Download Health Care for Immigrant Families – Current Policies and

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