Declining Immigrant Applications for Medi-Cal and Welfare Benefits in Los Angeles County

07/01/1998

Declining Immigrant Applications for Medi-Cal and Welfare Benefits in Los Angeles County 1

by Wendy Zimmermann Michael Fix

July 1998


The 1996 federal welfare reform law (the Personal Responsibility and Work Opportunity Reconciliation Act, PRWORA) barred many legal immigrants from receiving food stamps and gave states a number of options to restrict immigrant eligibility for other benefit programs. In California, however, immigrant eligibility has not changed for AFDC/TANF (now CalWORKs), Medicaid (Medi-Cal in California) or the county-funded cash assistance program, General Relief.2

Nonetheless, the complex reforms introduced by the welfare law as well as related policy changes and practices may be having a chilling effect on immigrants' use of benefits for which they remain eligible. Legal immigrants may mistakenly believe they and their families are no longer eligible for AFDC/TANF and Medi-Cal.3 Immigrants may be concerned about new requirements that state agencies verify citizenship and immigration status and report undocumented immigrants to the Immigration and Naturalization Service. Immigrants may also fear that their own or their children's use of benefits will render them a "public charge" under immigration laws which, they may believe, would affect their ability to gain legal permanent residence, to naturalize or even lead to deportation. Recently immigrants have mistakenly been made to repay Medi-Cal benefits in order to gain legal permanent resident status or re-enter the country after a trip abroad. News of these events also may limit immigrants' willingness to apply for benefits.

The following analysis is based on administrative data from the Los Angeles County Department of Public Social Services. The data provide information on monthly approvals of applications for AFDC/TANF, Medi-Cal and General Relief for January 1996 to January 1998. The data show that the number of non-citizen monthly approvals for these benefits has dropped significantly since January 1996 while the number of citizen approvals has either remained the same or declined more moderately. Since immigrant eligibility for these benefits has not changed in California since January 1996, this decline appears to reflect fewer immigrants applying for assistance for which they remain eligible.4

1. Non-citizen approved applications fell dramatically following welfare reform. Approved applications by non-citizen families for AFDC/TANF and Medi-Cal declined sharply in the months following August 1996 when federal welfare reform became law. Since then, the number of monthly approvals of non-citizen-headed cases has remained lower than it had been through most of 1996. In the initial months of 1996, about 3,000 non-citizen headed cases were approved for AFDC/TANF and Medi-Cal each month, compared to about 1,500 for most of 1997.5 At the same time, the number of monthly approvals of citizen-headed cases remained the same at about 4,000 per month. Monthly approvals of non-citizen-headed cases therefore dropped by 52 percent between January 1996 and January 1998 while the number of citizen cases approved each month did not change (Table 1). The decline in total monthly approvals during those two years (-23 percent) is, therefore, entirely attributable to the decline in approvals of non-citizen-headed cases.

2. The number of legal immigrant-headed cases has dropped faster than undocumented cases. The drop in approved applications was greater for cases headed by a legal immigrant than for cases headed by an undocumented immigrant (-71 vs. -34 percent) where an ineligible undocumented parent typically applies only for her citizen child (Table 1). One possible explanation for the sharper decline among legal than undocumented immigrants is that during 1996 and 1997 large numbers of legal immigrants naturalized those people would, of course, apply as citizens rather than non-citizens.6 It is also possible that many legal immigrants did not understand that although their eligibility for food stamps had changed, their eligibility for TANF/AFDC and Medi-Cal had not. Additionally, there may have been widespread (mistaken) concern among legal immigrants that using public benefits would hurt their chances for naturalization.

3. The number of citizen children applying for AFDC/TANF and Medi-Cal declined. Because so many non-citizen adults have U.S.-born citizen children, the drop in approvals of non-citizen- headed cases has led to fewer citizen children receiving assistance.7 The number of newly approved citizen children of non-citizen parents for AFDC/TANF and Medi-Cal dropped by 48 percent between January of 1996 and 1998, compared to almost no change (6 percent increase) for citizen children of citizen parents (Table 2). Since the vast majority of those receiving AFDC/TANF and Medi-Cal in Los Angeles receive food stamps as well, these drops also reflect a decrease in applications for food stamps by citizen children who remain eligible for them. The cumulative impact of this decline in approved applications may be significant: nearly 25,000 more children would have applied and been approved for AFDC/TANF and Medi-Cal between December 1996 and January 1998 if the number of citizen children of immigrant parents had remained at about the same level as it had been in January to November 1996.

