SCHIP and Access for Children in Immigrant Families

By Anne Morse

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Item # 6682

Contents

Executive Summary

SCHIP and Access for Children in Immigrant Families

Immigrant Children at Risk

Welfare Reform and Eligibility for Health Care

The Fear Factor: Perceived Dangers of Applying for Public Aid

States Respond

Conclusion

Appendix A. Common Immigration Terms

Appendix B. Federal Funds For Outreach

Suggested Resources

Some Useful Websites

56 Pages

Ordering Information

Executive Summary

In 1997, Congress created the State Children's Health Insurance Program (SCHIP) in an effort to expand coverage for low-income, uninsured children. Although enrollment in the program is proceeding apace, state policymakers continue to worry about their ability to reach out to specific subgroups, including the large population of children in immigrant communities.

This report provides an overview of citizen and noncitizen children in immigrant families in the United States and their access to SCHIP. The section entitled "Immigrant Children at Risk" describes the population, their rising numbers, and their lack of health insurance. The next section reviews the effects of the 1996 welfare reform law on immigrants' eligibility for health care, and studies that indicate enrollment is down even for eligible immigrant families. The report then examines some of the factors affecting enrollment, such as fears of public charge, verification of citizenship and immigrant status, and language and cultural barriers. Finally, the paper outlines examples of state responses through state-funded health care and improvements in outreach, application and enrollment. Examples from California, Texas, New Mexico and Florida are given. The appendices include definitions for common immigration terms and a description of federal funds available for outreach and enrollment to the immigrant population (SCHIP, Medicaid, and the Temporary Assistance for Needy Families program.)

One in five children under age 18 (14 million) is either an immigrant or is a member of an immigrant family. Three-fourths of the children are U.S. citizens (born in the United States), while the remaining one-fourth are noncitizens. Since 1990, the number of children in immigrant families has risen seven times faster than the number in U.S.-born families, and they are more likely than those with U.S.-born parents to live in poverty and are less likely to have health insurance and to receive medical care. For example, first-generation immigrant children are three times as likely as children with U.S.-born parents to lack health insurance, and second-generation children are twice as likely to lack it. One in four uninsured children, or 2.8 million, lives in a noncitizen family.

This lack of insurance for noncitizen and citizen children in immigrant families, combined with their lower access to health care, means that these children are " ... less likely to receive timely care for acute conditions (such as ear infections, injuries, or communicable diseases), less likely to have their chronic conditions (such as asthma or diabetes) diagnosed and appropriately managed, and less likely to receive preventive care." The lack of primary and preventive care is also potentially costly by allowing disease to become more serious and resulting in the increased use of hospital emergency rooms.

Confusion among immigrants about their eligibility for public assistance may stem in part from the 1996 federal welfare law, which instituted new restrictions on access to health care. The law complicated an already complex system of program eligibility for immigrants by creating new categories (qualified and not qualified) and by distinguishing between those who entered before and after enactment of the law.

Welfare reform has already had a measurable impact on immigrants' use of public benefits. A 1998 Urban Institute study of Los Angeles County, for instance, reported that the complex welfare reforms and policy changes appears to have had a chilling effect on use of benefits for which immigrants remain eligible. In New York, a series of focus groups found that parents are often unaware of Medicaid and SCHIP eligibility requirements and face significant barriers in enrolling their children, including a complex and lengthy Medicaid enrollment process; eligibility workers who are uninformed and who discourage enrollment; and language, literacy and cultural barriers.

Public Charge. Many immigrant families have become reluctant to seek health services for fear of jeopardizing their immigration status. The most significant factor in that equation is public charge, a federal law enacted more than 100 years ago to prevent immigrants from becoming reliant on public aid. In May 1999, the INS issued new guidance on the public charge law to state explicitly that immigrants will not be considered a public charge for using health care benefits, including Medicaid, SCHIP and other health programs (except government-paid institutionalization for long-term care).

Verification Issues--Citizenship, Immigration Status, Social Security Number. The 1996 welfare law requires states to verify that all applicants for SCHIP and Medicaid are citizens, nationals or qualified immigrants, without regard to sex, color, race, religion, national origin or disability. States must verify U.S. nationality by examining documents: 10 primary and 19 secondary evidence documents exist to prove U.S. nationality. Eligibility workers will need additional training to recognize the 29 documents and the 26 types of identification for immigrant status.

The U.S. Department of Justice has issued an interim guidance and a proposed rule on verification of citizenship and immigration status for determining eligibility for public benefits under welfare reform. Verification should be used only when the benefit is contingent on citizenship or immigration status, and applied only to the person receiving benefits. Once the proposed rule is finalized, there is a two-year implementation period to come into compliance.

A Social Security number is not required for SCHIP applicants, though it is required for applicants and recipients of Medicaid benefits. Children who are eligible for Medicaid may not be enrolled in SCHIP, which means they must first be checked for Medicaid eligibility, with the corresponding Social Security number requirement. If the child is ineligible for Medicaid, the state must avoid asking for the number on the subsequent SCHIP application. HCFA has notified states that when families apply for SCHIP or Medicaid, they may not require Social Security numbers for nonapplicant parents or other nonapplicant household members, though parents may voluntarily give their numbers. Noncitizen parents may be deterred from enrolling their children in SCHIP because they either do not have a Social Security number or are afraid that the information could be given to the INS.

Many immigrant children live in "mixed status" households in which one or more parents is a noncitizen and one or more children is a citizen. That means some children in the family may be eligible for SCHIP, while others may not. Nearly one in 10 U.S. families with children is of mixed-status, comprising legal immigrants, refugees, undocumented immigrants and/or naturalized citizens. That variation in eligibility within families may affect the parents' decision to seek benefits and may complicate the provision of services such as immunizations or treatment of communicable diseases.

