Immigrants and Health Care Reform: What s Really at Stake?

NATIONAL CENTER ON IMMIGRANT INTEGRATION POLICY Immigrants and Health Care Reform: What s Really at Stake? Randy Capps, Marc R. Rosenblum, and Michael Fix Ohio State University Columbus April 10, 2012

Today s Presentation Trends in total, illegal immigration Snapshot of immigrants health insurance coverage The scope of health care reform: eligibility rules and mandates Verification of legal status: issues and challenges The Supreme Court challenge: potential impact on immigrants coverage

40 Million Immigrants in 2010: Nearly 13% of US Population 40 40 Million (2010) 30 20 10 14.8% (1890) 12.9% (2010) 4.7% (1970) 0 1840 1860 1880 1900 1920 1940 1960 1980 2000 Source: Urban Institute and MPI analysis of the American Community Survey (various years) and Decennial Census (various years) 2011 Migration Policy Institute

Unauthorized 28% of All Immigrants Naturalized, LPR Shares Slightly Higher Unauthorized immigrants: (11.2 million) 28% 2005: 30% Legal temporary residents: (1.7 million) 4% Naturalized citizens: (14.9 million) 37% 2005: 31% Lawful permanent residents (LPRs): (12.4 million) 31% 40.2 million* foreign born (13%) as of March 2010 * Higher than published totals because amount includes undercounted immigrants Source: Passel, Jeffery S., and D Vera Cohn. 2011. Unauthorized Immigrant Population: National and State Trends. Washington, DC: Pew Hispanic Center. 2011 Migration Policy Institute

Unauthorized Immigrant Population Size Uncertain, Likely Not Growing Estimate based on weights using: Source: Hoefer, Michael, Nancy Rytina, and Bryan Baker. 2012. Estimates of the Unauthorized Population Residing in the United States: January 2011. Washington, DC: US Department of Homeland Security, Office of Immigration Statistics.

Employer-Sponsored Coverage of Working-Age Adults 18-64, 2007 67% 64% 46% All adults Low-income adults (income below 150% FPL) 31% 21% 19% 15% 14% US-born citizens Naturalized citizens Lawful permanent residents Unauthorized immigrants Source: MPI analysis of CPS Annual Social and Economic Supplement, March 2008, augmented by assignments of legal status to noncitizens provided by Pew Hispanic Center.

Employer-Sponsored Coverage of Children 0-17, 2007 All children 61% 60% Low-income children (income below 150% FPL) 38% 31% 22% 18% 11% 16% US-born citizens Naturalized citizens Lawful permanent residents Unauthorized immigrants Source: MPI analysis of CPS Annual Social and Economic Supplement, March 2008, augmented by assignments of legal status to noncitizens provided by Pew Hispanic Center.

Medicaid Coverage of Working-Age Adults 18-64, 2007 All adults 26% 24% 23% Low-income adults (income below 150% FPL) 7% 7% 10% N/A: Ineligible for Medicaid US-born citizens Naturalized citizens Lawful permanent residents Unauthorized immigrants Source: MPI analysis of CPS Annual Social and Economic Supplement, March 2008, augmented by assignments of legal status to noncitizens provided by Pew Hispanic Center.

Medicaid/SCHIP Coverage of Children 0-17, 2007 All children 58% 45% Low-income children (income below 150% FPL) 55% 23% 18% 33% N/A: Ineligible for Medicaid US-born citizens Naturalized citizens Lawful permanent residents Unauthorized immigrants Source: MPI analysis of CPS Annual Social and Economic Supplement, March 2008, augmented by assignments of legal status to noncitizens provided by Pew Hispanic Center.

Uninsured Working-Age Adults 18-64, 2007 All adults Low-income adults (income below 150% FPL) 56% 59% 73% 37% 43% 37% 16% 20% US-born citizens Naturalized citizens Lawful permanent residents Unauthorized immigrants Source: MPI analysis of CPS Annual Social and Economic Supplement, March 2008, augmented by assignments of legal status to noncitizens provided by Pew Hispanic Center.

Uninsured Children 0-17, 2007 All children Low-income children (income below 150% FPL) 44% 53% 10% 16% 14% 23% 25% 30% US-born citizens Naturalized citizens Lawful permanent residents Unauthorized immigrants Source: MPI analysis of CPS Annual Social and Economic Supplement, March 2008, augmented by assignments of legal status to noncitizens provided by Pew Hispanic Center.

Immigrants are 29% of Uninsured Working-Age Adults and Children US-born citizens (33.2 million) 71% Lawful permanent residents (4.2 million) 9% Unauthorized immigrants (6.8 million) 15% Naturalized citizens (2.3 million) 5% 46.6 million total uninsured adults 18-64, plus children 0-17 Source: MPI analysis of CPS Annual Social and Economic Supplement, March 2008, augmented by assignments of legal status to noncitizens provided by Pew Hispanic Center.