4. Fewer non-English speakers have applied and been approved for benefits. Data on monthly approvals by primary language of the applicant tell a similar story. Between January 1996 and January 1998, the number of cases approved in which the applicant's primary language is Spanish fell by 46 percent while it fell by only 9 percent for English speakers. For the much smaller group who speak an Asian language the number fell by 59 percent (Table 3).

5. The number of non-citizens applying for "Medi-Cal-only" benefits decreased. The number of persons applying for only Medi-Cal because they are ineligible for cash or food assistance has also dropped faster for non-citizens than citizens. Between 1996 and 1998 non-citizens approved each month for "Medi-Cal-only" dropped by 24 percent while citizen approvals stayed virtually flat, falling by only 7 percent (Table 4). The drop in applications among immigrant families is even higher, however, when the citizen children of immigrant adults (who are included in the citizen column) are considered.8 The full decline in non-citizen enrollment in Medi-Cal encompasses both the drop in Medi-Cal-only applications the decline in non- citizens plus their citizen children (Table 4) and the drop in applications for AFDC/TANF and Medi-Cal (Tables 1 and 2). Further, the decline in enrollment of undocumented immigrants in Medi-Cal-only (who make up about twenty percent of all approvals) means that welfare reform and related policies appear to be having an impact not only on legal immigrants' use of regular Medi-Cal but also on undocumented immigrants' use of emergency medical services and prenatal care.

6. Non-citizen applications for General Relief also decline. Similarly, the number of non- citizens approved on a monthly basis for General Relief, Los Angeles's safety net assistance program, declined more than twice as fast as the number of citizens. While the number of citizens newly approved for General Relief fell 22 percent between January 1996 and January 1998, the number of non-citizens dropped 47 percent during the same time period (Table 5).

These findings raise questions about a number of broader policy issues, including rising uninsurance rates and federal, state and local efforts to increase health insurance coverage among children. The federal government recently created the Child Health Insurance Program (CHIP), called Healthy Families in California, which provides funding to states to expand health insurance for low-income children. L.A. County recently adopted a plan to enroll 100,000 more children in Medi-Cal by September 1999 (the Los Angeles County Child Medi-Cal Enrollment Project) a goal that may be difficult to reach if Medi-Cal enrollment of children in immigrant families remains low. A recent GAO report found that most uninsured children in California are children of immigrants: in 1996, 73 percent of uninsured Medicaid-eligible children in California were either foreign-born or had a foreign-born parent.9 To include the children of immigrants in efforts such as these, policy reforms and outreach efforts will need to take issues specific to immigrant families such as a misunderstanding of immigrant eligibility rules and concerns over public charge laws into account.

These data also may have implications for the current debate over declining welfare caseloads. Although an initial examination of Los Angeles's AFDC/TANF caseload data for January 1995 to April 1997 does not suggest that the number of non-citizens receiving welfare has fallen faster than the number of citizens, it may be too soon to tell if the drop in immigrant applications is contributing to declines in overall caseloads.


Tables

Table 1. Cases Newly Approved for AFDC/TANF with Medi-Cal in Los Angeles County by Immigration Status of Household Head*: January 1996-January 1998

