Undocumented and Uninsured Barriers to Affordable Care for Immigrant Populations Steven P. Wallace, Jacqueline M. Torres, Tabashir Z. Nobari, and Nadereh Pourat UCLA Center for Health Policy Research AUGUST 2013 The Commonwealth Fund, among the first private foundations started by a woman philanthropist—Anna M. Harkness—was established in 1918 with the broad charge to enhance the common good. The mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. The UCLA Center for Health Policy Research is one of the nation’s leading health policy research centers and the premier source of health policy information for California. The Center improves the public’s health by advancing health policy through research, public service, community partnership, and education. UNDOCUMENTED and UNINSURED Barriers to Affordable Care for Immigrant Populations Steven P. Wallace, Jacqueline M. Torres, Tabashir Z. Nobari, and Nadereh Pourat UCLA CENTER FOR HEALTH POLICY RESEARCH AUGUST 2013 Abstract: The Affordable Care Act will significantly reduce the number of U.S. resi- dents without health insurance and ensure appropriate access to health services, but the law specifically excludes one group from all its provisions: the approximately 11 million undocumented immigrants residing in this country. Research nationally—and new data from California—show that undocumented residents are most often young, working adults who are in good health but infrequently use health services. Projections show the health reform law will have little impact on health insurance coverage for such individuals, and excluding them from coverage under the law will create new finan- cial pressures on safety-net hospitals. Strategies for improving coverage and access for undocumented immigrants include: providing comprehensive insurance coverage to some or all undocumented immigrants; providing coverage for specified services; and decreasing the out-of-pocket health care costs of undocumented immigrants by increasing direct funding to providers who offer free or low-cost services. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. To learn more about new publications when they become available, visit the Fund’s website and register to receive email alerts. Commonwealth Fund pub. 1699. CONTENTS ABOUT THE AUTHORS......................................................................................................................................... 6 ACKNOWLEDGMENTS.......................................................................................................................................... 6 EXECUTIVE SUMMARY.......................................................................................................................................... 7 INTRODUCTION................................................................................................................................................... 9 TRENDS AND DATA NATIONALLY AND IN CALIFORNIA.................................................................................... 9 HEALTH INSURANCE RATES AMONG UNDOCUMENTED IMMIGRANTS WILL REMAIN LARGELY UNCHANGED AFTER AFFORDABLE CARE ACT IMPLEMENTATION.................................................12 POLICY LESSONS FROM HOME AND ABROAD................................................................................................12 ABOUT THIS STUDY.............................................................................................................................................15 NOTES..................................................................................................................................................................16 LIST OF EXHIBITS EXHIBIT 1 LABOR FORCE PARTICIPATION RATES, POVERTY RATES, AND UNINSURANCE RATES, CALIFORNIA RESIDENTS AGES 18 TO 64, BY CITIZENSHIP AND IMMIGRATION STATUS (UNADJUSTED), 2009 EXHIBIT 2 HEALTH CONDITIONS AND HEALTH BEHAVIORS, CALIFORNIA RESIDENTS AGES 18 TO 64, BY CITIZENSHIP AND IMMIGRATION STATUS, ADJUSTED FOR AGE AND GENDER, 2009 EXHIBIT 3 HEALTH CARE ACCESS AND UTILIZATION, CALIFORNIA RESIDENTS AGES 18 TO 64, BY CITIZENSHIP AND IMMIGRATION STATUS, ADJUSTED FOR AGE AND GENDER, 2009 EXHIBIT 4 PERCENT OF UNDOCUMENTED IMMIGRANTS UNDER AGE 65 WITHOUT HEALTH INSURANCE, SELECTED STATES AND U.S., 2012 AND 2016 PROJECTIONS ABOUT THE AUTHORS Steven P. Wallace, Ph.D., is associate director of the UCLA Center for Health Policy Research and professor and chair of the department of community health sciences at UCLA Fielding School of Public Health. He has conducted research on immigrant incorporation and access to health care for almost 30 years, beginning