Figure 0 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Immigrants’ Health Care:...

Figure 1

K A I S E R C O M M I S S I O N O N

Medicaid and the Uninsured

Immigrants’ Health Care:Issues Related to Coverage and

Access

Dataspeak AudioconferenceMaternal and Child Health Bureau

June 13, 2002

Julie Hudman, PhD

Associate Director

Kaiser Commission on Medicaid and the Uninsured

Figure 2



Who Are the Immigrants in the United States?

Figure 3



Immigrants as a Percent of Total U.S. Population, 1850-2000

0%

4%

8%

12%

16%

1850 1860 1870 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

9.7%

14.8%

4.7%

11.2%

Note: Immigrant is defined as a person who is not a U.S. citizen who enters the U.S. with the intent to remain for an indefinite period of time. Total U.S. population in 2000 was 273 million.SOURCE: U.S. Census Bureau, 2001

Figure 4



U.S. Immigrant Population,by Region of Birth, 1900-2000

86% 83%75%

62%

39%23%

15%

11%9%

10%

9%

6%9%

19%

33%

44%51%

5% 9%19%

26%

8%

7%

4%

26%

3% 2%1% 1% 2% 3%

1900 1930 1960 1970 1980 1990 2000

10.3millio

n

14.2millio

n

9.7million

14.1million

19.8million

28.4million

Europe

Canada

LatinAmerica

Asia

Other

Note: For the 2000 data Canada was included in the other category.SOURCE: Schmidley and Gibson, 1999, Profile of the Foreign-Born Population in the U.S.: 1997, U.S. Census Bureau ;and Lollock, Lisa, 2001, The Foreign-Born Population in the U.S.: March 2000, U.S. Census Bureau.

9.6million

Figure 5



Geographical Distribution of Immigrants, 2000

California30%

Texas9%

New Jersey4%

Other30%

Illinois4%

New York13%

Florida10%

Note: An immigrant is a person who is not a U.S. citizen who enters the U.S. with the intent to remain for an indefinite period of time.SOURCE: Passel , Urban Institute from the March 2000 CPS.

Total Immigrants=28.4 million

Figure 6



Legal Status of Immigrants, 2000

Legal Permanent Residents

30%

Naturalized Citizens30%

Undocumented Aliens28%

Other5%

Refugees, Naturalized

2%Refugees, Noncitizen

5%

Total: 30.7 million immigrants

SOURCE: Passel ,Urban Institute preliminary estimates based on Census 2000, March CPS 2000, and analytic estimates.

Figure 7



Selected Employment Characteristics by Citizenship Status, 2000

61%

28%

27%

15%

84%

37%

46%

35%

26%

81%

Non-Citizen

Citizen

SOURCE: Urban Institute estimates based on March 2001 CPS data prepared for the Kaiser Commission on Medicaid and the Uninsured.

Poor

Full-time Worker

in Family

Work In Agricultural, Labor/Cleaning or Craft/

Repair

Percent of Population

Work for Small Business (<25)

Work In Managerial, Sales, Tech or Administration

Type of Work

Figure 8



What are the Programs and Policies that Affect Immigrants’

Health Care Coverage?

Figure 9



Medicaid’s Role in the Health System

• Covers the Low-Income Population – Covers 1 in 10 nonelderly Americans

– Covers 1 in 5 children (22 million)

– Pays for nearly 40% of births

– The State Children’s Health Insurance Programs (CHIP) covers an additional 3.5 million children

• Provides a Comprehensive Benefit Package– Mandatory services include inpatient hospital care, physician services, lab/x-ray

services, immunizations and EPSDT services, and family planning services

– Optional services include prescription drugs, dental care and vision care

• Improves Access to care– Improves access to physician services and preventive care

– Facilitates access to prenatal care

Figure 10



Welfare Reform’s Effects on Medicaidfor Non-Citizens

Before PRWORA

• Most persons who are legal immigrants and permanent U.S. residents are are entitled to full Medicaid coverage.

• Coverage for undocumented persons is restricted to emergency coverage only.

After PRWORA

• “Qualified immigrants” (legal permanent residents and others) who enter the country after August 22, 1996 are barred from receiving federal funding for Medicaid and CHIP for five years. After the five years, the sponsor’s income is “deemed” before determining eligibility. States may choose to deny Medicaid or CHIP to these immigrants after the five year ban.

• Coverage for undocumented persons is restricted to emergency coverage only.

• Refugees/asylees are exempt from these provisions for seven years after receiving their status.

Note: PWRORA is the Personal Responsibility and Work Opportunity Reconciliation Act of 1996.

Figure 11



State-Only Funding of Legal Immigrants arriving after August 22, 1996

1214

1817

13

Number of States

NOTE: State policies as of May 2002. Some states cover services in addition to prenatal care such as primary and preventative care for children (MA), long-term care (CA) or full Medicaid benefits (RI).SOURCE: National Immigration Law Center, 2002.

ChildrenPregnantWomen

Families/Elderly/Disabled

PregnantWomen

Separate CHIPProgram

Medicaid Medicaid Medicaid Prenatal CareRegardless of

Immigrant Status

Figure 12



How Does Immigrant Status Affect Health Coverage?