Month/Year Total Monthly Approvals** Citizens Percent of Total Non- Citizens Percent of Total Legal Immigrants Percent of Total Undocumented Immigrants*** (Unaided) Percent of Total
January 1996 7,332 4,085 56% 3,177 43% 1,545 21% 1,632 22%
February 1996 7,681 4,468   3,168   1,650   1,518  
March 1996 7,970 4,623   3,283   1,588   1,695  
April 1996 7,754 4,626   3,068   1,542   1,526  
May 1996 7,450 4,520   2,873   1,403   1,470  
June 1996 6,680 4,119   2,490   1,218   1,272  
July 1996 7,900 4,726   3,089   1,548   1,541  
August 1996 5,693 3,570   2,066   1,036   1,030  
September 1996 7,953 5,078   2,808   1,420   1,388  
October 1996 7,767 5,072   2,621   1,307   1,314  
November 1996 5,833 3,833   1,951   963   988  
December 1996 5,781 4,037   1,702   529   1,173  
1/96 - 1/97 Percent change -17% -1%   -38%   -59%   -19%  
January 1997 6,060 4,042 67% 1,967 32% 641 11% 1,326 22%
February 1997 5,691 3,923   1,731   564   1,167  
March 1997 5,938 4,173   1,705   532   1,173  
April 1997 5,846 4,272   1,491   457   1,034  
May 1997 5,089 3,765   1,255   444   811  
June 1997 5,262 3,819   1,387   441   946  
July 1997 5,667 4,148   1,433   476   957  
August 1997 5,689 4,170   1,457   472   985  
September 1997 6,109 4,413   1,619   505   1,114  
October 1997 6,543 4,774   1,696   489   1,207  
November 1997 4,899 3,554   1,270   368   902  
December 1997 6,257 4,466   1,702   454   1,248  
January 1998 5,669 4,072 72% 1,519 27% 450 8% 1,069 19%
1/97 - 1/98 Percent Change -6% +1%   -23%   -30%   -19%  
1/96 - 1/98 Percent Change -23% 0%   -52%   -71%   -34%  
*Data are provided by "first adult" in household. This person is typically the parent. Each case usually includes one or two parents and their child(ren). ** Citizens and noncitizens do not necessarily add to the total because this total includes "other" cases, including those in which the immigration status of the household head is unknown. ***Undocumented immigrants are not eligible for AFDC/TANF or regular Medi-Cal. These cases typically include citizen children who are eligible for assistance. Note: All AFDC recipients are automatically eligible for Medi-Cal. Most also receive federal food stamps (excluding ineligible immigrants). Data include both single- and two-parent families.

Table 2. Children Newly Approved for AFDC/TANF with Medi-Cal in Los Angeles County by Immigration Status of Household Head*: January 1996-January 1998

Month/Year Total Monthly Approvals** Citizen Children of Citizen Adults Percent of Total Citizen Children of Non-Citizen Adults Percent of Total Citizen Children of Legal Immigrant Adults Percent of Total Citizen Children of Undocumented Adults Percent of Total
January 1996 11,669 6,148 53% 5,144 44% 2,741 23% 2,403 21%
February 1996 11,954 6,586   4,984   2,803   2,181  
March 1996 12,489 6,917   5,178   2,689   2,489  
April 1996 12,330 6,926   5,075   2,761   2,314  
May 1996 11,467 6,644   4,418   2,288   2,130  
June 1996 10,343 6,100   3,882   2,086   1,796  
July 1996 12,476 7,161   4,815   2,531   2,284  
August 1996 8,952 5,496   3,147   1,630   1,517  
September 1996 12,572 7,761   4,415   2,348   2,067  
October 1996 12,606 7,846   4,359   2,294   2,065  
November 1996 9,197 5,834   3,111   1,613   1,498  
December 1996 9,269 6,161   2,868   1,025   1,843  
1/96 - 1/97 Percent change -17% +2%   -39%   -56%   -19%  
January 1997 9,725 6,245 64% 3,160 32% 1,203 12% 1,957 20%
February 1997 8,872 5,799   2,831   1,068   1,763  
March 1997 9,285 6,208   2,819   1,000   1,819  
April 1997 9,085 6,356   2,446   860   1,586  
May 1997 8,088 5,643   2,193   914   1,279  
June 1997 8,437 5,880   2,325   871   1,454  
July 1997 9,111 6,360   2,442   886   1,556  
August 1997 9,142 6,454   2,395   900   1,495  
September 1997 9,936 6,858   2,788   998   1,790  
October 1997 10,714 7,454   2,924   932   1,992  
November 1997 8,052 5,615   2,136   684   1,452  
December 1997 10,476 7,176   2,982   916   2,066  
January 1998 9,460 6,501 69% 2,693 28% 921 10% 1,772 19%
1/97 - 1/98 Percent change -3% +4%   -15%   -23%   -9%  
1/96 - 1/98 Percent change -19% +6%   -48%   -66%   -26%  
* Data are provided for children by "first adult" in household. In most cases, this adult is the child's parent. ** Columns do not add to the total because this total includes "others," including non-citizen children and those for whom immigration status is unknown. Note: All AFDC recipients are automatically eligible for Medi-Cal. Most also receive food stamps (excluding ineligible immigrants). Data include both single- and two-parent families.