As of 1990, 32 million U.S. residents-about 14 percent of the population-spoke a language other than English at home. More than half spoke Spanish, and the remainder spoke 24 different languages. In some states, the percentages are higher than the national average: 36 percent in New Mexico, 31 percent in California, and 20 percent each in Arizona, Hawaii, New Jersey, New York and Texas. The increasing diversity of the U.S. population is challenging the ability of health care providers to provide adequate translation and interpretation services for the needs of their patients.

Linguistic and cultural differences can lead to poor doctor-patient communication, possible improper diagnoses and the ordering of expensive, often unnecessary, tests. In many cases, providers have relied on the patient's English-speaking children or non-medical personnel for translation, which may affect patients' candor and potentially violate patient confidentiality. Ultimately, communication barriers can cause delays in treatment and an increase in the cost of care.

State-Funded Health Programs. Several states have stepped forward to fill the gap in health care by creating state-funded programs to serve the health needs of legal immigrant children who are barred from SCHIP and Medicaid by the federal welfare law. California, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Minnesota, Nebraska, New York, Pennsylvania, Rhode Island, Texas, Virginia and Washington are currently using their own funds to provide assistance to at least some of these children.

Outreach, Application and Enrollment. In an effort to focus outreach and enrollment in nontraditional ways to diverse ethnic populations, states have developed a variety of methods to get the word out and make it simpler to apply. In addition to outreach funds authorized under SCHIP, states are tapping into funds that are available through Medicaid and the Temporary Assistance to Needy Families (TANF) program to support education, outreach, training and enrollment activities. Within SCHIP, they can spend administrative funds on "health services initiatives" that can be targeted to low-income immigrant communities. Under both Medicaid and SCHIP, they may use administrative funds for outreach, while under TANF, they can use the TANF funds or state maintenance-of-effort funds to inform applicants and recipients of their eligibility for SCHIP and Medicaid. States may also count medical assistance, including insurance, as part of their maintenance-of-effort requirements under TANF. Finally, a $500 million TANF/Medicaid outreach fund, which was about to expire, has been extended past the year 2000. Created to address Medicaid administrative costs attributable to welfare reform, the fund provides states with an enhanced match rate for both outreach and administration.

Taking advantage of available federal and state SCHIP, Medicaid and TANF funds to expand outreach and enrollment and develop creative strategies, states are making some gains in enrolling uninsured children in immigrant families into SCHIP and Medicaid. Key to their success is working with local grassroots intermediaries that have a "reservoir of trust" in immigrant communities and can counteract misinformation about eligibility for care and the potential for adverse immigration effects for families that accept health care benefits.

Other effective outreach methods include creating translated materials that use clear and understandable language and are linguistically and culturally sensitive to the target community; promoting the programs on ethnic television, radio and print media; developing simplified applications and providing assistance in filling them out; and hiring and training bilingual staff. Particularly important is outreach that is independent of welfare offices, assuring noncitizen parents that health care is available for their children and that it will not endanger their immigration status with the INS.

Education and additional research is still needed, however. Public charge, for example, remains a serious concern for immigrant families, and there is a need for better data collection on ethnicity as well as examination of services to language-minority populations, the feasibility of providing health care only to children and not to families, the treatment of "mixed status" families, and ways for states to share "best practices."

In the long term, the five-year federal bar and loss of federal matching funds could have significant consequences for state SCHIP and Medicaid budgets. Congressional action is required to change the bar and restore the match for postenactment immigrant children. In the meantime, states must make their own decisions about providing and paying for health care for the population as well as addressing barriers for non-English-speaking families and targeting outreach to encourage parents to enroll their eligible citizen and noncitizen children.

In 1997, Congress created the State Children's Health Insurance Program (SCHIP) in an effort to expand coverage for low-income, uninsured children. (See Figure 1.) Although enrollment in the program is proceeding apace-as of April, 1999, one million of the estimated 2.5 million eligible children were participating-state policymakers continue to worry about their ability to reach out to specific subgroups, including the large population of children in immigrant communities, and bring them under the SCHIP umbrella.

As recent studies suggest, the number of children in immigrant families is on the rise, and they are less likely to have health insurance than are the children of native-born or naturalized parents. Nor, for a variety of reasons, are immigrant parents enrolling their eligible citizen or noncitizen children in CHIP. Among the confounding factors: confusion about program rules; fears associated with the 1996 welfare reform and immigration laws; family members with different immigration status and therefore mixed program eligibility; the perceived stigma of Medicaid (and by extension, CHIP) as welfare; and linguistic or cultural differences that stand as barriers to enrollment and obtaining services. (For ease of reference, the terms immigrant and noncitizen are used interchangeably in this paper and, unless specifically noted, refer to immigrants who are legal residents of the United States.).

According to a 1998 study by the National Research Council and Institute of Medicine, one in five children under age 18 (14 million) is either an immigrant or is a member of an immigrant family. Three-fourths of the children are U.S. citizens (born in the United States), while the remaining one-fourth are noncitizens. Since 1990, the number of children in immigrant families has risen seven times faster than the number in U.S.-born families, and they are more likely than those with U.S.-born parents to live in poverty and are less likely to have health insurance and to receive medical care. For example, first-generation immigrant children are three times as likely as children with U.S.-born parents to lack health insurance, and second-generation children are twice as likely to lack it. (1)

A 1999 report by the UCLA Center for Health Policy Research confirms and expands on those findings. According to the Center, the uninsured rate for noncitizen children is triple that of children whose parents are native-born or have become naturalized citizens. For citizen children with noncitizen parents, the rate is double that of those whose parents are citizens. Overall, the Center reports that one in four uninsured children, or 2.8 million, lives in a noncitizen family. (2)

