IMMIGRATION REFORM: CHALLENGES AND OPPORTUNITIES

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1 CALIFORNIA PROGRAM ON ACCESS TO CARE (CPAC) AND THE HEALTH INITIATIVE OF THE AMERICAS (HIA) UC BERKELEY SCHOOL OF PUBLIC HEALTH CO-SPONSORS: FARMWORKER JUSTICE, NATIONAL COUNCIL OF LA RAZA, & NATIONAL HISPANIC MEDICAL ASSOCIATION IMMIGRATION REFORM: CHALLENGES AND OPPORTUNITIES WEDNESDAY, OCTOBER 2, :30 3:00 PM UNIVERSITY OF CALIFORNIA WASHINGTON CENTER S AUDITORIUM 1608 RHODE ISLAND AVE, NW WASHINGTON, DC AGENDA WELCOME AND OPENING COMMENTS: Elena V. Rios, MD, MSPH, President and CEO, National Hispanic Medical Association Moderator: Xóchitl Castañeda, Director, Health Initiative of the Americas, School of Public Health, UC Berkeley PRESENTATIONS: IMPLICATIONS OF IMMIGRATION REFORM ON HEALTH AND ACCESS TO HEALTHCARE Virginia Ruiz, Director of Occupational and Environmental Health, Farmworker Justice STATUS OF IMMIGRANT HEALTH COVERAGE IN THE UNITED STATES Jennifer Ng andu, Director, Health and Civil Rights Policy Project, National Council of La Raza BINATIONAL OPPORTUNITIES FOR IMMIGRANT COVERAGE Arturo Vargas Bustamante, PhD, Assistant Professor, Department of Health Policy and Management, UCLA Fielding School of Public Health OPPORTUNITIES IN HEALTH CARE REFORM FOR IMMIGRANTS: A CALIFORNIA PERSPECTIVE Gilbert M. Ojeda, Director, California Program on Access to Care, School of Public Health, UC Berkeley ASSISTANCE FOR THIS BRIEFING PROVIDED BY THE OFFICE OF FEDERAL GOVERNMENTAL RELATIONS, UNIVERSITY OF CALIFORNIA, AND THE OFFICE OF CONGRESSWOMAN LUCILLE ROYBAL-ALLARD

2 IMPLICATIONS OF IMMIGRATION REFORM ON HEALTH AND ACCESS TO HEALTHCARE Virginia Ruiz Director of Occupational and Environmental Health Farmworker Justice

3 Farmworker Justice is a nonprofit organization that seeks to empower migrant and seasonal farmworkers to improve their living and working conditions, immigration status, health, occupational safety, and access to justice.

4 Overview: Immigration Reform and Health Overview: Immigration Reform Provisions that affect health and access to healthcare Indirect impacts of immigration reform on health

5 CURRENT LEGISLATIVE PROPOSALS

6 SENATE The Border Security, Economic Opportunity, and Immigration Modernization Act of 2013, S.744; passed Senate June 2013 Path to citizenship for 11 million undocumented immigrants currently in the U.S. Registered Provisional Immigrant (RPI) status (10 year path to LPR with work/income requirement) Blue Card status for agricultural workers and their families (5-8 year path to LPR with work requirement) DREAMers Expanded guestworker program (W-visas)

7 HOUSE OF REPRESENTATIVES No comprehensive bill Agricultural Guestworker AG Act (H.R. 1773) Bob Goodlatte (R-VA) No path to citizenship Lowers wages and offers fewer worker protections than notorious Bracero program Guestworkers will be even more vulnerable to exploitation and will have extremely limited access to judicial relief and legal assistance

8 PROVISIONS THAT AFFECT HEALTH AND ACCESS TO HEALTHCARE Eligibility for ACA programs Individuals with provisional status will be eligible to enroll in the health insurance marketplaces but would not be eligible for subsidies until they gain LPR status Will not be subject to the individual mandate 5-year bar still applies for Medicaid eligibility H-category visas and low-skilled workers who obtain W visas Eligible to enroll in the marketplaces and subsidies Subject to the individual mandate If they adjust to LPR status, the 5-year bar still applies for Medicaid eligibility Employers required to carry workers compensation insurance

9 INDIRECT IMPACTS OF IMMIGRATION REFORM ON HEALTH & ACCESS TO HEALTHCARE Valid work authorization = more opportunities for employer-provided insurance Fewer barriers to access healthcare Transportation (esp. drivers licenses) Ability to travel outside of US to home countries Residents of border states can access care in Mexico & Canada Better working and living conditions More willing to speak out about hazardous working conditions Lower stress and anxiety

10 FOR MORE INFORMATION Virginia Ruiz

11 Status of Immigrant Health Coverage in the United States Policy Briefing October 2, 2013 Jennifer Ng

12 MARCH 21, Inside the Capitol The Final Vote on the Historic Affordable Care Act

13 MARCH 21, Outside the Capitol Nearly 1 Million Gather in the Name of Fair, Comprehensive Immigration Reform

14 Presentation Overview Immigrant Coverage and the Affordable Care Act Briefly, Affordable Care Act Coverage Opportunities Options for Those Left Behind

15 Coverage Status

16 The Big Picture According to the most recent annual Census figures, immigrants comprise 13% of the population, but represent 20% of the uninsured.

