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Leighton Ku, PhD, MPH Director, Center for Health Policy Research Oct. 2016 Immigrants and Health Centers • Immigrants contribute to CHCs as patients and as staff. • Many patients are immigrants. Some CHCs are migrant health centers or focus on care for ethnic groups or immigrants. Immigrant patients serve on CHC boards. • Many physicians, nurses, and other staff at CHCs are immigrants (or children of immigrants). • CHCs should be trusted providers to immigrants, as well as other disadvantaged clients. • CHCs have special obligation to provide quality care, regardless of immigration or insurance status, including appropriate language services and cultural awareness. Immigration Can Be Controversial • A hot button issue this election season. • Some try to portray immigrants as: – Undermining traditional cultural values. – Stealing jobs. – Criminals. – Terrorists. – Not worthy of help. High users of welfare. • Xenophobia often mixed with racism & religious bias. • Often inflamed as “wedge” political issue, both in US and other countries. Immigrants Contribute to America • Create jobs, businesses & economic growth. Do not generally reduce employment or wages of citizens. (Nat. Acad Science) • Due to low domestic birth rate, immigrants will be majority of future US labor supply growth. Will drive future economy. • High labor participation & marital rates. • Less likely to commit crimes or be jailed. • Recent study found that the risk of being killed by an immigrant terrorist is 1 per 4 million population (mostly due to 9/11). Risk of gun homicide is 100x higher (mostly from citizens). • Pay taxes. Contribute to Social Security & Medicare surpluses. Immigrants as Americans • US has always been a nation of immigrants. Newcomers constantly refresh the nation. • About 1/8 of all Americans are immigrants. Another 1/8 are 2nd generation children of immigrants. • 25% of US children have immigrant parents. Mixed families. • Assimilation. 1st generation immigrants more disadvantaged & poorer than native-born, 2nd generation looks like other Americans in income, home ownership, education. Immigrants Become “Us” Two-thirds Who Enter as Child Immigrants Become Citizens by the Time They are 30. Not Yet Citizens 34% Naturalized Citizens 66% Source: Ku, 2009. March 2008 Current Population Survey data about citizenship status of those 30 years or older who entered as immigrants before the age of 18. Will Immigration Reform Occur? • Clinton supports a path to citizenship. Trump wants to sanction/deport undocumented and “build a wall.” • Either would be very difficult to pass in Congress without bipartisan support. Earlier bipartisan plans collapsed. • Even if something moves forward, major federal expansions of health insurance for unauthorized immigrants unlikely. Too controversial and expensive. • Changes at state levels more likely. (California) Immigrant Health Care Providers • About one-quarter of US physicians are immigrants (or foreign-educated) and about one-sixth of US nurses too. • Disproportionate share of primary care physicians, internists, family physicians, pediatricians. • Essential to care in safety net settings and primary care. • Data less available for other staff, but many others – whether clinicians or administrative or enabling staff – are immigrants. • Bring professional skills as well as language and cultural skills to enrich CHCs. Percent of Medical Residents Who Are Immigrants or Foreign Trained, by Field 42% 34% Internal Medicine Family Medicine 23% 21% Pediatrics All Other Specialties Sources: Accreditation Council for Graduate Medical Education, 2014 Immigrant Clinicians • Often practice in safety net settings. Often use J1 or H1B visas, linked to practice in underserved communities. • Must obtain visas and work permits. Even if experienced, typically must have a US medical residency. Face additional licensing barriers or delays because their education and experience is from another country and/or due to language proficiency. • Similar issues for nurses and other health professionals. • Challenge to help them adapt to new environment and encourage them to remain in safety net settings. Immigrants – A Complex Legal Tapestry ADULTS CHILDREN •Naturalized citizens •Lawfully Present •Lawful Permanent Residents (LPRs) •Refugees & asylees •Temporary legal (e.g., visas) •Unauthorized (Illegal) •Deferred Action (DACA) (DAPA suspended) •Citizens: US born with immigrant parents •Naturalized citizens •Lawfully Present •LPRs •Refugees & asylees •Temporary legal •Deferred Action (DACA) •Unauthorized Unauthorized & DACA • An unauthorized immigrant lacks legal authorization to be in the US at that time. Status can change. • Many immigrants enter legally with a visa, but visa expires or they violate terms of entry. Then unauthorized. • May get pending status or regain legal status. • Deferred Action for Childhood Arrivals (DACA) is an administrative program for temporary legal status of unauthorized children (under 31 in 2012) who have stayed in school and been crime-free. 2 year, may be renewed. • DAPA for parents proposed, but blocked in court. Complicated Insurance Eligibility Status Medicaid/CHIP Exchange/Subsidies Medicare Citizen (including US born children) Yes Yes Yes Lawfully Present Some, not DACA Yes, not DACA Yes Lawful Permanent Resident 5 year wait, except preg women & children (ICHIA) Yes Yes Refugee/Asylee Yes Yes Yes Temporary Legal Immigrant No Mostly Yes, not DACA Mostly No Unauthorized No