Overall national estimates of the number of noncitizen immigrants on Medicaid, based on the combination of QC and SSA data, are presented in Table ES-1. About 2.4 million of the 32 million Medicaid enrollees in an average month in 1994 were noncitizens (including undocumented aliens with emergency coverage only). This is 7.5 percent of the total caseload. Measured another way, about 3.2 million immigrants were enrolled in Medicaid over the course of a year. Insofar as noncitizens are 12.6 percent of the population under poverty, according to the 1996 Current Population Survey, the number of immigrants on Medicaid is less than might be expected given their poverty. Adult and aged beneficiaries were more likely to be immigrants than were children or the disabled. A major reason for the low percentage among children is that immigrants' children areoften native citizens born in the U.S. The total Medicaid expenditures for noncitizens (excluding Disproportionate Share Hospital or DSH payments) were $8.1 billion, or 6.9 percent of total expenditures.
Table ES-1. National Estimates of Noncitizen Immigrants on Medicaid in 1994,
Based on Combined QC and SSA Data
Source: Urban Institute analyses of Medicaid QC and SSA data
Number of Noncitizen Medicaid Enrollees
Proportion of Enrollees in Category Who Are Noncitizens
Medicaid Expenditures for Noncitizens
PRWORA and later legislation create a very complex set of rules for determining the Medicaid eligibility of immigrants. While legal permanent residents are barred from full Medicaid coverage for their first five years in the U.S., refugees and asylees may participate in Medicaid for their first seven years in the country. Undocumented aliens were already barred from full participation in Medicaid. More detailed data on the citizenship/immigration status of Medicaid beneficiaries are only available in the QC data base, which lacks complete information about aged, blind and disabled beneficiaries. In the QC data base, 7.4 percent of Medicaid enrollees are noncitizens, which is slightly different than the combined estimate of 7.5 percent. Table ES-2 provides national estimates of more detailed immigration status, based on the QC data in 1994.
Table ES-2. Distribution of Medicaid Enrollees in QC Sample, by Immigrant Category, 1994
* PRWORA designates some immigrants as "qualified" and the rest are "not qualified." Regular legal immigrants, refugees and asylees are "qualified", although this does not mean that they are entitled to benefits. Under the new law, PRUCOL and undocumented aliens are not qualified and are barred from many programs, including Medicaid. The PRUCOL group was previously eligible for Medicaid, but the undocumented aliens were not. In this report, the group labeled "not qualified" includes the PRUCOL immigrants, while undocumented aliens are reported separately. More complete definitions of each category are provided in Table 2 of the report.
Only a small share of the pre-enactment (i.e., arrived in the U.S. before August 1996) Medicaid enrollees has lost eligibility, the "not qualified" group, including PRUCOL immigrants. The main effects are for post-enactment (i.e., arrive after August 1996) regular immigrants, who will be ineligible for Medicaid for five years. Because of changes in the rules for "deeming" income, a large fraction (perhaps most) of the immigrants will still be ineligible after five years expires. In determining eligibility, the income of those who sponsored immigrants will be deemed available to them, making it more difficult for immigrants to qualify as sufficiently poor. The Balanced Budget Act of 1997 modified PRWORA, so that most immigrants who were on SSI in August 1996 will retain both SSI and Medicaid benefits. Those in the U.S. before that date who later become disabled can also qualify for SSI. However, the elderly and disabled immigrants arriving after August 1996 will not qualify for SSI or Medicaid unless they become citizens or meet other exemptions. In general, the immigrant-related rules no longer apply for those immigrants who naturalize into U.S. citizenship.
The discussion above describes the basic federal rules under welfare reform. States have leeway to customize rules. Wyoming, for example, has elected to extend the bar on Medicaid participation to immigrants who entered the U.S. before August 1996; immigrants who were already on Medicaid will lose benefits. Texas has announced that it intends to continue to extend the bar for post-enactment immigrants beyond five years, until they become citizens. Other states, such as Washington and Hawaii, have chosen to partially protect immigrants, using state funds to cover some benefits lost under the federal law.
At this time, California is continuing to provide full Medicaid coverage to post-enactment and PRUCOL immigrants. Although California's governor proposed changing the rules to match the basic federal guidelines, the legislature did not enact these changes. Thus, prior state eligibility rules still apply. The governor will probably propose these changes again in 1998, so that the policies may change in the future. It seems likely that the federal government will not match state expenditures for non-emergency care provided to post-enactment immigrants in California, but there are a number of technical issues that still need to be resolved in determining state and federal shares.