July 2017 | Issue Brief Health Coverage and Care for Immigrants Samantha Artiga and Anthony Damico Key Takeaways This brief provides an overview of health coverage for noncitizen immigrants and discusses key issues for health coverage and care for immigrant families today. It shows  In 2015, there were 23 million non-citizen immigrants residing in the United States, accounting for about 7% of the total U.S. population. Non-citizen immigrants include both lawfully present immigrants and undocumented immigrants. Many immigrants live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens.  Noncitizen immigrants are significantly more likely than citizens to be uninsured. Among the nonelderly population, 17% of lawfully present immigrants and four in ten (41%) undocumented immigrants are uninsured compared to less than one in ten (9%) U.S. born and naturalized citizens.  Changes proposed in the Better Care Reconciliation Act (BCRA) would further limit access to coverage and care for lawfully present immigrants. Specifically, the BCRA would make certain lawfully present immigrants ineligible for Marketplace coverage and tax credits. In addition, its proposed cuts to Medicaid could negatively affect coverage and care for lawfully present immigrants covered by the program and place further strains on other programs that serve immigrants.  Current immigration policies and attitudes towards immigrants may negatively affect their health coverage, access to care, and health outcomes. Increased fears among the immigrant community about deportation and use of public programs negatively affecting their immigration status may deter immigrant families from enrolling eligible family members in health coverage and seeking necessary health care for themselves and their children. Introduction This brief provides an overview of the noncitizen immigrant population and discusses key issues in health coverage and care for immigrants today. Immigrants and children in immigrant families have historically faced disproportionate barriers to accessing health coverage and care. The Affordable Care Act (ACA) offered new options to increase coverage for naturalized citizens and lawfully present immigrants, but undocumented immigrants remain ineligible for assistance. Increased fears among immigrants due to recent focus on immigration enforcement and proposed policies to limit immigrants’ use of public services may deter families from enrolling eligible children and adults in coverage and from obtaining needed care. In addition, changes proposed in the Better Care Reconciliation Act (BCRA) would further limit access to coverage and care for lawfully present immigrants. See here for methodology for the analysis included in this brief. Overview of Noncitizen Immigrants In 2015, there were 23 million noncitizen immigrants residing in the US, accounting for about 7% of the total population (Figure 1). About six in ten noncitizen immigrants were lawfully present immigrants, while the remaining four in ten were undocumented immigrants:1  Lawfully present immigrants are foreign- Figure 1 born individuals who have not become Non-Citizen Immigrants as a Share of the Total U.S. Population, 2015 citizens but are lawfully residing in the United States. This group includes legal permanent residents (LPRs, i.e., “green card” holders), refugees, asylees, other humanitarian Citizens immigrants, and other temporary immigrants. 93% Non-Citizens 7%  Undocumented immigrants are foreign- born individuals residing in the United States who are not legal residents. This group includes individuals who entered the 318.9 Million Total U.S. Population country without authorization and individuals NOTE: Total does not sum to 100% due to rounding. SOURCE: Kaiser Family Foundation analysis of March 2016 Current Population Survey, Annual Social and Economic Supplement who entered the country legally and stayed after their visa expired. Many immigrants live in mixed immigration status families. Mixed status families may include members who are lawfully present immigrants, undocumented immigrants, and/or citizens. For example, more than one in five (23%) children in the U.S. are citizen children with at least one immigrant parent.2 The remaining sections of this brief are limited to the nonelderly population since the ACA coverage expansions targeted the nonelderly. Key Characteristics of Figure 2 Age and Parental Status among the Nonelderly by Noncitizen Immigrants Citizenship Status, 2015 The large majority of nonelderly lawfully Age Parental Status 35-64 present and undocumented immigrants are 19-34 Non-Parent Parent 0-18 Child adults (Figure 2). In particular, young adults (age 19-34) make up a large share of undocumented 45% 57% 51% 47% 45% 49% immigrant adults. More than four in ten nonelderly 25% 23% 44% lawfully present and undocumented immigrants are 31% 40% 42% 30% 30% parents. Citizens 12% 9% Lawfully Present Undocumented Citizens 12% 9% Lawfully Present Undocumented Immigrants Immigrants Immigrants