HMPRG s Chicago Forum for Justice in Health Policy: Ensuring the Health of Non-Citizens

HMPRG s Chicago Forum for Justice in Health Policy: Ensuring the Health of Non-Citizens Andrea Kovach, Attorney, Sargent Shriver National Center on Poverty Law

The Shriver Center The Sargent Shriver National Center on Poverty Law provides national leadership in advancing laws and policies that secure justice to improve the lives and opportunities of people living in poverty. We specialize in practical solutions. Through our advocacy, communication, and training programs, we advocate for and serve clients directly, while also building the capacity of the nation s legal aid providers to advance justice and opportunity for their clients Like us on Facebook: Follow us on Twitter: www.povertylaw.org www.facebook.com/shrivercenter @shrivercenter

Agenda Health Coverage in Illinois Demographics of Illinois uninsured Eligible but unenrolled vs. ineligible? (focus on immigrants) New pathway to health coverage benefits immigrant families and Illinois overall Other states initiatives The Healthy Illinois Campaign

Source: WhiteHouse.gov, March 2016

Number of Uninsured Has Dropped For 3 Reasons 2015 uninsured rate for Illinois adults is10.6%. 1. ACA Medicaid Expansion: 626,248 enrolled in Illinois as of Nov. 2015 (Source: Illinois HFS) 2. Availability of Affordable Insurance in New Marketplaces: 388,179 Illinoisans enrolled in and paid for a Marketplace plan in 2016 75% receive financial help through premium tax credits in 2016 (Source: CMS) 3. Young Adults Up to Age 26 Staying on Parents Plan

1,122,000 uninsured nonelderly adults in Illinois Source: http://files.kff.org/attachment/issue-brief-new-estimates-of-eligibility-for-aca-coverage-among-the-uninsured

2015 Uninsured Rate in Most Populous Counties in Illinois Source: Enroll America, October 2015

Illinois Uninsured Rates for 2013 and 2015 Source: Enroll America, October 2015 African American men ages 18 to 34 (18%) have the highest 2015 uninsured rates, followed by Hispanic men ages 18 to 34 (18%) and Hispanic women ages 18 to 34 (15%).

Uninsured Illinois Residents: 1,122,000 Data published October 2015 563,000 have a pathway to health insurance coverage 397,000 (35%) are Medicaid eligible 166,000 (15%) are Marketplace eligible including the ACA tax credits 559,000 (50%) fall into one of 3 categories 1) 173,000 (15%): Eligible for ACA marketplace coverage but are ineligible for ACA marketplace financial assistance due to being over income 2) 151,000 (13%): They have an offer of employer sponsored coverage that the ACA deems is affordable 3) 235,000 (21%): They are ineligible for the marketplace or for Medicaid due to their immigration status Source: Kaiser, October 2015

Uninsured Illinois Residents: 1,122,000 Data published October 2015 563,000 have a pathway to health insurance coverage 397,000 (35%) are Medicaid eligible 166,000 (15%) are Marketplace eligible including the ACA tax credits 559,000 (50%) fall into one of 3 categories 1) 173,000 (15%): Eligible for ACA marketplace coverage but are ineligible for ACA marketplace financial assistance due to being over income 2) 151,000 (13%): They have an offer of employer sponsored coverage that the ACA deems is affordable 3) 235,000 (21%): They are ineligible for the marketplace or for Medicaid due to their immigration status

Reminder: Who Can Enroll in Medicaid? An adult (age 19-64) can enroll if A person who is 65+(aged), blind or disabled and is covered by Medicare can enroll if A pregnant woman or child under one can enroll if A child (age birththrough 18) can enroll if A U.S. citizen or non-citizen whose status meets Medicaid qualifiers Illinois resident Income below $1,354 [FPL 2015] for one person A U.S. citizen or non-citizen whose status meets Medicaid qualifiers Illinois resident Income below $981 (one person) (if over $981 [FPL 2015] then enrolled in Spend down) Resources limited to $2,000 (one person) or $3,000 for two people); if over enrolled in Spenddown Illinois resident Income below $2,828 [FPL 2015] (this is for a household of two and includes the unborn child) Illinois resident Income at or below $6,426 [FPL 2015] for a family of four When income is $4,224 [FPL 2015] or more (family of four) the child(ren) has to be uninsured for 12 or more months. This is the income level for All Kids Level 2 coverage. 11