with his study on the Immigration Reform and Control Act of 1986. He also leads several studies of the impact of state health policies on vulnerable populations. Wallace has a Ph.D. in sociology from the University of California, San Francisco. He can be emailed at swallace@ucla.edu. Jacqueline M. Torres, M.A., M.P.H., is a graduate student researcher at the UCLA Center for Health Policy Research. She is conducting research on the effect of migration on the health of older Mexicans, and has published on the effect of immigration stress on the health of Latino immigrants in the United States. Torres has an M.A. in Latin American Studies and an M.P.H. in Community Health Sciences from UCLA. Tabashir Z. Nobari, M.P.H., was a graduate student researcher at the UCLA Center for Health Policy Research. Her research interest is the nutritional outcomes of immigrants and low-income populations, and she has published on the effect of immigrant enclaves on obesity among very young children in Los Angeles County. Nobari has an M.P.H. in international epidemiology from the University of Michigan. Nadereh Pourat, Ph.D., is professor of health policy and management at the UCLA Fielding School of Public Health and director of research at the UCLA Center for Health Policy Research. Her research interests include disparities in access to health care for underserved populations such as undocumented, elderly, and the uninsured; implementation and outcomes of patient-centered medical home; safety-net system integration and care delivery challenges; long-term care services; and oral health care. She has a Ph.D. in health services from UCLA. ACKNOWLEDGMENTS The authors gratefully acknowledge reviewer comments from Sonal Ambegaokar, Frank Bean, Max Hadler, Manuel Pastor, Beatriz Solis, and Arturo Vargas Bustamante. This Fund issue brief was drawn from a longer report, which contains both adjusted and unadjusted California data and extensive citations to the literature, available at http://healthpolicy.ucla.edu/publications/search/pages/detail. aspx?PubID=1194. Editorial support was provided by Deborah Lorber. 6 UNDOCUMENTED AND UNINSURED EXECUTIVE SUMMARY Estimates presented in this report show that The Affordable Care Act will significantly reduce the the health reform law will have little impact on the number of U.S. residents without health insurance to coverage of undocumented residents. Nationally, an ensure appropriate access to health services, but the law estimated three-fifths (61.5%) of nonelderly adults specifically excludes one group from all its provisions: who are undocumented immigrants are expected to the approximately 11 million undocumented immi- remain uninsured. As a result, undocumented residents grants residing in this country. will make up a larger share of the remaining uninsured In California, where almost one-quarter of the population in the country. In states with the highest nation’s undocumented immigrants reside, data show concentration of undocumented immigrants, such as that, as compared with lawful permanent residents California, they will account for up to two-fifths of all (LPRs), naturalized citizen immigrants, and U.S.-born remaining uninsured residents. nonelderly adults, undocumented immigrants: Undocumented residents are concentrated in a small number of states. As a result, safety-net hospi- • have the highest male labor force participation tals in those states will be particularly affected by the (95%); reduction in disproportionate share hospital (DSH) • are younger (90% are between ages 18 and 44); payments scheduled under the Affordable Care Act • are more likely to live in families with children that have previously cushioned the impact of providing (61%); uncompensated care. Many hospitals are expected to • have the highest rates of poverty (57%); and have a lower uncompensated care burden as a result of fewer uninsured patients, but those with a large propor- • have the highest rate of being uninsured (51%). tion of undocumented immigrants may not experience the increase in insured patients that would otherwise be When statistically controlling for age and gen- expected. der, undocumented residents of California have a health Despite being in working families, most undoc- profile that is generally similar to U.S.