Immigrants 249.9 million 21.4 million 249.9 million 21.4 million *All non-citizen percentages show are statistically significantly different from the respective citizen percentage at the p<0.05 level. Note: Totals may not sum to 100% due to rounding. SOURCE: Kaiser Family Foundation analysis of March 2016 Current Population Survey, Annual Social and Economic Supplement Health Coverage and Care for Immigrants 2 Most nonelderly noncitizen immigrants live Figure 3 in a family with at least one full-time worker, Employment and Income among the Nonelderly Population by Citizenship Status, 2015 but they are more likely than nonelderly Citizens Lawfully Present Immigrants Undocumented Immigrants citizens are to be low-income. Nonelderly lawfully present and undocumented immigrants are 82% 83% 82% as likely as nonelderly citizens are to live in a family with at least one full-time worker, but they are more 53%* 43%* likely than citizens are to be low-income, since they 31% often work in low-wage jobs (Figure 3). Lawfully present immigrants have the same requirements as citizens to pay taxes and contribute to federal, state, At Least One Full-Time Worker in the Family Low-Income (<200% FPL) and local taxes. *Indicates statistically significant difference from citizens at p<0.05 level. SOURCE: Kaiser Family Foundation analysis of March 2016 Current Population Survey, Annual Social and Economic Supplement Health Coverage for Noncitizen Immigrants Nonelderly lawfully present and undocumented immigrants are significantly more likely to be uninsured than nonelderly citizens. Lawfully present immigrant children and nonelderly adults are about twice as likely as citizens to be uninsured, and Figure 4 uninsured rates for nonelderly undocumented Uninsured Rates Among Nonelderly Adults and Children by immigrants are even higher (Figure 4). Among the Immigration Status, 2015 nonelderly, undocumented immigrant adults are Citizens Lawfully Present Immigrants Undocumented Immigrants nearly four times as likely as citizen adults to lack coverage (42% vs. 11%), and the uninsured rate for 41% 42% undocumented immigrant children is five times the rate for citizen children (25% vs. 5%). These higher 25% 17% 18% uninsured rates reflect their more limited access to 9% 11% 13% 5% employer-sponsored coverage due to employment in jobs and industries that often do not offer coverage All Nonelderly Nonelderly Adults Children as well as more limited access to Medicaid and the *All non-citizen percentages shown are statistically significantly different from the respective citizen percentage at the p<0.05 level. Children’s Health Insurance Program (CHIP). SOURCE: Kaiser Family Foundation analysis of March 2016 Current Population Survey, Annual Social and Economic Supplement Lawfully present immigrants may qualify for Medicaid and CHIP but are subject to specific eligibility restrictions. To qualify for Medicaid and CHIP, lawfully present immigrants must have a “qualified” immigration status and many must wait five years after obtaining a qualified status before they may enroll. Some immigrants, such as those with temporary protected status or lawful temporary immigrants, are lawfully present but do not have a qualified status and are not eligible for Medicaid and CHIP (Appendix A). States have an option to eliminate the five-year waiting period and to cover the broader group of lawfully present immigrant children and pregnant women—including those without a qualified status. Over half of states have taken up this option for children and nearly half have elected the option for pregnant women. 3 Undocumented immigrants are not eligible to enroll in Medicaid or CHIP. However, Medicaid payments for emergency services may be made on behalf of individuals who are otherwise eligible for Medicaid but for their immigration status. These payments cover costs for emergency care for lawfully present Health Coverage and Care for Immigrants 3 immigrants who remain ineligible for Medicaid as well as undocumented immigrants. Since 2002, states have had the option to provide prenatal care to women regardless of immigration status by extending CHIP coverage to the unborn child. In addition, some states have state-funded health programs that provide coverage to some groups of immigrants regardless of immigration status. There are also some locally-funded programs that provide coverage or assistance without regard to immigration status. Eligibility for ACA Coverage Options for Noncitizen Immigrants The ACA expanded coverage options for lawfully present immigrants, although they continue to face eligibility restrictions for Medicaid. Thirty-two states, including DC, have implemented the ACA Medicaid expansion to adults with incomes up to 138% of the federal poverty level (FPL). Lawfully present immigrant adults may qualify for the Medicaid expansion, but they must have a qualified immigration status and are subject to the five-year waiting period before they may enroll. Lawfully present immigrants also