Regardless of their immigrant or citizenship status, uninsured children generally have parents who are employed: 90 percent of them have at least one working parent, and more than half have parents with full-time, full-year employment. Children with noncitizen parents in full-time jobs are less likely to enjoy job-based health insurance, however; only about half of them have such coverage, compared to 80 percent of citizen children whose parents are naturalized or U.S.-born. (3)

Poverty is a significant indicator in immigrants' lack of insurance. Forty-nine percent of noncitizen children in families with income below the federal poverty level are uninsured, compared to 26 percent of citizen children of naturalized parents and 19 percent of citizen children of U.S.-born parents. (4) Poor, noncitizen children whose parents lack job-based coverage or private insurance are also enrolled in Medicaid at lower rates than are poor citizen children: 41 percent have Medicaid coverage compared to 73 percent of poor children of U.S.-born parents. Although numerical estimates of uninsured noncitizen children who are eligible for SCHIP are difficult to assess, Table 1 demonstrates the high percentage of uninsured children in poor or near-poor immigrant families.

The lack of insurance for noncitizen and citizen children in immigrant families, combined with less access to health services, means that they are "...less likely to receive timely care for acute conditions (such as ear infections, injuries, or communicable diseases), less likely to have their chronic conditions (such as asthma or diabetes) diagnosed and appropriately managed, and less likely to receive preventive care." (5) The lack of primary and preventive care is also potentially costly by allowing disease to become more serious and resulting in the increased use of hospital emergency rooms.

Confusion among immigrants about their eligibility for public assistance may stem in part from the 1996 federal welfare law, which instituted new restrictions on access to health care. The law-known as the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, P.L. 104-193- complicated an already complex system of program eligibility for immigrants by creating new categories (qualified and not qualified) and by distinguishing between those who entered before and after enactment of the law. (The term qualified encompasses categories of immigrants considered to be in the U. S. legally but it does not connote automatic eligibility for benefits. Immigrants must meet the same eligibility requirements as citizens.)

 The main health care provisions of the welfare law are:

• Preenactment immigrants: Immigrant children legally in the U. S. before Aug. 22, 1996-the date the welfare law took effect-are considered qualified immigrants. The Health Care Financing Administration (HCFA) has determined that they must be covered by SCHIP and are eligible on the same basis as citizens. Under Medicaid, states have the option of covering preenactment children but they must cover refugees and refugee-like categories as well as veterans and active duty military. Currently, all states but Wyoming extend Medicaid to preenactment children.
• Postenactment immigrants: Children who legally enter the U. S. on or after Aug. 22, 1996, are also qualified immigrants, but they are barred from SCHIP and Medicaid for their first five years of residence. Refugees and refugee-like categories, as well as veterans and active-duty military, are exempted from the bar.
  
  After five years of residence, "deeming"-counting the income and resources of the sponsor and his or her spouse as the immigrant's in determining eligibility for federal means-tested benefits, which may increase the family's income above the eligibility threshold-applies to applicants for both SCHIP and Medicaid until the immigrant either becomes a citizen or earns 40 quarters of qualifying work. Sponsor deeming affects those immigrants who 1) entered the United States to join family and were required to have a financial sponsor and 2) signed the new legally binding affidavit of support after Dec. 19, 1997. To minimize the deeming period, two working parents could together earn 40 qualifying quarters in five years and credit the quarters to their minor children. In addition, states have the option of applying deeming to state means-tested programs.
• Illegal immigrants: Immigrants who enter or live in the U. S. without official authorization (by entering illegally or violating the terms of their visa) continue to be ineligible for any medical assistance, other than emergency care under Medicaid. The welfare law did, however, make an exception for public health assistance financed through sources other than Medicaid for immunizations and for testing and treatment of symptoms of communicable diseases. (One group of immigrants formerly considered legal and eligible for public benefits has now been shifted into the nonqualified category and is thus ineligible: Permanently Residing Under Color of Law (PRUCOL), which had covered about 16 categories of immigrants residing in the United States with the knowledge of the Immigration and Naturalization Service (INS). Some PRUCOL immigrants, such as refugees, were granted qualified immigrant status. See common terms in Appendix A).

Welfare reform has already had a measurable impact on immigrants' use of public benefits. A 1998 Urban Institute study of Los Angeles County, for instance, reported that the complex welfare reforms and policy changes appears to have had a chilling effect on use of benefits for which immigrants remain eligible. From 1996 to 1998, approved applications for welfare and Medi-Cal (California's Medicaid program) for families headed by noncitizens fell 52 percent; for citizen-headed families, there was no change. (6)

In New York, meanwhile, a series of focus groups found that parents are often unaware of Medicaid and SCHIP eligibility requirements and face significant barriers in enrolling their children, including a complex and lengthy Medicaid enrollment process; eligibility workers who are uninformed and who discourage enrollment; and language, literacy and cultural barriers. (7) The complex eligibility determinations also consume significant staff time because caseworkers must first determine whether the child is eligible for Medicaid. That process requires submission of a Social Security number, financial status, age of the child, size of the family and residency and immigration status. If the child is ineligible for Medicaid, the SCHIP application is processed. Different family income calculations are also involved for each program. (8)

Perceived Dangers of Applying for Public Aid

Many immigrant families have become reluctant to seek health services for fear of jeopardizing their immigration status. The most significant factor in that equation is public charge, (9) a federal law enacted more than 100 years ago to prevent immigrants from becoming reliant on public aid. Immigrants who the INS or the State Department determine to be a "public charge"-that is, dependent on government assistance-may be 1) denied admission into the United States; 2) ineligible for permanent resident status; and 3) in rare cases, deported. Because the welfare law has reduced immigrants' eligibility for Medicaid and SCHIP, moreover, confusion and ad hoc interpretations of the public charge law have led to mistaken requests for repayment of health benefits and the denial of green cards.