Table 3. Cases Newly Approved for AFDC/TANF with Medi-Cal in Los Angeles County by Primary Language*: January 1996- January 1998

Month/Year Total Monthly Approvals English Percent of Total Spanish Percent of Total Asian Languages** Percent of Total All Others Percent of Total
January 1996 7,445 4,483 60% 2,686 36% 135 2% 141 2%
April 1996 7,833 5,068   2,524   110   131  
July 1996 7,990 5,178   2,436   118   258  
October 1996 7,864 5,389   2,182   113   180  
January 1996 - January 1997 Percent Change -17% -10%   -32%   -33%   +32%  
January 1997 6,157 4,056 66% 1,825 30% 90 1% 186 3%
April 1997 5,946 4,277   1,412   68   189  
July 1997 5,716 4,258   1,274   62   122  
October 1997 6,586 4,766   1,620   65   135  
January 1998 5,727 4,096 72% 1,449 25% 56 1% 126 2%
January 1997- January 1998 Percent Change -7% +1%   -21%   -38%   -32%  
January 1996 - January 1998 Percent Change -23% -9%   -46%   -59%   -11%  
*Primary language is the language in which the applicant requests an application. **Asian languages include Vietnamese, Cambodian, Cantonese, Mandarin, Other Chinese, Laotian, and Korean. Note: All AFDC recipients are automatically eligible for Medi-Cal. Most also receive food stamps (excluding ineligible immigrants). Data include both single- and two-parent families.

Table 4. Persons Newly Approved for Medi-Cal-Only* in Los Angeles County by Immigration Status: January 1996- January 1998

Month/Year Total Monthly Approvals Citizens** Percent of Total Non-Citizens Percent of Total Legal Immigrants Percent of Total Undocumented Immigrants*** Percent of Total
January 1996 31,660 19,702 62% 11,958 38% 3,857 12% 8,031 25%
February 1996 32,262 20,152   12,110   4,011   8,038  
March 1996 40,043 24,522   15,521   4,973   10,485  
April 1996 37,493 23,349   14,144   4,789   9,278  
May 1996 37,182 22,768   14,414   4,950   9,403  
June 1996 32,639 20,382   12,257   4,079   8,111  
July 1996 33,660 21,271   12,389   4,041   8,269  
August 1996 32,406 20,266   12,138   3,836   8,238  
September 1996 29,522 18,588   10,934   3,631   7,221  
October 1996 32,819 20,922   11,897   4,060   7,765  
November 1996 28,831 18,634   10,197   3,494   6,626  
December 1996 25,833 16,942   8,891   3,267   5,550  
January 1996 - January 1997 Percent Change -12% -8%   -19%   -18%   -20%  
January 1997 27,725 18,053 65% 9,672 35% 3,174 11% 6,426 23%
February 1997 29,222 19,083   10,139   3,485   6,617  
March 1997 35,558 23,314   12,244   4,217   7,977  
April 1997 35,424 23,378   12,046   4,109   7,891  
May 1997 33,859 22,549   11,310   3,859   7,370  
June 1997 30,605 20,263   10,342   3,524   6,776  
July 1997 34,088 22,522   11,565   3,521   8,006  
August 1997 31,950 21,201   10,741   3,723   6,969  
September 1997 29,348 19,324   10,011   3,558   6,393  
October 1997 33,314 22,320   10,980   3,937   6,927  
November 1997 26,763 17,822   8,927   3,258   5,516  
December 1997 31,537 20,984   10,545   3,592   6,835  
January 1998 27,335 18,267 67% 9,054 33% 3,058 11% 5,862 21%
January 1997 - January 1998 Percent Change -1% +1%   -6%   -4%   -9%  
January 1996 - January 1998 Percent Change -6% -7%   -24%   -21%   -27%  
* This table includes only persons receiving Medi-Cal who do not receive any other public assistance such as AFDC/TANF. ** This table understates the drop in approved applications for immigrant families to the extent that citizen children of legal and undocumented immigrant parents are included in the citizen column. *** Undocumented immigrants are only eligible for emergency services and pre-natal care.

Table 5. Persons* Newly Approved for General Relief in Los Angeles County by Citizenship Status: January 1996- January 1998