-born residents. umented immigrants are not covered by health insur- Undocumented immigrants report the lowest rates of ance and face significant access-to-care barriers. Policy asthma but the highest rates of obesity and being over- innovations for undocumented residents from around weight. This is significant since obesity and being over- the United States and internationally provide examples weight increase the risk of diabetes, hypertension, and of how access to health care can be improved. These other conditions where timely access to medical care is include: essential. • expanding insurance options to undocumented Access to health care in California is signifi- residents, either directly as in Vermont’s proposed cantly worse for undocumented immigrants, even after single-payer system, or indirectly through increased controlling for age and gender. Compared with LPRs, employer coverage; naturalized citizen immigrants, and U.S.-born non- elderly adults, undocumented immigrants: • increasing access to specific high-value services through low-cost or free care to those without • have the highest rate of having no usual source of health insurance; and care (35%); • maintaining or increasing subsidies to safety- • are the least likely to have seen a doctor in the past net providers in communities with a high year (28%); and number of immigrants to allow them to provide • are the least likely to have used an emergency uncompensated or low-cost services to all persons department in the past year (12%). without health insurance. www.commonwealthfund.org7 The Affordable Care Act’s goal of affordable, quality health care for all will not be achieved unless policies also assist the country’s approximately 11 mil- lion undocumented residents. Helping improve access to care or health insurance coverage is an investment in maintaining the good health of this population and will also stabilize the financial viability of safety-net providers who are essential to the residents of their communities. 8 UNDOCUMENTED AND UNINSURED UNDOCUMENTED AND UNINSURED: BARRIERS TO AFFORDABLE CARE FOR IMMIGRANT POPULATIONS INTRODUCTION are somewhat less likely to be from Central or South The Affordable Care Act aims to provide affordable, America and Africa. quality health care for all Americans and reduce the growth in health care spending. The law improves Undocumented Immigrants Are Primarily access to coverage by expanding eligibility for the Young Adults in Working Families with Low Medicaid program, providing subsidies for middle- Incomes and Low Rates of Health Insurance income individuals to help buy individual insurance Nationally, undocumented immigrants are younger policies, and creating financial incentives for employ- than other immigrant groups and the U.S.-born adult ers to offer health insurance. However, despite efforts population. In 2009, the median age of undocumented to cover the entire population, the law explicitly bars immigrant adults was 35.5 years, compared with 45.9 undocumented residents from all of its provisions. for legally residing immigrant adults and 46.3 for U.S.- Furthermore, immigrants in two categories—those born adults.3 In California, nearly 90 percent of non- with “deferred action” status or those with registered elderly adult undocumented immigrants in 2009 were provisional immigrant status (both discussed later in between 18 and 44 years old, compared with only 40 this report)—are also excluded from receiving health percent of nonelderly adult U.S.-born citizens. insurance coverage under the law’s health exchanges or Undocumented immigrants are often mem- public benefits expansions.1 As a result, the Affordable bers of “mixed-status” families that include U.S.-born Care Act will not benefit the approximately 11 mil- children. An estimated 5.5 million children of undocu- lion undocumented residents in the United States and mented immigrants lived in the United States in their families, as well as the health care providers they 2009, the majority of whom (73%) were U.S.-born.4 rely upon. In addition to providing nationwide data, In California, 61 percent of undocumented adult resi- this report focuses on the state with the largest number dents lived in families with children, compared with 32 of undocumented residents, California. It reports on percent of U.S.-born residents.5 U.S.