- Background About the Four Cities
- Immigrants Access to Medicaid and the State Childrens Health Insurance Program (SCHIP)
- Immigrants Access to Health Services
- Safety Net Providers Organizational and Financial Responses
- Factors Shaping the Policy Responses
Even in the early 1990s, immigrants had challenges obtaining access to health care services in the United States because of their poverty, high levels of uninsurance, as well as their language and cultural differences. During the late1990s, immigrantsaccess to health care services became even more problematic, as immigrants began to lose Medicaid coverage, due to the 1996 federal welfare reform law which barred immigrants entering the U.S. after August 1996 from participating in Medicaid, and other policy changes that discouraged participation by eligible immigrants and by U.S.-born children of immigrants. The purpose of this report is to assess how these and related factors influenced changes in the health care systems for immigrants in four urban areas with large immigrant populations: Los Angeles, California; New York, New York; Houston, Texas; and Miami, Florida.
In late 1999 and early 2000, we conducted case study site visits to each area and met with clinic and hospital administrators, doctors and nurses, local Medicaid and health officials, community-based organizations and immigration and health experts and advocates. The purpose of our visits was to understand immigrants access to insurance and health care services, changes in state and local policies and practices and the response of local providers and agencies to the immigrant-related policy changes.
Los Angeles, New York City, Miami, and Houston all have large immigrant populations. Collectively, they have 9 million foreign-born residents, of whom almost 6 million are noncitizen immigrants. Each city has a distinctive ethnic blend; for example, Los Angeles and Houstons immigrants are primarily from Mexico, Central America, or Asia, while New York also has large Caribbean and Eastern European populations and Miami is dominated by Caribbean and Central American immigrants. But, in each area the population of noncitizen immigrants is disproportionately poor and uninsured, compared to native citizens in those areas.
All four urban areas have large health care safety nets, anchored by locally-owned public hospitals and clinics. In each city, these public facilities were dominant providers of care for low-income immigrants, whether they had Medicaid or were uninsured. Immigrants also received care at charitable hospitals and clinics in these cities, although the nonprofit safety nets were smaller in Houston and Miami.
National survey data show that Medicaid participation by low-income immigrants and their citizen children fell and their uninsurance rates climbed since the 1996 welfare reform law was passed. However, the most recent Census data indicate that the situation might have begun to reverse between 1998 and 1999 and that immigrants use of Medicaid rebounded somewhat. In all the cities, health care providers and local officials stated that the number of immigrants with Medicaid coverage had fallen sharply since 1996, although they often could not document this. (Most Medicaid and medical data systems did not indicate whether enrollees or patients were immigrants, so trend data were not available.) Data from Los Angeles County indicated that the number of noncitizen immigrants and their children on Medicaid fell more than 50 percent between 1996 and 1998, but some believed it had begun to climb again since then.
Key reasons cited for the loss of Medicaid coverage included both the actual changes in immigrants eligibility, as well as fears that participating in Medicaid could have adverse consequences for a persons or familys immigration status (e.g., be unable to get a green card or to reenter the United States after travelling abroad). The worries about the use of Medicaid appeared to be the most severe in Los Angeles, perhaps because there had been a long-running political debate about immigrants use of public benefits, but the fears cropped up in every community. Our site visits took place after the Immigration and Naturalization Service issued guidance clarifying that receipt of Medicaid (except long-term care) would not count in determining "public charge" status. Despite public education and outreach campaigns trying to emphasize that getting Medicaid or SCHIP would not endanger immigration status, many immigrants still had misgivings or were confused about the rules. New worries were being expressed concerning the recently adopted Affidavits of Support and the notion that immigrants sponsors might be billed for their Medicaid expenses.
State governments tried to cushion the loss of health insurance coverage, particularly for children, by using state funds to supplement their federally-funded programs.(1) In each state, recent immigrant children were eligible for SCHIP coverage through state-funded add-ons, although Florida recently limited the number who could participate. California had developed the most inclusive policies and developed state-funded add-ons to its Medicaid and SCHIP programs so that all recent immigrants were still fully eligible for insurance coverage. Thus, changes in immigrants Medicaid participation in California were not due to tightened eligibility criteria, per se, but due to other factors like worries over the public charge issue and confusion about the states rules.
Survey data indicate that over half of the low-income immigrants are uninsured, a level roughly double that of the native citizen population. Thus, immigrants are particularly reliant on safety net health care providers, like public and nonprofit hospitals and clinics, that offer free or reduced-price health care. Immigrants also avoided treatment, delayed care and used alternative sometimes underground sources of care. For example, some immigrants sought care from lower cost unlicensed health care providers, sometimes folk medicine providers, and many bought prescription drugs smuggled in from abroad, because of their inability to get prescriptions and because of the high costs of drugs.
In every city, language difficulties faced by immigrants with limited English capabilities were viewed as a major barrier to medical care and serious threat to medical care quality. Although there were many health care providers who speak Spanish or who have bilingual staff, Spanish-speaking immigrants often could not communicate with their doctors or nurses. Immigrants who spoke other foreign languages, such as Vietnamese, Cambodian, Creole, Russian and other languages, had greater difficulties with interpretation and translation services. The inability to communicate with health care providers not only limited immigrants access to care, but threatened the quality of medical services since clinicians could not get information to make good diagnoses and because patients might not understand the treatment regimens prescribed for them. Finally, some immigrants felt that health care providers and some welfare agencies treated them rudely or disrespectfully because of their language difficulties or ethnic backgrounds.