In May 1999, the INS issued new guidance on the public charge law to state explicitly that immigrants will not be considered a public charge for using health care benefits, including Medicaid, SCHIP and other health programs (except government-paid institutionalization for long-term care). Other programs excluded from public charge consideration include immunizations, prenatal care or other free or low-cost medical care at clinics, health centers or other settings; testing and treatment of communicable diseases; and emergency medical assistance. (10)

The agency's guidance defines public charge as someone who has become (for deportation) or is likely to become (for admission or adjustment of status) "...primarily dependent on the government for subsistence, as demonstrated by either the receipt of public cash assistance for income maintenance, or institutionalization for long-term care at government expense." Receipt of the excluded public health benefits will not jeopardize a person's immigration status because they do not make the person primarily dependent on the government. By law, refugees and those granted asylum are exempt from public charge. (The guidance and proposed rule were issued after extensive consultation with the U.S. Department of Health and Human Services, other benefit-granting agencies, state and local governments and health care providers.)

In publicizing the regulation, HCFA noted that the guidance should remove a major perceived barrier to enrollment for otherwise-eligible immigrants. Immigrant advocacy organizations report, however, that immigrant families remain reluctant to approach government agencies-including health agencies-for fear that workers will turn information over to the INS.

Citizenship and Immigration Status. States have been required to verify the citizenship or immigration status of applicants for Medicaid and some other federal benefit programs since the passage of the 1986 immigration reform law. For citizens, an attestation under penalty of perjury is sufficient, but immigration status must be verified by examining documents and contacting the INS through an electronic verification system called SAVE. States may obtain waivers from using SAVE if they have an equally effective verification method or if the costs of the electronic system would be more than the savings from using it.

The 1996 welfare law also requires states to verify that all applicants for SCHIP and Medicaid are citizens, nationals (11) or qualified immigrants, without regard to sex, color, race, religion or national origin (except that Cuban, Haitian and Canadian nationality may be relevant) or disability. States must verify U.S. nationality by examining documents: 10 primary and 19 secondary evidence documents exist to prove U.S. nationality. Eligibility workers will need additional training to recognize the 29 documents and the 26 types of identification for immigrant status.

Citizen children who are applying for Medicaid or SCHIP may establish citizenship on the basis of self-declaration (i.e., "I attest under penalty of perjury, that I am a citizen or national of the United States.") Immigrant children must provide documentation of their immigrant status, which must be verified by states with the INS. (12) Although the citizenship or immigration status of nonapplicant parents and other household members is irrelevant to the child's eligibility, immigrant families may not be confident that their status will not be investigated.

The U.S. Department of Justice has also issued an interim guidance and a proposed rule on verification of citizenship and immigration status for determining eligibility for public benefits under welfare reform. (13) Among other things, the guidance and rule provide the procedures for examining documents and requesting information from the INS to verify applicants. Agencies must first determine the applicant's eligibility under general program requirements before verifying immigrant status. Verification should be used only when the benefit is contingent on citizenship or immigration status and applied only to the person receiving benefits. The rule instructs agencies not to delay or deny benefits to recipients during the time it takes to verify immigration status. Once the proposed rule is finalized, there is a two-year implementation period to come into compliance. Until then, the procedures are advisory only; states should seek guidance from the federal agency administering the particular benefit for procedures or requirements that may supplement or amend the Department of Justice guidance.

Social Security Number and Income. A Social Security number is not required for SCHIP applicants, though it is required for applicants and recipients of Medicaid benefits. If an applicant does not have a Social Security number, the state is obligated to assist with obtaining one from the Social Security Administration (SSA). SSA cannot give numbers to illegal immigrants.

Children who are eligible for Medicaid may not be enrolled in SCHIP, which means they must first be checked for Medicaid eligibility, with the corresponding Social Security number requirement. If the child is ineligible for Medicaid, the state must avoid asking for the number on the subsequent SCHIP application. If the state's SCHIP is a Medicaid expansion, Medicaid rules apply. HCFA has notified states that when families apply for SCHIP or Medicaid, they may not require Social Security numbers for nonapplicant parents or other nonapplicant household members, though parents may voluntarily give their numbers. (14) Noncitizen parents may be deterred from enrolling their children in SCHIP because they either do not have a Social Security number or are afraid that the information could be given to the INS.

Income verification has been an issue for immigrants in the past because they often work in jobs where employers are "reluctant" to verify income or where income varies significantly from quarter to quarter. Unlike Medicaid, SCHIP does not require verification of income and resources. (States may establish verification requirements for SCHIP, and self-declaration of income and resources is permitted for both Medicaid and SCHIP. However, Medicaid requires verification of self-declared income and resources after the initial eligibility determination.) (15)

Many immigrant children live in "mixed status" households in which one or more parents is a noncitizen and one or more children is a citizen. That means some children in the family may be eligible for SCHIP, while others may not. A child entering the United States after Aug, 22, 1996, for example, would be ineligible for SCHIP, while siblings born in the country would be eligible. Nearly one in 10 U.S. families with children is of mixed-status, comprising legal immigrants, refugees, undocumented immigrants and/or naturalized citizens. (16) That variation in eligibility within families may affect the parents' decision to seek benefits and may complicate the provision of services such as immunizations or treatment of communicable diseases.

State officials also report that "stigma" associated with welfare may be affecting enrollment in health programs. Said Richard Brown of the UCLA Center for Health Policy Research, "We still have a legacy of the welfare origins of Medicaid to overcome. A lot of people perceive Medicaid as a welfare program, and they find it demeaning... that has discouraged people from applying." California officials report that Medi-Cal is associated in the public's mind with welfare, although Healthy Families (the state's SCHIP program) seems to be making progress in encouraging families to enroll.