-citizen children the health status and health usage of undocumented of undocumented immigrants are eligible for all public immigrants and suggests policy alternatives that could programs, but often face barriers to health care because improve their access to health care. of concerns that undocumented family members might be identified and reported to immigration authorities as the result of their children’s participation.6 TRENDS AND DATA NATIONALLY AND Undocumented immigrants are heavily engaged IN CALIFORNIA in the labor force. Nationally, undocumented immi- Few national studies provide information beyond grants accounted for 5.7 percent of the labor force the number and general characteristics of undocu- in 2010 although they composed only 3.7 percent of mented immigrants. With almost one-quarter of all the U.S. population.7 In California, undocumented undocumented immigrants living in California,2 the immigrant men ages 18 to 64 had the highest labor California Health Interview Survey provides a unique market participation rate of any group (Exhibit 1). data source on the health status and health care use of Undocumented immigrants pay a variety of taxes, mak- undocumented immigrants. Undocumented residents ing contributions at local, state, and federal levels. Those in California are more likely to be from Mexico than who receive registered provisional immigrant (RPI) undocumented immigrants nationally (70% v. 58%) and status under proposed immigration reform bills will be required to pay any back taxes owed.8 www.commonwealthfund.org9 Despite high levels of participation in the labor when data are adjusted for age and gender (Exhibit 2). force, undocumented immigrants have disproportion- The observed (i.e., unadjusted) rates of diabetes and ately low incomes. In California, over half (57%) of high blood pressure are much lower for undocumented undocumented immigrant adults were living in house- nonelderly adults (4.4% and 14.1%, respectively), holds with incomes below the federal poverty level in given their younger age distribution (data not shown). 2009,9 a rate five times higher than the approximately Asthma rates are lower for undocumented nonelderly 11 percent of U.S.-born and naturalized citizens adults compared with U.S.-born and naturalized citi- (Exhibit 1). zens, as well as immigrants with LPR status (Exhibit 2). Undocumented immigrant adults are gener- Undocumented immigrants report similar or ally not eligible for Medi-Cal, California’s Medicaid better health behaviors as U.S.-born or other immigrant program, and disproportionately work in industries that groups in studies nationally. In California, adjusted have low rates of employer-provided health insurance smoking rates of undocumented immigrants (10.9%) (e.g., construction). As a result they have the highest are lower than that of U.S.-born citizens and lawful rates of uninsurance; 51 percent were uninsured com- permanent residents (14.5% and 11.3%, respectively). pared with 34 percent for immigrants with lawful per- Overweight/obesity is common across all groups, manent residency (LPR) status (Exhibit 1). although undocumented immigrants have the high- est rates of all immigrant groups in California (Exhibit Health of Undocumented Immigrants Is 2). While the overall health status of undocumented Similar to Other Immigrant and U.S.-Born immigrants is favorable, overweight and obesity leads to Groups increased risk of diabetes, hypertension, and other con- Studies from around the country consistently show that ditions where timely access to medical care is essential. undocumented immigrants have similar or better levels of health compared with U.S.-born citizens, naturalized Undocumented Immigrants Experience citizens, and immigrants with LPR status. Significant Barriers to Access to Care The trend is similar in California. The health Maintaining the relatively good health status of undoc- status of the nonelderly adult undocumented resident umented immigrants requires adequate access to health population is quite good. The diabetes and high blood care. Nationally, studies have found that undocumented pressure rates of undocumented nonelderly adults (9.2% immigrants have substantially lower access to health and 24.8%, respectively) appear similar to other groups, EXHIBIT 1. LABOR FORCE PARTICIPATION RATES, POVERTY RATES, AND UNINSURANCE RATES, CALIFORNIA RESIDENTS AGES 18 TO 64, BY CITIZENSHIP AND IMMIGRATION STATUS (UNADJUSTED), 2009 U.S.-born Naturalized citizen Lawful permanent Undocumented Percent resident immigrant 100 95.0 80 89.5 91.0 84.7 60 56.6 51.3 40 31.6 33.6 20 16.7 17.8 11.2 11.5 0 Labor market (men only) < 100% of federal poverty level Uninsured Source: California Health Interview Survey, 2009. 10 UNDOCUMENTED AND UNINSURED EXHIBIT 2. HEALTH CONDITIONS AND HEALTH BEHAVIORS, CALIFORNIA RESIDENTS AGES 18 TO 64, BY CITIZENSHIP AND IMMIGRATION STATUS, ADJUSTED FOR AGE AND GENDER, 2009 6.7 9.0 Diabetes 15.7 9.2 U.S.-born 26.5 Naturalized citizen 25.1 Lawful permanent resident High blood pressure 25.2 24.8 Undocumented immigrant 16.3 7.9 Asthma 5.4 3.2 14.5 8.6 Current smoker 11.3 10.9 61.3 52.4 Overweight/Obesity 58.3 66.9 0 20 40 60 80 100 Percent Note: Overweight/Obesity defined as having a body mass index of 25 or higher. Source: California Health Interview Survey, 2009. care and use fewer health care services than their U.S.