Reminder: General Adult Immigrant Eligibility Rules for Medicaid Under the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, the following groups may be eligible for Medicaid and CHIP: Qualified" immigrants who entered the U.S. before 8/22/96 "Qualified" immigrants who entered on or after 8/22/96 who reach the end of a 5-year waiting period For example: lawful permanent residents (LPRs or green card holders) "Qualified" immigrants exempt from the 5-year waiting period For example: refugees asylees Cuban/Haitian entrants trafficking survivors veteran families NOTE: Immigrants who do not meet these immigrant eligibility rules (i.e. qualified immigrants in the 5-year bar and not qualified immigrants) may be eligible for Medicaid payment of limited emergency services (Emergency Medical Assistance or EMA) if they otherwise meet all Medicaid eligibility standards Source: Georgetown CCF 12

Uninsured Illinois Residents: 1,122,000 Data published October 2015 563,000 have a pathway to health insurance coverage 397,000 (35%) are Medicaid eligible 166,000 (15%) are Marketplace eligible including the ACA tax credits 559,000 (50%) fall into one of 3 categories 1) 173,000 (15%): Eligible for ACA marketplace coverage but are ineligible for ACA marketplace financial assistance due to being over income 2) 151,000 (13%): They have an offer of employer sponsored coverage that the ACA deems is affordable 3) 235,000 (21%): They are ineligible for the marketplace or for Medicaid due to their immigration status

Reminder: Who is eligible for the Anyone who: Marketplace? Is a citizen, or non-citizen who is lawfully present in the United States Meets Illinois state residency standards Can not be currently incarcerated 14

Immigration Categories Eligible for Marketplace Coverage Qualified Immigrants: Lawful Permanent Resident (LPR/green card holder) Refugee Asylee Cuban/Haitian Entrant Paroled into the U.S. for at least one year Conditional Entrant Granted Withholding of Deportation or Withholding of Removal Battered Spouse, Child and Parent Trafficking Survivor and his/her Spouse, Child, Sibling or Parent Others: Member of a federally-recognized Indian tribe or American Indian Born in Canada Other Lawfully Present Immigrants: Granted relief under the Convention Against Torture (CAT) Temporary Protected Status (TPS) Deferred Enforced Departure (DED) Deferred Action (except DACA)* Paroled into the US for less than one year Individual with Nonimmigrant Status (includes worker visas; student visas; U visas; citizens of Micronesia, the Marshall Islands, and Palau; and many others) Administrative order staying removal issued by the Department of Homeland Security Lawful Temporary Resident Family Unity *EXCEPTION: Individuals granted deferred action under the 2012 Deferred Action for Childhood Arrivals (DACA) program are not eligible to enroll in coverage in the Marketplace. 15

Reminder: Who is eligible for premium tax credits? Ineligible for government insurance (eg: Medicaid, Medicare, CHIP) Household income between 100% - 400% FPL, with exceptions Lawfully residing immigrants with income under 100% FPL & ineligible for Medicaid Not offered affordable or minimum value employersponsored coverage Get coverage through Marketplace Agree to file taxes and have an eligible tax filing status 16

Uninsured Are Unaware of Tax Credits Source: Understanding the Uninsured Now, June 2015. Robert Wood Johnson Foundation & PerryUndem Research/Communication

Steps Needed to Cover Eligible But Unenrolled Immigrants Provide more language enrollment assistance resources Smooth out system glitches that make enrolling much harder for naturalized citizens and lawful residents Provide high quality language translations of all important documents Have Outreach and Enrollment where people are, especially community based orgs, schools, clinics, and faith based institutions

Uninsured Illinois Residents: 1,122,000 Data published October 2015 563,000 have a pathway to health insurance coverage 397,000 (35%) are Medicaid eligible 166,000 (15%) are Marketplace eligible including the ACA tax credits 559,000 (50%) fall into one of 3 categories 1) 173,000 (15%): Eligible for ACA marketplace coverage but are ineligible for ACA marketplace financial assistance due to being over income 2) 151,000 (13%): They have an offer of employer sponsored coverage that the ACA deems is affordable 3) 235,000 (21%): They are ineligible for the marketplace or for Medicaid due to their immigration status