17 Coverage for the Unauthorized According to the Migration Policy Institute s May 2013 brief: Seven in ten (71%) of unauthorized workers and nearly half (47%) of unauthorized children are uninsured. Of those unauthorized and uninsured, just under one in three (29%) of adults receive coverage through an employer and negligible numbers (estimated at 0%) receive public coverage. One in five (21%) unauthorized children receive coverage through an employer; 32% of children receive coverage through public programs.

18 THE ACA: Current Eligibility

19 Eligibility: U.S. Citizen Employer-Sponsored Coverage Employers with more than 50 employees responsible for providing affordable insurance options Medicaid Current Medicaid program continues to operate Blanket expansion for new Medicaid package for all persons with annual income* under 133% of the federal poverty level ($30,700 per year for family of 4) New Health Insurance Marketplaces, Exchanges Tax credits for individual coverage SHOPs for small businesses

20 Eligibility: Lawfully Present Immigrant Employer-Sponsored Coverage remains unrestricted Seasonal workers are not counted towards employer responsibility requirements New Health Insurance Marketplaces, Exchanges available to all defined as lawfully present.* Protects low-income immigrants ineligible for Medicaid Administration inserts a partial rollback, denying coverage to DACA recipients. Medicaid Unchanged, with continued legal immigrant restrictions. Qualified immigrants barred for five-years Not-Qualified barred indefinitely unless status changes Emergency Medicaid available to those who would otherwise qualify

21 Eligibility: Undocumented Employer-Sponsored and Private Market Coverage Outside Exchanges No explicit ban New Health Insurance Marketplaces, Exchanges are restricted to individuals SHOPs have no explicit ban Medicaid Explicit bar from full-scope Medicaid dating prior to ACA enactment Emergency Medicaid available to those who would otherwise qualify

22 Core Enrollment Challenges IMMIGRANT HOUSEHOLDS LANGUAGE BARRIERS LOW- INCOME FAMILIES

23 Common Questions Can I enroll a child or another family member if I am not eligible? Can DHS access this information for immigration purposes? Will using the Affordable Care Act hurt my chances to become a legal permanent resident or a citizen? What are the options for the remaining uninsured?

24 ALTERNATIVES TO COVERAGE

25 Solutions to Implement Now Emergency Medicaid Basic Health Plans Community Health Centers/Free Clinics Charity Care State-Funded Programs

26 Potential Solutions Moving Forward? Binational Health Insurance Non-Insurance Health Products Uncompensated Care Pools (e.g. Improved Section 1011 legislation) Health Insurance Buy-Ins and External Co-op Plans Immigration Reform Related State Impact Aid

27 RESOURCES

28 Critical Resources Enrollment (Enrollment on October 1 st ) (Enrollment mid- October) (150 Languages, including Spanish) General Policy Information Basics of Health Care Reform Subpage

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31 My Contact Information Jennifer Ng andu Director, Health and Civil Rights Policy National Council of La Raza (NCLR) (202)

32 Binational Opportunities for Immigrant Coverage Immigration Reform: Challenges and Opportunities Arturo Vargas Bustamante, PhD, MPP Assistant Professor of Health Policy & Managemnt UCLA Fielding School of Public Health

33 Outline Overview of Mexican Immigratns in the U.S. Experience of Californa: Binational Health Coverage Options in Mexico: Mexican Institute of Social Security, Seguro Popular, Private Sector Outlook: healthcare and immigration reforms

34 Mexicans in the U.S million individuals of Mexican origin resided in the U.S. in 2012 (U.S. Census) million immigrants born in Mexico million born in the U.S. who self-identified as Mexican Americans In 1970, fewer than 1 million Mexican immigrants lived in the U.S. By 2010, immigrants accounted to 9.8 million.