As of 1990, 32 million U.S. residents-about 14 percent of the population-spoke a language other than English at home. More than half spoke Spanish, and the remainder spoke 24 different languages. (17) In some states, the percentages are higher than the national average: 36 percent in New Mexico, 31 percent in California, and 20 percent each in Arizona, Hawaii, New Jersey, New York and Texas. (18) The increasing diversity of the U.S. population is challenging the ability of health care providers to provide adequate translation (written) and interpretation (verbal) services for the needs of their patients. Bilingual interpreters, particularly those with medical training, are in short supply.

Federal regulations for Medicaid require state programs to operate consistently with the rights of individuals under the Civil Rights Act-the availability of interpretation services, for example, and explanations of rules in simple and understandable terms. Several states have also enacted legislation addressing communication with patients who cannot speak English well or requiring Medicaid contractors to provide language-appropriate services. (19)

Linguistic and cultural differences can lead to poor doctor-patient communication, possible improper diagnoses and the ordering of expensive, often unnecessary, tests. In many cases, providers have had to rely on the patient's English-speaking children or nonmedical personnel for translation, which may affect the patient's candor and potentially violate confidentiality. Ultimately, communication barriers can cause delays in treatment and an increase in the cost of care. Such issues are beginning to be addressed by states that are attempting to extend SCHIP and Medicaid to non-English proficient individuals. (20)

Culturally appropriate treatment is also important because cultural norms vary and causes of disease may be interpreted differently. In some immigrant communities, for example, coughing attacks can be viewed as a "sudden fright," or possession by spirits, and parents may turn to traditional healers or use home remedies such as teas or poultices to treat their children's illnesses Pediatricians need to ask parents about their beliefs-what causes the coughing-and what types of treatments they are providing the child. Then, they can then assess whether the treatments are harmless (or harmful), educate the parents about asthma treatment regimens used in Western medicine and recommend a health educator who speaks the parents' language to explain the disease and the proper use of an inhaler.

Inadequate communication is also a barrier to enrollment for linguistic minorities. Without translated materials or public announcements about the program on television or radio in different languages, non-English-speakers will find it difficult to learn about a program's existence and the fact that they are eligible. After enrollment, these families may continue to face barriers in service delivery if local clinics or safety net providers do not provide bilingual services or employ staff who understand local residents. Immigrant families must also contend with the service issues common to all low-income patients, such as the availability of care at convenient hours for working parents and the availability of transportation and child care.

Several states have stepped forward to fill the gap in health care by creating state-funded programs to serve the health needs of legal immigrant children who are barred from SCHIP and Medicaid by the federal welfare law. California, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Minnesota, Nebraska, New York, Pennsylvania, Rhode Island, Texas, Virginia and Washington are currently using their own funds to provide assistance to at least some of these children. (21) For example, in California, legal immigrant children who entered the United States after Aug, 22, 1996, are eligible for the state's Healthy Families program for a one-year period, although future support is conditioned on federal legislation and funds. In 1991, well before the federal SCHIP program was created, New York established Child Health Plus with state money, with the goal of providing health insurance to all New York children independent of the legal status of children or their parents and of length of residence in the U. S. Now that Child Health Plus has been converted to SCHIP, New York is considering a separate, state-only program to serve the large number of uninsured immigrant children who have been barred from SCHIP by the 1996 federal welfare law. (22)

In an effort to focus outreach and enrollment in nontraditional ways to diverse ethnic populations, states have developed a variety of methods to get the word out and make it simpler to apply. Among the strategies: bilingual advertisements and application forms; interpreters; application assistance; toll-free telephone hotlines and Internet-based application forms; use of ethnic media; and partnerships with community organizations, ethnic associations and businesses that serve immigrants.

In addition to outreach funds authorized under SCHIP, states are tapping into funds that are available through Medicaid and the Temporary Assistance to Needy Families (TANF) program to support education, outreach, training and enrollment activities. Within SCHIP, they can spend administrative funds on "health services initiatives" that can be targeted to low-income immigrant communities. Under both Medicaid and SCHIP, they may use administrative funds for outreach, while under TANF, they can use the TANF funds or state maintenance-of-effort funds to inform applicants and recipients of their eligibility for SCHIP and Medicaid. States may also count medical assistance, including insurance, as part of their maintenance-of-effort requirements under TANF. Finally, a $500 million TANF/Medicaid outreach fund, which was about to expire, has been extended past the year 2000. Created to address Medicaid administrative costs attributable to welfare reform, the fund provides states with an enhanced match rate for both outreach and administration. (Appendix B contains information about federal funds that are available for outreach in SCHIP, Medicaid, and TANF.)

California, home to about a third of the nation's immigrants, has developed community-based partnerships (with schools, clinics, tax preparers and day care centers, for example) to expand outreach and enrollment for its SCHIP program, Healthy Families, as well as for Medi-Cal. The state also provided $1 million in contracts in 1998 for community organizations to provide education and outreach, increased to $6 million by the state legislature in 1999.

California has publicized its SCHIP program through advertising in English and Spanish on radio, television and billboards and is now focusing on local ethnic media and talk shows, especially for the Latino population. It also conducts outreach through corporate sponsorships such as drug stores, grocery stores, public transit and utilities.

In addition, the state has simplified and shortened the application form from 28 pages to four and has translated it from English into 10 languages (Spanish, Vietnamese, Cambodian, Laotian, Hmong, Armenian, Cantonese, Korean, Russian and Farsi). Application assistance is available through a toll-free telephone number with multilingual staff available to answer eligibility questions and public charge concerns. The state also trained 15,000 people in 3,000 community-based organizations (CBOs) to be certified application assistants. The CBOs initially received a state-funded incentive payment of $25 per approved application, later increased to $50.