No No Other Key Rules State, income, age & category Income, other insurance 10 years Soc Sec earnings Does the Individual Mandate Apply? • In 2016, uninsured individuals subject to $695/adult or 2.5% of income federal income tax penalty. Half as high for uninsured children. • Mandate applies to citizens and lawfully present immigrants. • Mandate does not apply to unauthorized immigrants, but does to legal family members. • Exemptions for those with income below federal tax level, those not eligible for Medicaid or exchange, or those whose insurance premiums would cost more than 8% of income. Application & Verification • Healthcare.gov website in English and Spanish. Some info in other languages • Medicaid, exchange applications ask legal status. Nonapplicants (e.g., family members) need not report. • Applicants should not be asked if they are unauthorized. • Asked for Social Security numbers. Don’t use ITIN. • Verified against DHS SAVE database. If SAVE cannot identify legal status, they need to provide more documentation. If they can’t, they may be dropped. • These data not used for immigration enforcement. • All application information is confidential. Language Access • Under Executive Order 13166 and Civil Rights Act of 1964, health providers must provide free interpretation/translation services to patients who have “limited English proficiency.” • HHS Culturally and Linguistically Appropriate Services (CLAS) Standards (thinkculturalhealth.hhs.gov) • Almost all CHCs provide language access, including interpreters, language lines, etc. • Relevant not only for clinical staff, but admin staff too. Outreach Issues for Immigrants • Many come to CHCs for care, but are uncertain about enrolling in insurance due to complications and fears. • Staff should try to gently encourage insurance enrollment. Don’t ask whether unauthorized. • CHCs can provide primary care to uninsured unauthorized, but some may be deterred by sliding scale fees. • Without insurance, immigrants may have problems specialty or hospital care, or affording medications. • Language barriers. Often bring family or friends to help. Multilingual eligibility staff and forms important. • Can work with local community groups, schools and foreign language media to help spread word. Among Low-income, Non-citizen Immigrants Receive Fewer Public Benefits • Because immigrants tend to have lower incomes, a large share of non-citizen immigrant families have a member who receives public benefits like Medicaid or SNAP. • But, after accounting for income and the fact that most children in immigrant families are citizens, immigrants actually receive fewer benefits than low-income citizens. • Immigrants less likely to get medical care, even ER care. • As a result, immigrants are more likely to need care from CHCs and to use other charitable services. • Immigrants tend to use fewer health services. Low income Immigrants Adults Less Likely to Use Medicaid, More Likely to be Uninsured, 2011 58.9% 25.6% 29.0% 27.9% 31.3% 19.7% Medicaid Native-born Source: Ku & Bruen, 2013 Uninsured Naturalized Non-citizen Low income Immigrant Children Likely to Use Medicaid or CHIP. More Likely to be Uninsured, 2011 65.1% 69.7% 48.9% 37.7% 12.2% Medicaid/CHIP 16.9% Uninsured Citizen Child w Citizen Parents Citizen Child w Non-citizen Parents Non-citizen Child Source: Ku & Bruen, 2013 Non-citizen Immigrant Adults Less Likely to Have Office-Based Doctor or ER Visit in Last Year 93.8% 83.4% 9.3% Any doctor visit Citizen 5.2% Any ER visit Non-citizen Source: GW analysis of 2012 National Health Interview Survey Both differences are significant p < .001 21 Myth: After Health Reform, Most of the Uninsured Are Illegal Aliens Fact • In 2015 73% of uninsured Citizens were citizens. 27% were noncitizen immigrants. 20.9 mil. (73%) • Unauthorized smaller share (12-15%?) • The health care safety net remains essential for both citizens AND noncitizens. Uninsured Noncitizen immigrants 2015 National Health Interview Survey 7.6 mil. (27%) Trends for CHC Patients in PA 20% 17% 15% 12% 10% 5% 5% 0% Limited English 2013 Latino 2014 Source: Uniform Data System reports, HRSA Asian 2015 Census Data about PA Immigrants • Foreign-born rose from 4.1% in 2000 to 6.4% in 2014 • 51% are naturalized citizens, 49% noncitizens • Region of birth: Asia 39%, Latin America 31%, Europe 20%, Africa 7%, North America 2% • Speak English less than “very well” or not at all: naturalized citizens 33%, noncitizens 52% • Primary languages among those with limited English: Spanish, Chinese, Vietnamese, Russian, Korean (>10,000) • 22% work in education or health care fields • 18% below 100% poverty, 21% 100-199% poverty PA Refugee Resettlement • Refugees often have special needs, including language, mental health and medical and social services. • Federal govt and local agencies provide transitional help. • Resettlement program assists in finding homes, social assistance, employment training, English as 2nd language, etc. • Leading regions of resettlement: Central PA (Lancaster area), Philadelphia, Erie and Pittsburgh areas. • Leading countries of origin: Syria, Congo, Bhutan, Somalia, Burma, Afghanistan Special Issues for Immigrants • HHS CLAS standards. • State legislation? • Appropriate language services (bilingual staff, interpreters, language lines) and forms. Enrollment assistance. • Medical-legal partnerships for social or immigration issues • Linkages with community groups, including refugee resettlement • Patient education • Special sensitivity about mental health issues