- Limited Safety-Net System Provides a Porous born and other immigrant counterparts. Patchwork of Services But Leaves Major Gaps In California, nonelderly undocumented adults in Care were more than twice as likely to report having no usual Under current laws, Medicaid covers low-income, source of care as U.S.-born and naturalized citizens undocumented individuals for life-saving emergency of similar ages and genders. Similarly, undocumented care, labor and delivery, and, in some states, dialysis for immigrants were almost twice as likely to report mak- end-stage renal disease.10 Many states do not cover pre- ing no past-year doctor visits as U.S.-born residents. natal care,11 outpatient dialysis services, or life-saving Despite having no usual source of care and reporting chemotherapy.12 Limited disease-specific screening and significantly fewer doctor visits than their U.S.-born treatment is also available, regardless of immigration and naturalized citizen counterparts, undocumented status.13 Most safety-net clinics provide free or low-cost immigrants were the least likely to have used an emer- primary care services to all uninsured persons based on gency department in the past year (Exhibit 3). their ability to pay, regardless of immigration status. When undocumented immigrants do visit the Prenatal care regardless of immigration status is doctor, they often face high out-of-pocket costs since available in some states through the Children’s Health over half do not have health insurance coverage. Among Insurance Program (CHIP), which was reauthorized Californians who reported having medical bills, 42 under the Affordable Care Act through 2015. Local- percent of undocumented immigrants said they were level initiatives, such as the Los Angeles Healthy Kids unable to pay for basic necessities because of these bills, program, offer health insurance coverage to all low- a significantly higher proportion than the 27 percent of income children who are not eligible for other coverage, U.S.-born citizens who reported similar problems (data including undocumented children, but do not cover all not shown). www.commonwealthfund.org11 EXHIBIT 3. HEALTH CARE ACCESS AND UTILIZATION, CALIFORNIA RESIDENTS AGES 18 TO 64, BY CITIZENSHIP AND IMMIGRATION STATUS, ADJUSTED FOR AGE AND GENDER, 2009 U.S.-born Naturalized citizen Lawful permanent Undocumented Percent resident immigrant 60 40 34.7 31.9 28.4 20 23.2 19.1 19.3 15.1 15.6 15.3 15.4 16.1 12.2 0 No usual source of care No doctor visit in past year Emergency deparment visit in past year Source: California Health Interview Survey, 2009. eligible children because of high demand and limited immigrants is not projected to change significantly. The funding.14 highest rates of uninsurance will be in North Carolina Whether insured or not, immigrants and their and Texas and the lowest rates in New York and families face a number of other barriers to adequate California (Exhibit 4). health care, including language, transportation, and Because the number and proportion of undocu- concerns about immigration authorities.15 mented immigrants without health insurance are not projected to change much, these individuals will make up a larger share of the shrinking group of U.S. resi- HEALTH INSURANCE RATES AMONG dents who remain uninsured after the law is fully imple- UNDOCUMENTED IMMIGRANTS mented. Assuming full implementation of Medicaid WILL REMAIN LARGELY UNCHANGED expansion by all states, undocumented immigrants are AFTER AFFORDABLE CARE ACT estimated to account for 24.5 percent of the remain- IMPLEMENTATION ing uninsured population in the United States by 2016, Undocumented immigrants are likely to experience up from 9.5 percent in 2012. This figure is higher in little change in coverage under the health reform law. states with large undocumented immigrant populations. They will be excluded from Medicaid expansions and Undocumented immigrants will account for up to two- cannot purchase insurance through the exchanges, fifths (41%) of the remaining uninsured in California even with their own money at full price. While some and at least a third of the uninsured population in employers may be motivated to add insurance benefits, Arizona, Florida, North Carolina, and Texas. others are expected to drop current coverage. The net effect is estimated to be a negligible increase in health insurance coverage of undocumented immigrants. POLICY LESSONS FROM HOME According to estimates based on a simulation model, AND ABROAD three-fifths (61.5%) of the undocumented immigrant Undocumented immigrant adults tend to be relatively population nationwide will remain uninsured in 2016. young, healthy, and in the labor force; however, they This model predicts a small increase in employer-spon- are also more likely to live in poverty and be uninsured sored coverage for undocumented immigrants under the compared with either legal immigrants or U.S-born law, from 25 percent in 2012 to 25.5 percent in 2016. populations. Because of a lack of affordable coverage The proportion of uninsured undocumented residents options for undocumented immigrants, hospitals and in states with the largest numbers of undocumented 12 UNDOCUMENTED AND UNINSURED EXHIBIT 4. PERCENT OF UNDOCUMENTED IMMIGRANTS UNDER AGE 65 WITHOUT HEALTH INSURANCE, SELECTED STATES AND U.S., 2012 AND 2016 PROJECTIONS Percent uninsured 2012 2016 100 80 79.8 80.0 60 74.0 74.3 72.9 72.8 68.3 69.2 61.0 61.5 57.0 58.5 40 50.1 52.1 20 0 North Carolina Texas Georgia Florida California New York NATIONAL Source: Gruber MicroSimulation Model (GMSIM), 2012. individual providers are often left with uncompensated Mexico while providing coverage of primary care in care costs when they provide necessary treatment.16 the United States. The policies are designed to cost less After the Affordable Care Act is fully imple- than those providing comparable coverage only in the mented, safety-net hospitals may face additional chal- U.S. Binational policies could decrease the financial lenges to providing life-saving care because of sched- barriers to purchasing insurance for some currently uled cuts in disproportionate share hospital (DSH) pay- undocumented immigrants during the registered pro- ments that were designed to help safety-net hospitals visional immigrant (RPI) phase that occurs before they cover the costs of uncompensated care for all uninsured gain lawful permanent resident (LPR) status. patients. While the total number of uninsured persons will decline under the law, the majority of undocu- POSSIBLE OPTIONS FOR IMPROVING HEALTH mented immigrants will have little choice but to depend CARE ACCESS FOR THE UNDOCUMENTED on safety-net hospitals for care.17 • Provide comprehensive insurance coverage to Undocumented immigrants will constitute some or all undocumented immigrants. a significant proportion of the remaining uninsured • Provide coverage for specified services. population and their concentration in a small number • Decrease out-of-pocket health care costs by of states and localities places an uneven burden on the increasing direct funding to providers that offer safety-net facilities in those areas. The United States is free or low-cost services. not the only country facing these issues. A recent survey • Allow binational insurance coverage that preferentially pays for high-cost services to be of European countries18 illustrates policy approaches performed in Mexico, while providing coverage of that would improve access to care for undocumented primary care in the United States. immigrants and assist providers who face uncompen- sated care burdens. These include: providing com- prehensive insurance coverage to some or all undocu- Reducing the number of undocumented immi- mented immigrants; providing coverage for specified grants through federal immigration reform would even- services; and decreasing the out-of-pocket health care tually ameliorate many of the issues discussed in this costs of undocumented immigrants by increasing direct report. Certain reform proposals would grant undocu- funding to providers who offer free or low-cost services. mented immigrants RPI status, which would provide In addition, immigration reform offers the opportunity applicants with a status that allows them to work legally to allow binational insurance coverage that preferen- and the potential to move out of poverty. This, in turn, tially pays for high-cost services to be performed in is likely to improve health outcomes in the long term. www.commonwealthfund.org13 However, such proposals would also bar immigrants of the United States that offer coverage without regard who are on the path to citizenship from public benefits to immigration status.23 such as Medicaid or CHIP for as long as 10 years, pos- Another alternative is to allow undocumented sibly causing health care problems to persist or worsen. state residents to purchase insurance in their state In addition, individuals who have obtained “deferred health benefit exchange without subsidies. Current law action” status under the Deferred Action for Children excludes undocumented immigrants from purchasing of Arrivals (DACA) Initiative