation in April of 2000 of the state-funded assistance program for children discussed above. Many immigrants go to the neighboring city Matamoros, Mexico for medicine and certain health care services such as dental care. Although the quality of health care is reportedly not as good in Mexico as in Texas and is not much more affordable, immigrants noted that they go to Mexico because there are no wait times and medicines are much cheaper and easier to access. To get an appointment at the community health center [in Brownsville] for a physical you have to make it six months ahead if you re sick, it s three months. When my husband gets sick, there were times when we ve been there early from 8am and we get out sometimes at 5pm Sometimes he can t miss work so he has to go to Matamoros to get the medicines otherwise it will take all day to go to the clinic and get the appointment. [Mexican woman, LPR] It s faster in Matamoros. Here if you go to a clinic, they ll make the appointment for you in two months. [Mexican woman, LPR] Immigrants Ability and Willingness to Seek Emergency Care Services Immigrants in Brownsville are willing to seek emergency care services and this has not been significantly affected by the 1996 welfare and immigration reform laws. However, there are many factors that are not directly related to the changed laws that affect an immigrant s decision to seek emergency care. Many immigrants in Brownsville reported that it is very easy for pregnant women to apply for Medicaid benefits to cover the expense of child delivery under the emergency Medicaid program. Securing Medicaid coverage for non-pregnancy related health emergencies can sometimes prove more difficult. Many immigrants reported that they were suffering from conditions that should be cared for, but they were not severe enough to be deemed an emergency. Some reported being shuffled between hospitals before finding a doctor who would declare the condition an emergency. One woman described an experience her husband had after fracturing his leg. One Brownsville hospital told him it was not an emergency and referred him to the other hospital where he was treated and covered under the emergency Medicaid program. 11

13 For many immigrants, the issue of having a condition classified as an emergency predates the 1996 welfare and immigration reform laws. Undocumented immigrants have always faced a challenge in having a (non pregnancy-related) condition deemed an emergency because they were only eligible for emergency Medicaid. However, the number of immigrants now facing this challenge of qualifying for emergency Medicaid coverage is growing because postenactment LPRs are not eligible for Medicaid. These circumstances are adding to the numbers of uninsured immigrants seeking emergency care. Prior to 1996, many of these legal immigrants would have been eligible for Medicaid and would not have had to wait until a condition was life threatening before receiving coverage. Immigrants reported that many immigrants delay seeking primary health care until a condition became an emergency or would be determined an emergency by providers so that Medicaid would cover the cost of treatment. One immigrant explained that his wife needed a surgery and was suffering, but the hospital was waiting to perform the operation until her condition escalated to emergency status because the couple was unable to afford the operation otherwise. An important factor in an undocumented immigrant s decision to seek emergency health care in Brownsville is fear of the INS. Immigrants reported that fear of the INS is common among undocumented immigrants and has increased since the passage of the 1996 welfare and immigration reform laws. One undocumented immigrant stated that many would rather forego medical care even in an emergency than risk arrest because, It is too difficult to come here and be deported. [Mexican man, undocumented] As discussed above, legal immigrants reported that it is common to claim undocumented status in order to avoid producing documentation and filling out extensive paperwork. The immigrants perceive policies toward legal immigrants to be stricter than they were in the past and they feel they are experiencing more problems accessing health care and assistance because of the documentation requirements. This situation was illustrated repeatedly during discussions about accessing emergency care services. So when you go to the ER and they ask, Do you have documents? you say No I don t. and that s it. They ll attend to you better without so much problems without explanations. [Mexican woman, pre-enactment LPR] Now we know to say that we do not have permanent resident documentation. They do not ask for any other information when you are an illegal alien. Once you have a social security number, they send you a bill. [Mexican woman, pre-enactment LPR] Impact on Immigrants Health-Related Quality of Life Many immigrants reported that their access to health care services was limited in recent years coinciding with the post-prwora period, and therefore the health status of their family had worsened. Limitations on Medicaid eligibility, a more complicated application process, divided access to Medicaid and health services for different family members, overcrowded 12