can purchase coverage through the ACA Marketplaces and may receive subsidies to offset the cost of this coverage, which are available to people with incomes from 100% to 400% FPL who are not eligible for other coverage. In addition, lawfully present immigrants with incomes below 100% FPL may receive subsidies for Marketplace coverage if they are ineligible for Medicaid based on their immigration status. This group includes lawfully present immigrants who are not eligible for Medicaid or CHIP because they are in the five year waiting period or because they do not have a qualified status. Undocumented immigrants are ineligible for ACA coverage options. Undocumented immigrants were ineligible for Medicaid prior to the ACA and remain ineligible. They also are prohibited from purchasing coverage through a Marketplace or receiving premium subsidies. Most uninsured nonelderly lawfully present immigrants are eligible for coverage options under the ACA, while uninsured undocumented immigrants remain ineligible for coverage options. As of 2016, 17% of uninsured nonelderly lawfully present immigrants were eligible for Medicaid, and half (50%) were eligible for tax credit subsidies (Figure 5). Many Figure 5 uninsured lawfully present immigrants are eligible Eligibility for ACA Coverage Among Nonelderly Uninsured but not enrolled in coverage because they face a by Immigration Status as of 2016 range of enrollment barriers including fear, 20% Ineligible for Financial Assistance confusion about eligibility policies, difficulty 29% Ineligible Due to Immigration Status 12% In the Coverage Gap navigating the enrollment process, and language and 11% Tax Credit Eligible Eligible for Medicaid literacy challenges. Previous experience suggests that 100% 37% 50% direct one-on-one outreach assistance from trusted individuals is key for overcoming these barriers. 22% 17% Uninsured undocumented immigrants remain Citizens Lawfully Present Undocumented ineligible for coverage options due to their Immigrants Immigrants immigration status. In the absence of coverage, they Notes: Totals may not sum to 100% due to rounding. Ineligible for Financial Assistance Share includes those ineligible due to offer of ESI or income. Tax Credit Eligible share includes adults in MN and NY who are eligible for coverage through the Basic Heal th Plan. remain reliant on safety net clinics and hospitals for Source: Kaiser Family Foundation analysis based on 2016 Medicaid eligibility levels and 2016 Current Population Survey. care and often go without needed care. Health Coverage and Care for Immigrants 4 Current Issues Changes proposed in the BCRA would further limit access to coverage and care for lawfully present immigrants.  BCRA would make some lawfully present immigrants ineligible to purchase Marketplace coverage. As noted, under current law, lawfully present immigrants are eligible to purchase coverage through the Marketplace and receive tax credit subsidies for this coverage. BCRA would limit eligibility for Marketplace coverage and tax credits to lawfully present immigrants who have a qualified status. This means certain groups of lawfully present immigrants would become ineligible to purchase coverage through the Marketplace or receive tax credits, including people here on a work or student visa and people in the process of gaining permanent resident status like those who are newly married to U.S. citizens. This restriction would also exclude individuals from the Federated States of Micronesia, Republic of the Marshall Islands, and Republic of Palau who work and reside in the United States under Compacts of Free Association (COFA).  BCRA would make large reductions in federal funding for Medicaid that could lead to cutbacks in coverage for lawfully present immigrants enrolled in the program and increase pressures on other state programs that serve immigrants. Medicaid is an important source of coverage for lawfully present immigrants, covering more than one in four (25%) nonelderly lawfully present immigrants. BCRA would make significant reductions in Medicaid by eliminating enhanced federal financing for the ACA Medicaid expansion to low-income adults and capping the amount of federal funding provided to states. The Congressional Budget Office estimates that these changes will result in a $772 billion reduction in federal funding for Medicaid over 10 years and that enrollment will decline by 15 million by 2026 compared to current law.4 In response to these cuts, states will likely need to make cutbacks in their Medicaid programs, such as eligibility reductions, elimination of optional benefits, and/or reductions in provider payments. These reductions could result in coverage losses and increased barriers to care for lawfully present immigrants covered by the program. Moreover, the reductions could increase financial pressures and strains on other state programs that serve immigrants. Increased fear within the immigrant community will likely deter immigrant families, including those with