have been excluded policies through exchanges even with their own funds. from public benefits. Individuals who are eligible for Some states, including California, require insurers in DACA are those who are undocumented but arrived the exchange to offer the same policies with similar pre- in the United States as children; under DACA they are miums outside the exchange, which will expand options allowed to remain lawfully present and work in the U.S. for health insurance coverage for undocumented However, neither DACA nor RPI residents are eligible immigrants. to purchase health insurance coverage through the An additional approach is to create low- or exchanges created under the health care reform law.19 no-cost insurance for a limited set of services for those If those with RPI status are allowed to leave the not otherwise covered by insurance. The services could U.S. for medical care without it affecting their appli- cover high-value care,24 such as coverage for chronic cation, binational health insurance offered in Mexico disease management or clinical preventive services that would be an option for this largest group of undocu- are required benefits under the Affordable Care Act. It mented immigrants.20 Receiving care in Mexico is not is likely that this coverage would save money in the long practical for most primary care, particularly for those run by helping young, healthy immigrants avoid health not residing in Southwestern communities, but the problems and maintain general good health. Along low cost of coverage could significantly reduce out-of- these lines, the National Breast and Cervical Cancer pocket costs for many diagnostic and nonemergency Early Detection Program provides resources to detect services. and treat cancer early in uninsured women, which helps Since immigration reform is unlikely to reduce to save lives and money. the number of currently undocumented and uninsured The last approach is to directly provide low- individuals, policymakers must consider other possible cost care, rather than insurance, to reduce the access solutions.21 One approach is to provide insurance to all barrier created by high out-of-pocket costs. Increased residents, regardless of immigration status. Vermont, funding under the health reform law for community for example, is proposing to institute a single-payer health centers (CHCs) helps accomplish this for pri- health care system under the Affordable Care Act that mary care because CHCs charge fees that vary with will cover all state residents without regard to their patients’ incomes and are already a common source of immigration status. The proposal includes using state care for all uninsured persons. Even with the increases, funds to provide free or subsidized coverage as needed though, funding for CHCs may not be sufficient to for undocumented residents.22 Alternatively, the federal cover expanded need for care. People may remain government could require employers to offer insurance, with their CHC, if it is one of few providers in a low- as is currently the case in Hawaii. Since employment income area, and these newly insured individuals may rates are very high among undocumented adults, this be more likely to use health care services. This surge would result in higher coverage rates for undocumented in demand could overwhelm CHCs’ ability to provide employees and their families. Or, low- or no-cost insur- care and crowd out those without insurance. In addi- ance coverage could be provided to some categories of tion, low-cost access to specialist and hospital care, and low-income individuals, like children. Undocumented sometimes even basic laboratory and diagnostic services, children have benefitted from programs in some parts would continue to be limited. The burden on safety-net 14 UNDOCUMENTED AND UNINSURED hospitals for providing emergency services to undocu- mented immigrants could be ameliorated by targeted special funding for facilities serving large numbers of immigrants, such as that provided in the Balanced Budget Act of 1997 and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.25 The Affordable Care Act’s goal of affordable, quality health care for all will not be achieved unless policies also assist the country’s approximately 11 mil- lion undocumented residents. Helping improve access to care or health insurance coverage is an investment in maintaining the good health of this population and will also stabilize the financial viability of safety-net providers who are essential to the residents of their communities. ABOUT THIS STUDY Original data are from a special run of the Gruber MicroSimulation