Another successful technique has been the creation of local coalitions that include health care providers, schools, public health and social service agencies and community groups. In the San Francisco Bay Area, for example, such a coalition held a one-day enrollment event, enrolling 489 children in 209 families. Commenting on the strategy, Glenda Arellano, chief of one of the Medicaid eligibility sections in California's Department of Human Services, said that "for the immigrant population, what's really important is for people to talk to someone they know and trust in the community to understand that the INS public charge rule makes it safe to apply for health coverage."

In addition to the state efforts, the California Primary Care Association spearheaded a comprehensive, statewide educational campaign on public charge. Among other things, the association developed a guide for outreach workers, conducted a series of training workshops for clinics and produced a public service announcement in English and Spanish publicizing a toll-free number for clinic referrals and the services and languages available at each clinic.

Of an estimated 328,000 uninsured children eligible for SCHIP, California has enrolled as many as 70,000 in the first year and receives an additional 10,000 to 15,000 applications per month.

After California, Texas has the largest number of uninsured children (1.4 million). more than half of whom are Hispanic. An estimated 240,000 Texas children are citizens with noncitizen parents and are twice as likely to be uninsured as those in citizen families. (23) In January 1999, the Texas Legislature convened for the first time since CHIP was enacted. As part of its state CHIP package, the Legislature decided to offer CHIP-style coverage for legal immigrant children who are affected by the five-year bar, using $35 million of the state's tobacco settlement funds. If federal law is amended to authorize a state option to cover these children, the state will apply for the federal SCHIP and Medicaid matching funds.

Jason Cooke of the Texas Health and Human Services Commission said the plan will begin enrolling children in spring 2000, "capitalizing on the best practices from other states." The outreach program is being informed by focus groups of U.S. citizens and immigrants around the state, with a strong emphasis on the Spanish-speaking population. It will tackle the public charge issue, he said, "by working with community-based organizations that have a reservoir of trust in the community" to communicate the message that applying for benefits does not pose a risk to immigration status.

The state will require that the marketing contractor demonstrate cultural competence for different ethnic populations and recognize both local needs and the concerns of immigrant and U.S. citizen populations. The new SCHIP application will be connected to the Medicaid application, but will not require information from the parent that could be a deterrent to enrolling an eligible child.

New Mexico has created a pilot project targeted at enrolling underserved and special populations in the southern part of the state, particularly the immigrant population and citizen children in noncitizen families. The state is matching a $1 million grant from a private foundation with state Medicaid funds.

The project trains "promotoras"-lay health education volunteers who live in the community,-to provide information about the availability of services and information about Medicaid and public charge. Promotoras are very well known, particularly in immigrant communities, and can help working families learn whether they qualify for medical assistance and allay fears about public charge. In October 1999, the project provided a workshop on the public charge issue and cultural sensitivity training for all state income support workers who process Medicaid, TANF and food stamps.

Carla Chavez of New Mexico Advocates for Children and Families said lessons from the immigrant project can also be applied to other populations such as Native Americans, migrants and rural residents. For example, Medicaid recertification is required annually, and notices are sent out by mail. Often, families are no longer at the same residence and don't receive the notice or don't receive it in time, and automatically fall off the rolls. In another example, New Mexico residents often cross state borders to work in Arizona and Colorado. The system, however, is not set up to handle workers who move from state to state, and their children often lose coverage when managed care providers refuse to pay for out-of-state care. Such problems are causing state officials to examine the system in a much broader sense so it can better serve rural residents and migrant workers.

Florida

As part of its outreach and enrollment effort, Florida convened focus groups to develop materials for multicultural families. One example: migrant farm workers assisted with the creation of a one-page, easy-to-read fact sheet explaining eligibility and issues relevant to immigrants. Enrollment is accomplished through a one-page mail-in application for both SCHIP and Medicaid (available in English and Spanish). The assets test has been eliminated, and applicants may self-declare income. Applications were mailed in English, Spanish and Creole to 30,000 low-income families. People can obtain application assistance and have their questions answered via a toll-free number in Creole, Spanish and other languages. A website, translated into Spanish, Creole and English, provides information on eligibility, enrollment and application forms; the forms can be downloaded in any of the three languages. The state also launched a multimedia campaign in Spanish and English that aired on 1,800 network and 10,600 cable television spots. Univision contributed a video to target the Hispanic population. The Interagency Coordination Project will track changes in enrollment of children and linkages to hard-to-reach populations, including immigrants.

Other states have responded to the challenge by developing a simplified joint application form for SCHIP and Medicaid to avoid the burden of applying for two separate programs (New York) and creating forms that address the special considerations of immigrants, such as, not requiring Social Security numbers, explaining the public charge rule and explicitly stating that information will not be turned over to the INS (Massachusetts).

Taking advantage of available federal and state SCHIP, Medicaid and TANF funds to expand outreach and enrollment and develop creative strategies, states are making some gains in enrolling uninsured children in immigrant families into SCHIP and Medicaid. Key to their success is working with local grassroots intermediaries that have a "reservoir of trust" in immigrant communities and can counteract misinformation about eligibility for care and the potential for adverse immigration effects for families that accept health care benefits.

Other effective outreach methods include creating translated materials that use clear and understandable language and are linguistically and culturally sensitive to the target community; promoting the programs on ethnic television, radio and print media; developing simplified applications and providing assistance in filling them out; and hiring and training bilingual staff. Particularly important is outreach that is independent of welfare offices, assuring noncitizen parents that health care is available for their children and that it will not endanger their immigration status with the INS.

Education is still needed, however. Public charge, for example, remains a serious concern for immigrant families. Although the information from the INS clearly defines how public charge determinations will be made, repeated efforts will be needed to disseminate the message and encourage parents to enroll their children. Researchers and organizations representing immigrants note that the following issues remain to be addressed.