citizen children, from enrolling eligible individuals in health coverage and from using health care. The Administration has increased immigration enforcement activities and signaled interest in making it more difficult for low-income immigrants who use certain benefits, including Medicaid or CHIP, to enter the country or obtain lawful permanent status.5 These actions have increased fears of deportation and use of public programs among immigrant communities, including mixed status families with citizen children. These fears may deter them from enrolling eligible family members in health coverage and seeking necessary health care for themselves and their children, which may lead to negative health consequences and further widen disparities in health and health care for immigrant families. Samantha Artiga is with the Kaiser Family Foundation. Anthony Damico is an independent consultant to the Kaiser Family Foundation. Health Coverage and Care for Immigrants 5 Appendix A: Lawfully Present Immigrants by Qualified Status Qualified Immigrant Categories Other Lawfully Present Immigrants  Lawful permanent resident (LPR or green card  Granted Withholding of Deportation or holder) Withholding of Removal, under the immigration  Refugee laws or under the Convention against Torture  Asylee (CAT)  Cuban/Haitian entrant  Individual with Non-immigrant Status, includes  Paroled into the US for at least one year worker visas, student visas, U-visa, and other  Conditional entrant granted before 1980 visas, and citizens of Micronesia, the Marshall  Granted withholding of deportation Islands, and Palau  Battered non-citizen, spouse, child, or parent  Temporary Protected Status (TPS)  Victims of trafficking and his/her spouse, child,  Deferred Enforced Departure (DED) sibling or parent or individuals with pending  Deferred Action Status, except for Deferred application for a victim of trafficking visa Action for Childhood Arrivals (DACA) who are  Member of a federally recognized Indian tribe or not eligible for health insurance options American Indian born in Canada  Lawful Temporary Resident  Administrative order staying removal issued by the Department of Homeland Security  Resident of American Samoa  Applicants for certain statuses  People with certain statuses who have employment authorization Source: “Coverage for lawfully present immigrants,” HealthCare.gov, https://www.healthcare.gov/immigrants/lawfully-present-immigrants/, accessed July 2017. Health Coverage and Care for Immigrants 6 Endnotes 1 The Pew Research Center estimates of the non-citizen population totaled to approximately 25 million U.S. residents in 2014. This number is two million higher than the total number of individuals responding to the 2015 Current Population Survey's Annual Social and Economic Supplement. Pew reported 1.7 temporary legal immigrants and 11.7 million permanent legal immigrants, in addition to 11.1 undocumented immigrants. To reconcile the difference between Pew's estimate of 24.5 million resident non-citizens with the 22.5 million reported by the 2015 Current Population Survey, we assumed that legally present individuals were accounted for in the survey while undocumented individuals made up the residual of the non-citizen population. This resulted in 13.4 million legally present non- citizens and 9.0 million undocumented non-citizens in our 2014 population. Therefore, our estimate of 9.0 million undocumented immigrants may be lower than other estimates because of the overall undercount of total non-citizens in CPS. The 2015 weighted populations were computed in a similar manner; however, the Pew estimates were interpolated from 2012 and 2014 statistics. 2 Migration Policy Institute, Children in U.S. Immigrant Families (By Age Group and State, 1990 versus 2015), (Washington, DC: Migration Policy Institute (MPI) Data Hub, n.d.) http://www.migrationpolicy.org/programs/data-hub/charts/children-immigrant- families. 3 Tricia Brooks, et al., Medicaid and CHIP Eligibility, Enrollment, Renewal and Cost-Sharing Policies as of January 2017: Findings from a 50-State Survey, (Washington, DC: Kaiser Family Foundation, January 2017), http://www.kff.org/medicaid/report/medicaid- and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2017-findings-from-a-50-state-survey/. 4 Congressional Budget Office (CBO), Congressional Budget Office Cost Estimate: H.R. 1628 Better Care Reconciliation Act of 2017, (Washington, DC: CBO, June 2017), https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/52849- hr1628senate.pdf. 5 “Executive Orders on Protecting the Homeland,” Department of Homeland Security, updated June 29, 2017, accessed July 11, 2017, https://www.dhs.gov/executive-orders-protecting-homeland. The Henry J. Kaiser Family Foundation Headquarters: 2400 Sand Hill Road, Menlo Park, CA 94025 | Phone 650-854-9400 Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270 www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/KaiserFamFound Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.