"Despite the far-reaching potential expansion of Medicaid under the [Affordable Care Act], our estimates demonstrate that a substantial portion of low-income uninsured adults will be ineligible for Medicaid because of their immigration status."
That is a key finding of a new study by the Robert Wood Johnson Foundation, which highlights four states with high percentages of immigrants: Arizona, California, Nevada and Texas. In these states, the challenge of developing "strategies for meeting the health care needs of" immigrants will be "particularly difficult for safety-net providers" because of "large numbers of immigrants who will not be eligible for Medicaid."
For years, health officials in Southern and Southwestern states have struggled to provide adequate care for immigrants, and now it seems that the ACA will do little to ease their burden.
Immigrants Excluded From ACA
The ACA does not change the current eligibility standard preventing most documented immigrants from enrolling in Medicaid or the Children's Health Insurance Program if they have resided in the U.S. for fewer than five years. States are permitted to cover such immigrants in the programs at their own expense, and Medicaid will cover emergency care for all immigrants.
Undocumented immigrants are not eligible for public health insurance programs, and the ACA in most cases will further exclude them from new coverage opportunities, including state health insurance exchanges and Medicaid expansions.
Lawful immigrants who have lived in the U.S. for less than five years may participate in health insurance exchanges and obtain subsidies if income-qualified, but in most states, they still will not be able to qualify for full Medicaid coverage.
Study: Immigrants Make Up 'Significant Portion' of Low-Income Uninsured
According to the RWJF study, "Consideration of immigration status is particularly important because unauthorized and recent legal immigrants are much more likely to be low-income and uninsured than their non-immigrant and more established immigrant counterparts." Therefore, it explains, "even though unauthorized and/or recent legal immigrants may make up a relatively small portion of the non-elderly population in general, they can make up a significant proportion of the low-income uninsured."
The authors note, "[E]stimates that do not take an individual's immigration status into account will overestimate the population eligible for the [Medicaid] expansion."
The study finds that 6% of nonelderly adults in the U.S. are either undocumented immigrants or recent legal immigrants. Immigrants make up 10% of the population considered low income. Considering only the population of nonelderly adults who are low-income and uninsured, the percentage of undocumented or recent legal immigrants climbs to 17%.
In Nevada, 34% of potential recipients of Medicaid coverage under the expansion are immigrants who ultimately will not qualify, according to the study. The analysis found that in Arizona, 31% of potential recipients would be ineligible for Medicaid, while in California and Texas, 26% would be ineligible under the expansion.
The authors conclude, "Safety-net health care providers are likely to continue to be key providers for this population after health reform, and the need for safety-net care will not be spread evenly across states," adding, "The capacity of safety-net providers to fill this gap will need to be assessed."
Alternative Avenues of Coverage for Immigrants
The study's findings reinforce a negative outlook on the prospects for immigrant health care in Texas. Bobbi Ryder -- president and CEO of the National Center for Farmworker Health -- told California Healthline, "The need for access to care has always been a major issue for immigrants in Texas," adding that "the demand always has exceeded capacity and resources available."
However, Ryder added, "Texas has recognized the need for unique solutions to unmet need from both immigrants and low-income Hispanic residents through programs like the certification of lay health midwives and lay" community health workers, in addition to federally required emergency medical services for immigrants through Medicaid.
In California -- where officials are working to expand Medi-Cal, the state's Medicaid program -- "services for undocumented immigrants, including prenatal care, pregnancy-related services, nursing home care, and limited breast and cervical cancer treatment," are provided through Medi-Cal, according to Norman Williams, spokesperson for the state Department of Health Care Services.
In addition, he told California Healthline that state officials are proposing that recent legal immigrants who currently are not enrolled in Medi-Cal be able to obtain coverage through the state health insurance exchange beginning in 2014.
Does Medi-Cal Expansion Limit Options for Immigrant Care in Calif.?
Some say that efforts to expand Medi-Cal, California's Medicaid program, ultimately may hinder indigent care options for immigrants.
Gov. Jerry Brown's fiscal year 2013-2014 budget proposal earmarked $350 million to cover the increased Medi-Cal enrollment. Although the federal government will fund the expansion for the first few years, Brown has said that the state might try to cover costs in subsequent years by reducing the roughly $2 billion it provides counties each year to cover health care services for uninsured individuals.
County officials have expressed concern that such proposals could have a negative effect on their safety-net facilities -- with the exception of FQHCs, which will receive a payment boost under the ACA.
In response to such concerns, Williams said that even if the state reduces indigent care payments, there will be sufficient funding for counties to provide care for undocumented and recent legal immigrants.
According to Williams, "As the state assumes these new [Medi-Cal] responsibilities and costs, and counties experience a decrease in responsibilities and costs, it is appropriate for funding to be shifted so the changes are sustainable." He added, "At the same time, the state is committed to ensuring that counties continue to have a strong, sustainable safety-net system."
An Underlying Stigma
Some observers question whether non-FQHCs in California and Texas are not expecting any extra funding because money must go toward helping larger percentages of the population or because of a stigma against undocumented immigrants in general.
Ryder said, "I doubt there will be a funding boost to deal with this issue." She added, "Anti-immigrant fervor is rampant, and there seems to be a prevailing sense of resentment towards [so-called] illegals who are somehow taking something away from taxpayers, with little recognition of how dependent our economy is on those workers."
Here's a look at other health reform-related news:
The Medicaid expansion substitute: A recent deal allowing Arkansas to use federal funds to shift Medicaid-eligible residents into private health plans isn't the big deal that everyone's making it out to be, Avik Roy argues in Forbes' "The Apothecary."
Sticker shock: Over at Health Care Policy and Market Review, Robert Laszewski explains why many consumers could see their health care premiums jump under the ACA. He also questions the Congressional Budget Office's original cost estimate for the law.
Michelle Andrews at Kaiser Health News
provides a helpful Q&A on whether young people will have access to reasonably priced health plans through state health exchanges.