14 clinics and hospital emergency rooms, and discrimination are all factors that affect immigrants health-related quality of life that were exacerbated by the 1996 laws. One pre-enactment LPR discussed how the Medicaid eligibility changes could have long term effects on the immigrant community. On the news they say there s a lot of sickness among Hispanics Hispanics die of [diabetes], cholesterol, and heart problems. Well, how are they not going to die if they seek help and it s denied? As opposed to the American who walks in with their health insurance policy, because that s the first thing they ask for, insurance. Even if you re dying, you have to give them your insurance information. [Mexican woman, preenactment LPR] Several immigrants interviewed believed they were experiencing hardships that were directly caused by the changed Medicaid eligibility policies. The man whose wife had to postpone receipt of a needed operation until her condition is classified as an emergency and coverable under the emergency Medicaid program is one example. Others commented about the lack of access to prenatal care for post-enactment LPRs. Another interesting perspective on the effect of the laws on an individual immigrant s life is taken from the immigrant discussed above who has a heart condition but cannot access Medicaid because of his post-enactment LPR status. This immigrant s unique experience in having left the US in 1993 and having returned after the laws were enacted illustrates how the 1996 laws arbitrarily changed legal immigrants opportunities for health care coverage, making a distinction between groups of immigrants based solely on their entry dates to the US. The immigrant commented, When I got my residency, I didn t know that I would get this heart condition. I didn t come to the US with that in mind. It happened a year after I got my residency. These are special cases which Medicaid should change the laws that are a bit hard for special cases. I think in that aspect [the new law] has affected me I would like a more stricter checkup because it s a heart condition and not something simple. For me to get that kind of attention I need Medicaid or money to see the doctor that I want. [Mexican man, postenactment LPR] CONCLUSION The 1996 welfare and immigration reform laws prevented most post-enactment LPRs from having access to Medicaid and other public benefits. The state of Texas has not chosen to offer state-funded assistance to post-enactment LPR adult and children in order to mitigate the impact of the federal laws. Consequently, as exemplified by the Brownsville immigrants accounts, growing numbers of legal immigrants are facing significant barriers to accessing health care. Although most Brownsville immigrants interviewed are willing to apply for Medicaid for eligible family members, the 1996 welfare and immigration reform laws impaired these immigrants ability to apply. Immigrants are faced with more paperwork and increased 13

15 discrimination against their immigration status. Caseworkers are reportedly hostile to immigrants and are not forthcoming with information. Some immigrants reportedly lie about their immigration status when applying for benefits for citizen children and claim to be undocumented in order to avoid producing documentation and filling out more paperwork. Primary health care is a priority for children of immigrants in Brownsville and parents are willing to endure long waits in order to access care for their children. Immigrants ability and willingness to access primary care was not significantly affected by the laws, however, mixed Medicaid eligibility status among children in the same family makes it more difficult for many parents to have the health care needs of all their children adequately met. Adult immigrants are less likely to seek primary health care services in Brownsville because of long waits in clinics, and the inability to pay for care. Legal immigrants often travel to Matamoros, Mexico for health care or for prescription drugs as an alternative to seeking health care in Brownsville. Immigrants are willing to seek emergency care services in Brownsville, although immigrants report that it is increasingly difficult to obtain emergency Medicaid coverage for non-pregnancy related conditions. Fear of the INS affects the decision to seek emergency care for undocumented immigrants. Long-standing problems for immigrants such as discrimination, long waits in clinics and hospitals, inability to pay for care, frustration of legal immigrants with undocumented immigrants, and mixed eligibility status among family members have been exacerbated by the 1996 laws and continue to impact on immigrants ability to access Medicaid and health care. However, despite the barriers to apply for Medicaid and access health care, immigrants in Brownsville work to secure health care for their family and Medicaid for eligible children. 14