Figure 13



Health Insurance Coverage of the Low-Income Population by Citizenship Status, 2000

27%

59% 52% 57% 64%28%

15% 27% 15% 8%10%

5% 6%34%

22% 19% 22% 23%

4%2%

Citizen Non-Citizen

Children AdultWomen

Adult Men

Employer

OtherPublic/Private

Medicaid

Uninsured

70.0 9.4

Note: Low-income is less than 200% of poverty. Incomes less than 200% of federal poverty level would be less than $27, 476 for a family of three in 2000. Includes non-elderly only.SOURCE: Urban Institute estimates based on March 2000 CPS data prepared for the Kaiser Commission on Medicaid and the Uninsured.

Non-Citizens

1.9Total # in group(millions):

3.8 3.7

Figure 14



Health Insurance Coverage ofLow-Income Immigrants, 1995-2000

59%

15%

54%

19%

0%

25%

50%

75%

1995 1996 1997 1998 1999 2000

Note: Low-income is less than 200% of poverty ($27,476) for a family of three. SOURCE: Urban Institute analysis of March 1996-2001 CPS

Uninsured

Medicaid

Figure 15



Low-Income Uninsured Population by Citizenship Status, 2000

Total= 24.5 million low-income uninsured

Note: Low-income is less than 200% of poverty ($27,476) for a family of three in 2000.SOURCE: Urban Institute estimates based on March 2001 CPS data.

Noncitizen Resident 6+

Years13%

Naturalized U.S. Citizen

4%

Noncitizen Resident <6

years10%

U.S.-Born Citizen

73%

Figure 16



Health Insurance, Access and Health Status of Children, by Parents’ Immigrant Status, 1999

4%

4%

10%

9%

14%

22%

Fair/PoorHealth

No UsualSource of

Care

Uninsured

Children ofImmigrants

Children of U.S.Born Citizens

Note: Children of immigrants are defined as those with one or more foreign-born parents. 78% of children born to immigrants are U.S. born citizens. Low-income is less than 200% of FPL or $26,760 for a family of three. Data: The 1999 National Survey of America’s Families, Urban Institute. SOURCE: Capps, 2001.

Figure 17



Percentage of Uninsured Low-Income Children, by Family Citizenship Status and Language,

1999

17% 16%

26% 28% 31%

72%

Hispanic

Citizen Family

English Spanish

White, Citizen Family

Families with Mixed Citizenship Status

Non-Citizen Families

Parents’ Primary Language

Data: The 1999 National Survey of America’s Families, Urban Institute.SOURCE: Source: Ku and Waidman, How Race, Immigration Status and English Proficiency Affect Insurance Coverage and Access to Care, Forthcoming Report for the Kaiser Commission on Medicaid and the Uninsured

Figure 18



Barriers to Medicaid/CHIP Coverage for Immigrants

Eligibility:

• Legal immigrants arriving after August 1996 are barred from Medicaid/CHIP federal funds for five years,

• Eligibility for Medicaid/CHIP has limits regardless of immigrant status,

• Undocumented immigrants are ineligible for any federal public coverage except emergency care.

Enrollment:

• Immigrants face barriers to enrollment, such as:

– Language not spoken by Medicaid workers or providers,

– Discrimination by caseworkers or providers,

– Fear/misinformation about consequences of enrolling in coverage.

Figure 19



How Does Immigrant Status Affect Access to Health Care Services?

Figure 20



Usual Source of Care for Low-Income Adults by Citizenship Status, 1997

31%32%

4%

32%

43%

32%

6%

19%20%

38%

4%

37%

Doctor's Office Clinic Emergency Room None

Non-Citizen Naturalized Citizen Native Citizen

Note: Low-income is less than 200% of poverty or $26,660 for a family of three in 1997.Data: National Survey of America’s Families, Urban Institute. Source: Ku and Matani, 2000.

Figure 21



Health Care Utilization for Low-Income Children, by Citizenship Status, 1997

3.7

0.7

1.5

0.9

3.1

0.5

1.3

0.2

1.5

0.2

1.2

0.1Non-Citizen Child and Adult

Citizen Child/Non-CitizenAdult

Citizen Child and Adult

Note: Low-income is less than 200% of poverty or $26,660 for a family of three in 1997.Data: National Survey of America’s Families, Urban Institute.Source: Ku and Matani, 2000.

Provider Visits

Emergency Room Visits

Dental Visits

Mental Health Visits

Average Number of Visits Per Year

Figure 22



Low-Income Children with a Doctor Visit in the Last Year, by Family Citizenship Status and

Language, 1999

71% 74% 73% 71%

59%

29%

Hispanic

Citizen Family

English Spanish

White, Citizen Family

Families with Mixed Citizenship Status

Non-Citizen Families

Parents’ Primary Language

Data: The 1999 National Survey of America’s Families, Urban Institute.SOURCE: Source: Ku and Waidman, How Race, Immigration Status and English Proficiency Affect Insurance Coverage and Access to Care, Forthcoming Report for the Kaiser Commission on Medicaid and the Uninsured

Figure 23



Key Issues Facing Immigrant Populations

• Changes in where immigrants come from and where they settle;

• Lack of health care coverage;

• Barriers to accessing health care services;

• Policies treating new immigrants differently;

• Constantly changing political environment and economy.

Figure 0 K A I S E R C O M M I S S I O N O N Medicaid and the Uninsured Immigrants’ Health Care:...

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