The Patchwork System of
Public Insurance Coverage
for Immigrants
Leighton Ku, PhD, MPH
ku@cbpp.org
AcademyHealth, Orlando, June 2007
What Share of the Uninsured Are
Immigrants?
Naturalized
Citizens
5%
Native-born
Citizens
74%
Source: March 2006 CPS
Non-citizen
Immigrants
21%
Immigrants & Uninsured Immigrants Are
Mostly Working Age Adults
100%
12%
5%
0.1 mil
83%
8.3
mil.
12%
1.0 mil.
Non-citizens
Uninsured Noncitizens
80%
60%
60%
40%
20%
28%
0%
Native-born
Source: CPS, March 2006
Elderly
Adults
Children
Almost Half of All Non-citizen Immigrants Are
Uninsured
Native-born
Citizens
Non-Citizen
Immigrants
0%
Uninsured
20%
Medicaid/SCHIP
40%
Other Public
60%
80%
Employer-sponsored
Source: March 2005 Current Population Survey
100%
Other Private
Public Programs Serve Small Fraction of Lowincome Immigrants (Below 200% Poverty)
Native-born
Citizens
Non-Citizen
Immigrants
0%
Uninsured
20%
Medicaid/SCHIP
40%
Other Public
60%
80%
Employer-sponsored
Source: March 2005 Current Population Survey
100%
Other Private
Complex Medicaid/SCHIP Eligibility Rules
• Medicaid usually not available for childless adults.
• Citizens fully eligible, including naturalized and USborn citizen children.
• Lawful permanent residents (LPRs) not fully eligible
during 1st five years in US, but:
– Refugees and asylees eligible for 1st seven years in
US. Veterans, etc. eligible.
– Many states use state funds to cover immigrants
during 5 year bar in Medicaid or SCHIP.
• Undocumented and other immigrants eligible for
emergency Medicaid coverage, including child birth.
Barriers to Participation
• Participation low even among eligible
immigrants (or citizen children of immigrants)
• Lack of knowledge
• Lack of language assistance during enrollment
• Confusion and fear about rules
• Medicaid citizenship documentation
• Community outreach can help, but outreach
funds have been limited in recent years.
Immigrant Growth Among States, 1990-2005
NH
VT
WA
ME
ND
MT
MN
OR
ID
SD
WI
MI
RI
WY
PA
IA
NE
NE
NV
CO
CA
KS
WV
VA
NC
AZ
OK
NM
TN
TX
AK
AL
DC
SC
AR
MS
DE
MD
KY
MO
CT
NJ
OH
IN
IL
UT
MA
NY
GA
LA
FL
HI
Traditional High Migrant States (11 + DC)
(above US avg in 1990)
New Growth States (27)
(# immigrants at least doubled 1990-2005)
Substantial State Coverage of LPR Children, 2007
WA*
ME*
MN*
NY*
PA*
NE
NE*
IL*
CA*
VA*
MA*
RI*
CT *
NJ*
DE *
MD*
DC *
TX *
HI *
11 Traditional Migrant States
*Coverage (10 + DC)
No Coverage (1)
FL*
27 New Growth States
*Coverage (6)
No Coverage (21)
12 Other States
*Coverage (2)
No Coverage (10)
Source: Cox, forthcoming Kaiser Commission on Medicaid and the Uninsured report
Substantial State Coverage of LPR Parents, 2007
WA*
ME*
MN*
NE
NE*
CA*
11 Traditional Migrant States
*Coverage (5 + DC)
No Coverage (6)
Source: Cox, forthcoming
NY*
PA*
MA*
CT *
NJ*
DE *
DC *
27 New Growth States
*Coverage (4)
No Coverage (23)
12 Other States
*Coverage (2)
No Coverage (10)
Source: Cox, forthcoming Kaiser Commission on Medicaid and the Uninsured report
Medicare Eligibility
• Non-citizens less likely to be elderly. Many
immigrants return to home country when elderly.
• LPRs and refugees eligible for Medicare, same as
citizens.
– If have less than 40 quarters of work, may buy into
Part A.
• Legally present “non-qualified” eligible if they had at
least 40 quarters of authorized work.
• Undocumented ineligible.
Other Public Care
• Sec. 1011 – to cover costs of uncompensated
emergency care for uninsured, undocumented aliens.
Underused. EMTALA requires basic emergency
treatment for all.
• Health centers – all immigrants eligible for free or
subsidized care at federally-funded health centers.
• Public & nonprofit hospitals & clinics often offer free
or subsidized charity care, but sometimes eligibility
for undocumented is limited due to state or local
rules.
Average Annual Medical Expenditures for NonElderly Adults by Type, Los Angeles County
$3,500
$3,000
$2,500
$2,963
52%
$2,340
$2,000
58%
$1,760
$1,500
$1,000
46%
41%
28%
$500
$0
$1,341
20%
Native-born
Citizen
20%
23%
23%
22%
30%
36%
Naturalized
Citizen
Out of Pocket
Legal Perm
Resident
Public
Undocumented
Private
Source: Adapted from Goldman, Smith and Sood. Health Affairs 2006
Potential Federal Policies
• Could include option to cover LPR children and
pregnant women during SCHIP reauthorization.
• Comprehensive immigration reform??
• May include a long pathway to earned legal status &
citizenship and stronger immigration enforcement.
Effect on public coverage modest and slow.
• Legal status and reduced flow of immigrants may
lead to better jobs and increased private coverage.
• Binational insurance could reduce private insurance
costs in border areas for legally present immigrants.
Potential State Actions
• Immigration volatile issue in many states. Usually not
a visible issue in state health reforms.
• Some expansions presented as “all kids” proposals, as
in Illinois or California counties.
• Mixed story in broader health coverage expansions.
• Proposals to expand coverage by diverting DSH or
UPL funds may impair safety net for immigrants.
• State or local anti-immigrant laws could cause access
problems for undocumented and other immigrants.
But It’s Not Just Coverage…
• Even when insured, immigrants have less access to
care and receive poorer quality care due to language
barriers.
• Federal civil rights policies require free interpretation
for LEP, but no funding stream and little enforcement.
• HRET: Only 3% of hospitals get any reimbursement
for interpretation, from Medicaid.
• Potential for language reimbursement (Medicare,
Medicaid, private insurance).
Questions for the Future
• What are costs of uncompensated care and of statefunded coverage for immigrants?
• How can we improve enrollment among eligible
immigrants or access among insured immigrants?
• Quality of care for immigrants? More hospitalization
for ambulatory-sensitive conditions?
• How do immigrants’ health coverage, utilization and
cost change over time? What are effects of changes
in immigration status?
• How can public perceptions of immigrants be
improved?