Coverage Varies by State Employer coverage of working-age LPRs: 60% in PA, MI, WA; 41% in AZ, 40% in CA, and 36% in TX. Unauthorized employer coverage: Over 40% in PA, MI, MA, IL; Under 25% in TX, GA, NC, and 20% in AZ. Uninsurance is reverse: Highest in TX and Southeast, lowest in MA, NY, other Northeast. Most significant Medicaid coverage of LPR adults in NY, MA (22% each). Children s coverage same pattern but lower uninsurance, higher Medicaid/SCHIP

Noncitizens as Share of Uninsured Working-Age Adults 18-64, 2007 50% Unauthorized immigrants Lawful permanent residents 40% 30% 20% 10% 0% US CA NY TX FL NJ IL GA AZ MA VA MD WA NC Source: MPI analysis of CPS Annual Social and Economic Supplement, March 2008, augmented by assignments of legal status to noncitizens provided by Pew Hispanic Center.

Overview of the Main Affordable Care Act Provisions Medicaid coverage extended for adults with incomes up to 133% of federal poverty level Subsidies to buy private insurance up to 300% FPL State insurance exchanges Employer penalties Individual mandates

Eligibility for Medicaid and Insurance Subsidies Medicaid: Current law imposes a 5-year wait for LPR eligibility Subsidies: No waiting period Options not taken: Eliminate Medicaid waiting period Impose waiting period for subsidies

Eligibility for Medicaid and Insurance Subsidies Number affected (LPRs <5 yrs residency): Medicaid: 600,000 adults Subsidies: 550,000 adults + 90,000 children Costs of including recent LPRs: Medicaid: $6,120 per enrollee Subsidies: $4,600 - $6,000 per enrollee Cost of excluding recent LPRs: Cost-shifting to states/emergency providers Cost-shifting to future Increased premiums for US citizens

Unauthorized Population Cannot Access Exchanges Number affected: 360,000 currently buy their own insurance 6.6 million currently uninsured Costs of including unauthorized immigrants in exchanges: no direct costs Costs of excluding unauthorized: Screening costs Cost-shifting to states/emergency providers Cost-shifting to future Increased premiums for US citizens

Employer Penalties: Limited Reach Fines for employers not providing insurance Fines only imposed on firms with 50+ workers. 38% of LPRs work for firms with <25 employees (versus 28% of US born). Only 32% of LPRs in these small firms have employer coverage (versus 71% of US born). 46% of unauthorized work for these small firms. 22% of unauthorized in small firms are covered. Many immigrant workers will be uncovered

Scope of Penalties/Mandates Employer penalties may favor hiring unauthorized workers, because they are NOT in exchanges and therefore do NOT subject employers to fines. Unauthorized are exempt from mandates, but legal immigrants are subject to them. Insurance may become more unaffordable for lower-income immigrants.

Verification Issues Verification challenges Identity authentication Eligibility verification Scope of the problem Loss of coverage/delays for eligible workers Fraudulent access by the unauthorized Tools available Documents SAVE system Tax system

Verification Policy Questions Medicaid Document checks + presumptive eligibility SAVE system Subsidies + access to exchanges SAVE vs. EITC style screening Avoid additional screening Private insurance markets Avoid employer/insurer screening

Potential Impact of Supreme Court Challenge If the individual mandate is dropped No major impact on unauthorized immigrants (because ineligible) Legal noncitizen adults (LPRs) more affected than citizens because less likely to have coverage currently Naturalized citizen adults have similar coverage to US born, so equally affected Children more reliant on public coverage, less affected

Potential Impact of Supreme Court Challenge If the Medicaid expansion is dropped Legal noncitizen adults (LPRs) more affected (because lower incomes than citizens) Little impact on unauthorized immigrants If health insurance gets more expensive Legal noncitizen adults (LPRs) more affected Little impact on unauthorized immigrants If small employers drop coverage Both unauthorized and LPRs affected Affects family coverage as well as adults

Remaining Concerns for Immigrant Access to Health Care How will safety net for the uninsured fare? Will federally qualified community health center network expand, as promised? Will public hospitals continue to be reimbursed for charity care? How will partial implementation/blockage of the Affordable Care Act interact with federal/state/local budget cuts? Will Medicaid survive in its current form?

For More Information Find data, reports, and other analysis by state and for the nation: www.migrationpolicy.org and www.migrationinformation.org 2010 ACS data and new databases are coming online! www.migrationpolicy.org/datahub

For More Information Randy Capps (202) 266-1938 rcapps@migrationpolicy.org www.migrationpolicy.org