Model (GMSIM) and from the 2009 California Health Interview Survey (CHIS 2009). CHIS 2009 interviewed 44,567 adults from households in every county in California, including 1,515 who were likely undocumented immigrants. Interviews were conducted in English, Spanish, Chinese (Mandarin and Cantonese), Vietnamese, and Korean. More information on the GMSIM and the calculation of undocumented immigrant respondents to the CHIS is available in a methodological appendix at http://healthpolicy. ucla.edu/publications/search/pages/detail.aspx?PubID=1194. CHIS is conducted by the UCLA Center for Health Policy Research in collaboration with the California Department of Public Health, the Department of Health Care Services, and the Public Health Institute. For more information on CHIS, visit http://healthpolicy.ucla.edu/chis. www.commonwealthfund.org15 13 NOTES Centers for Disease Control and Prevention, 1 "Breast and Cervical Cancer Prevention and National Immigration Law Center, “Frequently Treatment Act of 2000," National Breast and Asked Questions: Exclusion of People Granted Cervical Cancer Early Detection Program (Atlanta, ‘Deferred Action for Childhood Arrivals’ from Ga.: CDC, 2011), available at http://www.cdc.gov/ Affordable Health Care” (Los Angeles, Calif.: cancer/nbccedp/legislation/law106-354.htm. National Immigration Law Center, 2012; revised 14 Nov. 26, 2012), available at http://www.nilc.org/ E. M. Howell, L. Dubay, and L. Palmer, The Impact acadacafaq.html. of the Los Angeles Healthy Kids Program on Access to 2 Care, Use of Services, and Health Status (Washington, J. S. Passel and D. Cohn, Unauthorized Immigrant D.C.: The Urban Institute, Jan. 2008). Population: National and State Trends, 2010 15 (Washington, D.C.: Pew Hispanic Center, Feb. B. H. Gray and E. van Ginneken, Health Care for 2011). Undocumented Migrants: European Approaches 3 (New York: The Commonwealth Fund, Dec. 2012). J. S. Passel and P. Taylor, Unauthorized Immigrants 16 and Their U.S.-Born Children (Washington, D.C.: K. Sack, "Hospital Falters as Refuge for Illegal Pew Hispanic Center, Aug. 2010). Immigrants," New York Times, Nov. 20, 2009, p. A1. 4 17 Passel and Cohn, Unauthorized Immigrant Kaiser Family Foundation, "Summary of the Population, 2011. Affordable Care Act" (Menlo Park, Calif.: The Henry 5 J. Kaiser Family Foundation, 2011; updated April 23, Data from the 2009 California Health Interview 2013). Survey, not shown on tables; see http://healthpol- 18 icy.ucla.edu/chis. Gray and van Ginneken, Health Care for 6 Undocumented Migrants, 2012. K. M. Perreira, R. Crosnoe, K. Fortuny et al., 19 Barriers to Immigrants’ Access to Health and Human National Immigration Law Center, "Frequently Services Programs (Washington, D.C.: Office of the Asked Questions," 2012. Assistant Secretary for Planning and Evaluation, 20 Office of Human Services Policy, U.S. Department M. A. González Block, A. Vargas Bustamante, L. A. of Health and Human Services, May 2012). de la Sierra et al., "Redressing the Limitations of the Affordable Care Act for Mexican Immigrants 7 Passel and Cohn, Unauthorized Immigrant Through Bi-National Health Insurance: A Population, 2011. Willingness to Pay Study in Los Angeles," Journal of 8 Immigrant and Minority Health, e-published ahead J. Preston, "Readers Have Questions, Too, on a of print Sept. 2, 2012. Complex Measure," New York Times, April 22, 2013, 21 p. A10. Gray and van Ginneken, Health Care for 9 Undocumented Migrants, 2012. The federal poverty guideline for the annual 22 income for a family of four in 2009 was $22,050; State of Vermont, Report Regarding the Costs of see http://aspe.hhs.gov/poverty/09poverty.shtml. Health Services Provided to Undocumented 10 Immigrants (Montpelier, Vt.: Green Mountain Care A. M. Siskin, Federal Funding for Unauthorized Board, Jan. 2013). Aliens’ Emergency Medical Expenses (Washington, 23 D.C.: Congressional Research Service, Oct. 2004). Howell, Dubay, and Palmer, Impact of the Los 11 Angeles Healthy Kids Program, 2008. Perreira, Crosnoe, Fortuny et al., Barriers to 24 Immigrants’ Access, 2012. R. Z. Goetzel, R. J. Ozminkowski, V. G. Villagra et 12 al., "Return on Investment in Disease G. A. Campbell, S. Sanoff, and M. H. Rosner, "Care Management: A Review," Health Care Financing of the Undocumented Immigrant in the United Review, Summer 2005 26(4):1–19. States with ESRD," American Journal of Kidney 25 Diseases, Jan. 2010 55(1):181–91. Siskin, Federal Funding, 2004. 16 UNDOCUMENTED AND UNINSURED One East 75th Street 1150 17th Street NW New York, NY 10021 Suite 600 Tel 212.606.3800 Washington, DC 20036 Tel 202.292.6700 www.commonwealthfund.org