Access problems appeared to be the most severe for undocumented aliens who, in addition to the above-mentioned problems, also feared that government institutions might report them to the Immigration and Naturalization Service and who were sometimes completely ineligible for subsidized services. For example, at the time of our visits, the main public hospital systems in Houston and Miami would not provide locally-subsidized health care services to undocumented aliens, although the policies appear to have broadened since our visits.
For immigrants who retained coverage, Medicaid managed care could be quite confusing. Immigrants often did not understand managed care plan and primary care provider choices and often were assigned to unfamiliar health care providers who did not speak their languages or know their medical histories. In many cases, immigrants did not get information materials in their languages. There were also cultural misunderstandings because the requirements of managed care were so much more complicated than the health care systems that they were familiar with in their home countries.
In each area, the core public safety net providers reported that they were losing Medicaid patients and revenue, while the number of uninsured patients were rising. Immigrant eligibility changes were just one part of broader array of difficulties, such as broader reductions in Medicaid caseloads, new requirements under Medicaid managed care and general competition in the health care arena. Facilities were shifting resources to try to hold down expenses while also looking for new revenue streams. Thus, there was often increased competition for the remaining Medicaid clientele and the new SCHIP enrollees.
Analyses of data from New York indicated that hospitals in high immigrant areas faced greater problems with bad debt and uncompensated care and higher growth in the uninsured patient load. Birth data from Los Angeles indicated that the number of deliveries paid by Medicaid fell twice as rapidly for foreign-born mothers as for native-born mothers.
In some cases, the loss of Medicaid revenue was at least partially offset by new revenue sources. For example, Los Angeles Public Private Partnership program (funded under a Medicaid Section 1115 waiver) was helping nonprofit clinics pay for care for low-income uninsured patients, many of whom were immigrants. Similarly, the expansion of New Yorks SCHIP program, Child Health Plus, was also helping to ensure that immigrants children were still getting insurance coverage.
Despite these problems, in each community there were also innovative attempts to improve services for immigrants. For example, Medicaid managed care contracts in New York added requirements for language accessibility and encouraged the use of services like AT&T Language Line or similar telephone-based interpretation services where applicable. In Houston, a Catholic hospital system developed a mobile van to improve access to preventive services for hard-to-reach people, especially immigrants, in the community. In Los Angeles, community groups had developed a small insurance network for low-income immigrants. In many cases, community service organizations were partnering with health clinics or hospitals to improve outreach and translation services.
The loss of federal Medicaid and SCHIP funding for recent immigrants effectively meant that state and local governments must bear heavier responsibilities in determining whether to cover the gaps left by the change in federal policies. Each of these four states opted to cover recent legal immigrant children in their SCHIP programs, although Florida recently decided that it was not going to cover any more of them unless federal matching funds were available.
California made the broadest commitment to continue to provide full Medicaid and SCHIP coverage to recent immigrants, using state-funded add-ons. This policy action may seem somewhat paradoxical because California was also the state with the most visible and contentious policy debate concerning immigrants, particularly under the administration of former Governor Wilson. The other three areas had more inclusive political rhetoric, but did not extend any state-funded Medicaid coverage for recent immigrants. One possible explanation is that the controversy generated by the public debate in California helped coalesce immigration advocates in that state to generate the political will to enact the broad policies, while the lower level of conflict or controversy in the other three states made it difficult to do anything but accept the federal default policies.
In each area, the policies were not entirely shaped by monolithic government decisions, but were also influenced by local advocacy groups and by the interplay of state and local policies. Advocates used education, persuasion and sometimes litigation to broaden immigrants services. Local governments sometimes took special efforts to help support immigrants insurance eligibility, knowing that they would otherwise bear much of the cost of uncompensated care through their public hospitals and clinics.
A final important element was the traditional strength of the health and social safety nets in each area. New York and California are more affluent states with deeper safety net capacity, so that Los Angeles and New York City could more readily absorb the additional responsibilities for the care of uninsured immigrants than Houston or Miami. While Medicaid offers greater federal support in low-income areas, through the design of the Medicaid matching rate, additional health care responsibilities that must be financed outside of Medicaid can pose more difficulties in lower-income areas.
Low-income immigrants access to health care services was precarious before welfare reform was enacted and has weakened since then. There have been numerous responses to the loss of Medicaid coverage. Immigrants appear to have shifted care increasingly toward safety net providers that can offer free or reduced-price care, but have also delayed or avoided medical care and turned to alternative, sometimes underground, health care providers for services.
The actions of state and local governments and safety net providers cushioned the effects of the federal policy changes; they bore additional responsibilities and costs. These state and local efforts might not be sustainable. With time, the number of immigrants who arrived after 1996 and who are ineligible for Medicaid will grow. Some state and local economies are showing signs of weakening after many years of economic growth. It is not clear whether they will be able to continue these policies, much less improve upon them. In addition to insurance eligibility and health care financing issues, there are many other issues like language and outreach services that can be equally important in ultimately affecting immigrants access to health care.
1. Under federal law, immigrants who entered the United States after 1996 are not eligible for full Medicaid or SCHIP coverage, but the costs of emergency care provided under Medicaid can be covered. States can opt to use state funds without federal matching funds to add-on nonemergency coverage to either SCHIP or Medicaid coverage for these immigrants. [ Back to text ]