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37 Mexicans in the U.S. Previous research shows that Mexicans living in the U.S. go back to Mexico to receive some health care Since NAFTA was signed, economic and social integration between the U.S. and Mexico has accelerated US-Mexico border is the busiest international border in the world. 350M people cross it legally each year Mexicans sent $23 billion last year as remittances. Almost half of recipient families (46%) used a share for health spending

38 Motivations for binational health coverage Access to care challenges for Mexicans in the U.S. Cultural familiarity with the health system in Mexico Geographic proximity Lower costs of care in Mexico (50% - 90%)

39 California s experience In 1998, California enacted legislation allowing binational health coverage in Mexican border cities. In 2001 Texas tried to introduce a similar law but failed. Three private plans were licensed to provide services in California and Mexico. Enrollment is ~20K individuals

40 California s experience According to the California Health Interview Survey an approximately 800K California adults use medical, dental, and/or prescription services in Mexico Approximately 50% are Mexican immigrants

41 California s experience Mexican immigrants >15 years 225,000 Mexican immigrants <15 years 263,000 US-born Non-Latinos 89,000 US-born Mexican Americans 232,000 Source: Wallace, Castañeda et al

42 California s experience Among Mexican immigrants the main predictors of use are: need, no insurance, delay seeking care, more recent immigration and limited English Living closer to the border increased use, although half of immigrants seeking services lived more than 120 miles from the border

43 Options in Mexico Program Share of population Health Coverage Responsibility Social Security (e.g. IMSS) 52% comprehensive Federal government Seguro Popular 48% 284 services Federal and state governments Private 2-3% varies Private insurers (FFS)

44 IMSS-Social Security Institute Mexican immigrants can enroll since 1997 Now they should enroll in Mexico Different fees according to age of enrollees No co-payments or deductibles. Excludes pre-existing conditions

45 Seguro Popular 99% enroll for free No co-payments or deductibles. Covers pre-existing conditions Seguro Popular enrollees can include their relatives in the U.S. Enrollment in Mexico

46 Private Sector Approximately 52% of health spending in Mexico is private and most of it is out-of-pocket Private health insurance is underdeveloped Medicare in Mexico has produced high expectations Increasing consolidation of services

47 Outlook: ACA If HC reform is effective: Binational health utilization could decrease among currently uninsured Mexicans who are ACA eligible Uncertain among those who currently have insurance and still prefer to purchase care in Mexico

48 Outlook: ACA Opportunities to expand binational health coverage: ACA pilot programs to cut Medicare costs could consider Medicare in Mexico Health plans in the exchanges will compete based on cost. Binational coverage could take advantage of lower-cost Mexican providers. Potential partnerships between Medicaid and FQHCs and Mexican providers

49 Outlook: Immigration reform More than half (55%) of the 11.1 million Mexican immigrants in the U.S. live are undocumented Granting legal status to this population could make them eligible for health coverage and would allow them to receive care in Mexico Potential guest worker program could consider low-cost binational health insurance coverage.

50 Next steps Idea Policy Paper Pilot Legislation Implementation Evaluation Mexican plans lack coverage in the U.S. U.S.-Mexico cooperation could ease the flow of transnational populations ACA and immigration reform opportunities

51 Binational Opportunities for Immigrant Coverage Immigration Reform: Challenges and Opportunities Arturo Vargas Bustamante, PhD, MPP Assistant Professor of Health Policy & Managemnt UCLA Fielding School of Public Health

52 Opportunities in Health Care Reform for Immigrants: a California Perspective Gilbert Ojeda, Director California Program on Access to Care. UC Berkeley School of Public Health UC Berkeley School of Public Health A Public Service Program of UC Office of the President UC Forum-- Immigration Reform: Challenges & Opportunities October 2, 2013

53 THE CPAC PERSPECTIVE Established in 1997 by University of California Office of President at request of CA Legislature Mission as set by UC & the Legislature is to promote access to health care for farmworkers, immigrants & the working poor Has assisted multiple State initiatives to maintain & expand health coverage to low-income populations during a tight fiscal period Supported start-up of Health Initiative of the Americas which established Latin American migration & health programs with focus on US-Mexico health & public health (beginning in 2001) Has implemented grant programs, coverage initiatives & Technical Assistance projects with CA s decision makers

54 MEDICAID/MEDI-CAL: CORE ELEMENT OF HEALTH REFORM Largest Medicaid program- 7.2 million persons; approximately 50% Latino; over 60% in managed care plans (largely private sector); soon over 80% Eligible but not enrolled- 1 million; almost 60% Latino & partly immigrant-based Child Health/CHIP- CA s program for under age 19 (Healthy Families): 900K enrollees; 60% Latino, with many in mixedstatus families; integrated into Medi-Cal by January 2014 Medicaid Childless Adults- expansion adopted in CA; about 55% Latino; 1.4 million in total by end of 2014