Month/Year Total Monthly Approvals Citizens Percent of Total Non-Citizens Percent of Total
January 1996 8,533 7,666 90% 867 10%
February 1996 9,763 8,587   1,176  
March 1996 9,701 8,555   1,146  
April 1996 9,190 8,210   980  
May 1996 8,703 7,750   953  
June 1996 7,970 7,139   831  
July 1996 8,968 8,056   912  
August 1996 8,919 7,886   1,033  
September 1996 7,366 6,709   657  
October 1996 8,965 8,206   759  
November 1996 7,404 6,827   577  
December 1996 7,913 7,230   683  
January 1996 - January 1997 Percent Change -11% -10%   -26%  
January 1997 7,557 6,912 91% 645 9%
February 1997 8,321 7,629   692  
March 1997 8,234 7,602   632  
April 1997 7,997 7,379   618  
May 1997 8,182 7,542   640  
June 1997 7,046 6,561   485  
July 1997 7,825 7,213   612  
August 1997 7,718 7,040   678  
September 1997 7,052 6,523   529  
October 1997 8,526 7,848   678  
November 1997 5,931 5,464   467  
December 1997 7,375 6,800   575  
January 1998 6,450 5,994 93% 456 7%
January 1997 - January 1998 Percent Change -15% -13%   -29%  
January 1996 - January 1998 Percent Change -24% -22%   -47%  
*Most persons approved for General Relief are single adults.

Notes

1. This analysis was funded by the Office of the Assistant Secretary for Planning and Evaluation, the Administration for Children and Families and The Health Care Financing Administration(now known as Centers for Medicare and Medicaid Services(CMS)), U.S. Department of Health and Human Services, The Food, Nutrition and Consumer Services and the Economic Research Service, U.S. Department of Agriculture, and the Immigration and Naturalization Service.

2. PRWORA gave states the option of providing TANF and Medicaid to immigrants who had entered the United States by August 22, 1996. It barred immigrants who enter the country after that date from receiving any federally-funded TANF and Medicaid for their first five years in the country. California has opted to provide TANF and Medi-Cal to immigrants in the United States regardless of date of entry and is using state funds to pay for benefits to newly entering immigrants during the five year bar. California has not implemented new Medi-Cal eligibility restrictions on certain immigrants who were formerly considered permanently residing under color of law, or PRUCOL. Undocumented immigrants were, and continue to be, ineligible for TANF and General Relief and are eligible for only emergency services under Medicaid. California continues to provide state-funded pre-natal care under Medicaid to undocumented women. Governor Wilson's efforts to end this pre-natal care have been blocked by litigation.

3. Although most of its provisions have been held up by litigation, California's Proposition 187, which attempted to restrict undocumented immigrants' access to a wide array of public services, may also have contributed to confusion and misunderstanding of eligibility rules.

4. During the time period examined (January 1996 to January 1998) the overall number of applications for AFDC/TANF and Medi-Cal declined while the overall denial rate did not change. These trends are consistent with the observation that falling numbers of approved applications for immigrants and their families are a product of declining numbers of applications. Data are not available, however, on application denial rates by immigration status. In addition, no general eligibility or program changes to AFDC/TANF were implemented during the period examined. Los Angeles County began implementing its new welfare-to-work program, CalWORKs, in April 1998.

5. In Los Angeles County, a family can apply for AFDC/TANF, Medi-Cal and food stamps using only one application. Everyone who is eligible for AFDC/TANF is also eligible for Medi-Cal and most also receive food stamps, excluding non-citizens who were made ineligible for them under the federal welfare reform law. Data on case approvals for AFDC/TANF and Medi-Cal combine all members of a household (usually the parent (s) and children). A non-citizen-headed case is one where the "first adult" in the household is a non-citizen; a citizen-headed case is one where the first adult is a citizen. Data on children approved for AFDC/TANF and Medi-Cal (Table 2), on General Relief (Table 5) and on "Medi- Cal-only" (Table 4) are for individuals and reflect each person's immigration status.

6. It cannot be determined, however, how much of the decline in approved applications is accounted for by rising naturalization, though it is unlikely to account for the steep drop in the number of legal-immigrant headed cases.

7. In the Los Angeles metropolitan area, sixty-three percent of children in families with incomes below 200 percent of the federal poverty level had at least one non-citizen parent and one citizen child. March 1997 Current Population Survey, Urban Institute tabulations.

8. We cannot tell how many of the citizens in column 1 of Table 4 are the children of immigrants since the Medi-Cal-only data are not available by alien status of household head. The change in applications for Medi-Cal-only, therefore, cannot be compared to that for AFDC/TANF with Medi-Cal (in Table 1) since the Medi-Cal-only data are presented for individuals while the AFDC/TANF with Medi-Cal data are presented for families (cases), by immigration status of the household head.

9. The proportion of uninsured children who had a non-citizen parent (as opposed to foreign- born), which was not included in the report, would be somewhat lower. The report used data from the Current Population Survey (CPS) for its analysis. U.S. General Accounting Office, "Medicaid: Demographics of Nonenrolled Children Suggest State Outreach Strategies," GAO/HEHS-98-93, March 1998.