• Continued lack of data on ethnicity in SCHIP enrollment. In a 1998 report, the National Research Council recommended better data collection on country of birth and citizenship status and studies to track the health and well-being of immigrant children.
• Services to language-minority populations once they are enrolled. One issue, for example, is whether there are sufficient medical interpreters to provide quality care.
• The feasibility of providing health care only to children and not to families. Some studies demonstrate that parents are unlikely to get care for children they don't have for themselves. For example, one study shows that children are 12 times more likely to receive dental care if their parents have dental coverage.
• The treatment of "mixed status" families, or similarly situated children in the same family who have different immigrant status and are thus not equally eligible for health care.
• Ways for states and communities to share "best practices," such as examples of effective outreach practices, and to find solutions to particular enrollment barriers.

In the long term, the five-year federal bar and loss of federal matching funds could have significant consequences for state SCHIP and Medicaid budgets. Congressional action is required to change the bar and restore the match for postenactment immigrant children. In the meantime, states must make their own decisions about providing and paying for health care for the population as well as addressing barriers for non-English-speaking families and targeting outreach to encourage parents to enroll their eligible citizen and noncitizen children.

The definitions listed below include commonly used terms for immigrants and the conditions for their admission to the United States, as well as new terms created under the 1996 welfare reform law. The definitions follow a continuum of permanent to temporary to unauthorized immigrants.

Immigrant. The term is often used generally to refer to aliens residing in the United States, but its specific legal meaning is any legal alien in the United States other than those in the specified class of nonimmigrant aliens such as temporary visitors for pleasure or students. Immigrant is also used synonymously with lawful permanent resident.

Qualified Alien: The term, created in the 1996 welfare reform legislation (P.L. 104-193), refers to lawful permanent residents, refugees, Cuban and Haitian entrants, asylees, aliens paroled into the United States for a period of at least one year, aliens granted withholding of deportation by the INS, aliens granted conditional entry into the United States, and certain battered alien spouses and children. "Qualified" immigrants are generally eligible for federal public benefits on the same basis as citizens if they entered before Aug. 22, 1996, when the welfare law was enacted. Qualified immigrants entering after Aug. 22, 1996, are generally barred from federal assistance for five years. Different restrictions and limits apply to qualified immigrants' eligibility, depending on the immigration category.

Not Qualified Alien: The term means any immigrant who is not a "qualified alien," including undocumented immigrants, nonimmigrants and most PRUCOL immigrants. "Not qualified" immigrants are ineligible for federal, state and local public benefits covered by welfare reform, unless a specific exception applies.

Lawful Permanent Resident (LPR). An LPR is an immigrant who has been lawfully accorded the privilege of residing permanently in the United States. Lawful permanent residents are granted admission to the United States on the basis of family relation or job skill. Refugees and asylees may adjust to LPR status after one year of continuous residence. Lawful permanent residents may be issued immigrant visas by the Department of State overseas or adjust to LPR status with the INS after entering the United States. Generally, lawful permanent residents are those individuals who have "green cards" and are permitted to apply for naturalization after five years of U.S. residence.

Refugee. A person who flees his or her country due to persecution or a well-founded fear of persecution because of race, religion, nationality, political opinion or membership in a particular social group. Refugees are eligible for federal resettlement assistance. The year 2000 ceiling for refugee arrivals is 90,000. The term "refugee" as a legal definition includes both those admitted as refugees into the United States and asylees-those who are already present in the country when asylum is requested and granted.

Permanently Residing Under Color of Law (PRUCOL). PRUCOL is not an immigration status provided by the INS; rather, it is a term that applies to aliens in the United States " ... under statutory authority and those effectively allowed to remain in the United States under administrative discretion." Before enactment of the 1996 federal welfare reform law, PRUCOL status meant that an alien was considered to be legally residing in the country for an indefinite period for the purpose of determining benefit eligibility for public assistance, including Medicaid. Examples of PRUCOL include those granted indefinite voluntary departure, those residing in the United States under orders of supervision, aliens granted stays or suspension of deportation, and aliens whose departure INS does not contemplate enforcing.

Unauthorized immigrant. Also known as an illegal alien or undocumented worker, this is someone who enters or lives in the United States without official authorization, either by entering illegally or by violating the terms of his or her admission (for example, entering without inspection by the INS, entry based on fraud, overstaying the authorized period of admission or working without authorization). Approximately 300,000 undocumented immigrants enter and stay in the United States each year.

In the past, immigrants who entered the United States to rejoin families were often, but not always, sponsored. Beginning Dec.19, 1997, immigrants who are seeking to join their families in the United States must have an affidavit of support from their sponsor(s). (Note: Refugees are not sponsored immigrants. Employment-based immigrants are generally not sponsored.) Sponsors must now be citizens, nationals or lawful permanent residents; age 18 or over; a resident of the 50 states or Washington, D.C.; and the petitioner for admission of the immigrant. Sponsors must sign an affidavit of support, now a legally enforceable document, agreeing to financially assist the immigrant. The 1996 immigration reform law requires sponsors to have an income at 125 percent of the federal poverty level and to maintain the immigrant at that level. Active duty military personnel must have an income of 100 percent of the federal poverty level to become a sponsor.

Deeming means that the income and resources of the sponsor and his or her spouse count as the immigrant's income and resources in determining the immigrant's eligibility for federal means-tested public benefits. Previously, deeming applied only to AFDC, SSI and Food Stamps. Deeming now applies to all federal means-tested programs until the sponsored immigrant becomes a naturalized citizen or has accumulated 40 quarters of qualifying work. Qualifying quarters may be credited to a spouse or minor child. Deeming for all federal and state means-tested programs applies only to the newly executed affidavits of support, effective December 19, 1997. Newly arriving immigrants are subject first to the five-year bar on federal benefits. Then, deeming applies for federal benefits until the immigrant attains citizenship or 40 quarters of work.