55 CA HEALTH INSURANCE EXCHANGE: THE STRUCTURE Board of Covered CA only 5 members; in place since Jan 2011; five advisory bodies reflecting CA s diverse population & complex health industry A staff of over 800 including service centers reflects state s diversity 13 health plans, including state s 4 largest health plans (which serve 80% of commercial market), selected as Qualified Health Plans (QHPs) for state s 19 regions Most plans commercial; other plans are public, county-based or multi-county. All have experience with Medicaid/Medi-Cal

56 COVERED CA: THE STRUCTURE Safety net providers- depending on region & its responsible health plans, community clinics, traditional Medicaid docs & public hospitals have difficulty securing contracts No wrong door entry (Single Portal)- premise of system is entry into Medicaid & Covered CA through plans, counties, State service centers, providers & CBOs Markets for individuals & businesses- through Covered CA in individual insurance marketplace and small business marketplace (SHOP); only undocumented are not eligible

57 HEALTH BENEFITS EXCHANGE: STATUS 13 Qualified Health Plans & State s Medicaid plans beginning enrollment on October 1st Outreach & Education (O&E) contracts (almost $60 million & 60 contractors) started in August after training period (public & foundation funding) Priority focus on young adults & populations of color, including Latinos & other immigrant populations O&E materials developed to support O&E contracts & over $100 million media campaign just beginning, including balanced use of Latino and Asian-based broadcast media Certification of Certified Enrollment Entities proceeding apace; over 10,000 Certified Enrollment Counselors (CECs) in training or certified by early next year

58 STATE-ONLY & STATE-DRIVEN PROGRAMS California, one of 14 states, supporting State-only Medicaid & CHIP programs for immigrants under 5-year immigration bar (Legal Permanent Residents) State budget maintains existing State-only programs for Medicaid & a State-only component for new Childless Adult expansion as well Prenatal Limited Scope Medi-Cal program covering almost a third of Medicaid births annually also maintained Program has served all immigrant mothers without legal restriction for 25 years

59 STATE-ONLY AND STATE-DRIVEN PROGRAMS, Cont d Consistent with State s administration of EMTALA, State provides an Emergency Medicaid component without concern to immigration status State also administers other residency-based health programs including: family planning (Family PACT) & Child Health Development Program (prevention screening to age 20)

60 THE STATE S SAFETY NET PROGRAMS State-only programs enacted when Legislature was responding to deficiencies in federal coverage resulting from Welfare & Immigration reforms of Outcomes have been positive & withstood efforts initiated by Proposition 187 to eliminate numerous immigrant protections Section of State s Health & Welfare Code designates counties as providers of last resort More liberal counties have provided coverage to indigent including undocumented Some counties have limited coverage to legal residents only Through initiatives over last 20 years, State has supported through direct funding indigent care at county level 14 counties operate public hospitals & others contract with hospitals & clinics (including CHCs); counties have been fiscally challenged in last decade from State budget deficits & the Great Recession to lower county funding for indigent care

61 IN THE SHADOW OF IMMIGRATION AND HEALTH REFORM Need program to address health & human services at state level similar to SLIAG program under 1986 IRCA Models to address these needs, in the face of restrictions for federally meanstested benefits, would address needs of Republican and Democratic led states If Federal legislation passes, as many as 6 million immigrants nationwide are projected to become newly legal as Registered Provisional Immigrants (RPIs). These immigrants could assume such status starting as early as 2015 into early 2016 These numbers could reach 1.5 million in California alone Amendment to recent CA State budget requires Health Department to conduct study as early as Spring 2014 of implications to state s health & human service network for such a newly legal population Designation of over a million immigrants to offer avenue for legal action against counties resisting care to their newly legal immigrant populations & for any efforts to withdraw State indigent funds from counties due to coverage for indigent population through ACA

62 SUMMARY FOR CALIFORNIA: THE ROADS TAKEN & UNDER REVIEW Medicaid Expansive benefits & income groups Private plan participation Integrate large CHIP component Compact w provider community Broad support for higher rates Childless Adult expansion brought provider, public, advocate support Expansion of immigrant coverage through State-only, mixed families efforts Covered CA (Exchange) Administer portion of State-only Conduct aggressive outreach to non-medicaid eligible immigrants e.g., multi-language broadcasting Supporting a culture of insurance for small business employing millions of immigrant workers Immigrant Postures Under Review Maintain State-funded indigent $ s Study impact of RPI s on county indigent programs Review, enhance resident-based programs

63 FOR ADDITIONAL INFORMATION: Gilbert Ojeda Director California Program on Access to Care UC Berkeley School of Public Health Phone: b