Uninsured Illinois Residents: 1,122,000 Data published October 2015 563,000 have a pathway to health insurance coverage 397,000 (35%) are Medicaid eligible 166,000 (15%) are Marketplace eligible including the ACA tax credits 559,000 (50%) fall into one of 3 categories 1) 173,000 (15%): Eligible for ACA marketplace coverage but are ineligible for ACA marketplace financial assistance due to being over income 2) 151,000 (13%): They have an offer of employer sponsored coverage that the ACA deems is affordable 3) 235,000 (21%): They are ineligible for the marketplace or for Medicaid due to their immigration status

Uninsured Illinois Residents: 1,122,000 Data published October 2015 563,000 have a pathway to health insurance coverage 397,000 (35%) are Medicaid eligible 166,000 (15%) are Marketplace eligible including the ACA tax credits 559,000 (50%) fall into one of 3 categories 1) 173,000 (15%): Eligible for ACA marketplace coverage but are ineligible for ACA marketplace financial assistance due to being over income 2) 151,000 (13%): They have an offer of employer sponsored coverage that the ACA deems is affordable 3) 235,000 (21%): They are ineligible for the marketplace or for Medicaid due to their immigration status

235,000 (21%): They are ineligible for the marketplace or for Medicaid due to their immigration status

Undocumented Illinois Residents by Federal Poverty Level 11.7% Source: Rob Paral

Undocumented Illinois Residents by Poverty Level and Insurance Status There are approximately 141,000 uninsured undocumented adults earning less than 138% FPL SOURCE: Rob Paral and Associates

What are current health care options for undocumented individuals? Some private insurance options (cost-prohibitive) Private health insurance market outside of the marketplace Employer-Sponsored Insurance Medicaid: All Kids (up to age 19) or Moms & Babies (throughout pregnancy and 60 days post-partum) Hospital emergency rooms FQHCs and other community clinics, migrant health centers Emergency Medicaid Financial Assistance and Charity Care /Hospital Programs

Let s create a new pathway for affordable, comprehensive health insurance coverage

The Solution: Expanding health insurance coverage will Increase use of primary/preventive care and decrease emergency room use Network of providers Promote insuring kids Increase financial security Promote Care Coordination Lower mortality Increase access to free/lowcost Prescriptions and Medical Supplies Promote early detection of disease/ chronic disease management

Illinois can t afford to create a new health coverage pathway, right? Employers save money on reduced turnover/ absenteeism Ease burden on safety net clinics Ease burden on privately insured Fill fiscal gap from DSH reduction Reduce uncompensated care Positively affects public health We are already paying for their care uncoordinated, fragmented SICK care

Amount spent in charity care by hospitals in the counties with the highest number of uninsured in 2014 Source: http://www.hfsrb.illinois.gov/hospprof_abr.htm

Which Illinois hospitals spent the most in charity care in FY 2014? Source: http://www.hfsrb.illinois.gov/hospprof_abr.htm

Policy Options 1. Expanding Medicaid to undocumented adults 18-64 years old, < 138% FPL 2. Basic Health Program that provides a Medicaid look-alike program to Illinois residents < 200% FPL 3. Subsidized, comprehensive individual health insurance policy: with low or no premiums, low deductible and low cost-sharing

Other States are Leading the Way State New York California Minnesota Washington D.C. Massachusetts Washington Coverage program for Undocumented /DACA Immigrants Covers children regardless of immigration status. Lawfully present adults including DACA are eligible for their Basic Health Plan. Low-income LPRs < 5 years and DACA can enroll in state-funded Medicaid program. Undocumented adults can pre-register for Emergency Medicaid. Advocates investigating expanding BHP to undocumented immigrants and/or having state pay for bronze plans and some cost sharing. Starting May 1, 2016, covers children regardless of immigration status. California s state marketplace board recommends asking Feds to allow DACA recipients and undocumented residents to purchase health plans through state exchange and legislation pending to do the same; (no subsidies would be provided). Governor- and Legislature-formed taskforce on Health Care Financing workgroup recommended using state funds to provide public coverage to children and adults up to 200% FPL regardless of immigration status Covers children regardless of immigration status; provides public health coverage to low-income undocumented adults and LPRS < 5 years Covers children regardless of immigration status. Pre-enrolls undocumented in emergency Medicaid Covers children regardless of immigration status

Healthy Illinois Campaign Endorsed by over 80 civic, faith, business leaders and institutions, the Healthy Illinois Campaign works to make quality, affordable health care coverage accessible to all people in Illinois For more information please visit www.healthyillinoiscampaign.org

Contact: Andrea Kovach andreakovach@povertylaw.org