Naturalization. This is the process by which a foreign-born individual becomes a citizen of the United States. To naturalize, immigrants must be at least 18 years old; have been lawful permanent residents of the United States for five years (three years if married to a U.S. citizen); demonstrate a basic knowledge of English, American government and history; and have good moral character. During FY 1999, more than 1 million people became naturalized citizens.

Federal funds are available for outreach and enrollment to the immigrant population in SCHIP, Medicaid, and the Temporary Assistance for Needy Families program (TANF).

Each program-expanded Medicaid, separate SCHIP and combined Medicaid/SCHIP-provides different match rates for outreach. Outreach activities for SCHIP programs are matched from the state's SCHIP grant, which caps administrative funds (including outreach) at 10 percent of the federal and state funds spent on child health insurance assistance. In the Medicaid program, outreach activities are allowable administrative expenses and are matched at the 50 percent Medicaid rate.

For expanded Medicaid programs, states may choose to match outreach activities from either the enhanced SCHIP match or at the traditional Medicaid match rate. If states choose the enhanced SCHIP match, expenditures are claimed against the 10 percent limit; additional expenditures may be matched at the regular Medicaid rate.

Separate SCHIP programs must adhere to the 10 percent limit above. (A U.S. General Accounting Office report issued in May 1999 found that including outreach within the cap can be problematic for states that have stand-alone SCHIP programs, causing unmatched costs for outreach while enrollment is low during program start-up.) (24)

For combined Medicaid-SCHIP plans, states must claim expenditures under the 10 percent cap first; additional expenses are matched at the traditional 50 percent match for Medicaid administrative expenses.

States can also spend administrative funds on "health services initiatives" and may target low-income immigrant communities, including temporary communities of migrant and seasonal farm workers, for health services initiatives such as health education activities, school health programs and direct services. (25) States may request a waiver of the 10 percent cap for administration, outreach and health services initiatives in order to use a "cost-effective" community-based delivery system.

Temporary Assistance to Needy Families (TANF) is a capped block grant to states of approximately $16 billion annually. TANF, which replaced Aid to Families with Dependent Children (AFCC, or individual entitlement to cash assistance), provides assistance to low-income families with minor children. Within TANF, three funding sources can be tapped to serve the immigrant population: the TANF block grant, the state maintenance of effort (MOE) fund, and the TANF/Medicaid outreach fund. TANF block grant funds may be used for outreach and training activities for Medicaid and SCHIP.

TANF. Funds must be spent on eligible families under TANF, and services and benefits must accomplish at least one of the purposes of TANF. The basic principle is to strengthen low-income families and serve their children. Legal immigrant families who lived in the United States before Aug. 22, 1996, are eligible for TANF at the state's option. All states currently provide TANF to that population. The purposes of TANF are to:

Provide assistance to needy families so that children may be cared for in their own homes or in the homes of relatives;

End the dependence of needy parents on government benefits by promoting job preparation, work and marriage;

Prevent and reduce the incidence of out-of-wedlock pregnancies and establish annual numerical goals for preventing and reducing the incidence of these pregnancies; and

Encourage the formation and maintenance of two-parent families. (26)

State MOE. This provision requires states to continue to spend 80 percent of their historical AFDC outlays (75 percent if they meet federal work participation rates). State MOE funds must also be spent on the four purposes of TANF listed above. If kept separate from federal funds, the state funds can be used to serve legal immigrants who would be eligible but for the new federal bar (for example, those entering the United States after Aug. 22, 1996.) States have also used state MOE funds to provide food stamps and nutritional assistance to immigrants.

If kept separate, state MOE funds are also more flexible than federal TANF funds. State MOE does not have to be limited to the TANF program; funds can be spent in state health agencies and can be used for medical assistance, including health insurance, medication, substance abuse treatment and medical treatment. Medicaid spending may not be counted for TANF MOE. (27)

TANF/Medicaid outreach. Historically, low-income families were automatically eligible for Medicaid if they were eligible for AFDC. When Congress ended AFDC in 1996 and created TANF, it also ended the automatic eligibility for Medicaid. A $500 million fund for enhanced matching of Medicaid outreach and administrative costs was created to address the implementation costs of welfare reform and inform new TANF applicants and those leaving TANF of their eligibility for Medicaid and SCHIP. Two matching rates apply to these funds. At a 90 percent match rate, funds are available for outreach and administration, including educational activities, public service announcements, outstationing of eligibility workers, training on Medicaid eligibility, outreach, new publications, and local community activities. Other activities are matched at a 75 percent rate. These include hiring new Medicaid eligibility workers, designing new forms, identifying "at risk" TANF-related individuals, state and local government organizational changes related to implementing welfare reform, and changes related to the eligibility system. This fund was scheduled to expire in December 1999 but was extended by Congress in the FY 2000 omnibus appropriations bill. Although originally limited to 12 calendar quarters after implementation of the state's TANF plan, states may now use the fund for expenses incurred after that date.

Brown, E. Richard; Roberta Wyn; and Victoria D. Ojeda. Noncitizen Children's Rising Uninsured Rates Threaten Access to Health Care. Los Angeles: UCLA Center for Health Policy Research, June 1999.

Fix, Michael, and Jeffrey S. Passel. Trends in Noncitizens' and Citizens' Use of Public Benefits Following Welfare Reform:1994-97. Washington, D.C.: The Urban Institute, March 1999.

Health Care Financing Administration, Administration for Children and Families, U.S. Department of Health and Human Services. Supporting Families in Transition: A Guide to Expanding Health Coverage in the Post-Welfare Reform World. Available at http://www.acf.dhhs.gov/news/welfare/welfare.htm

Ku, Leighton, and Bethany Kessler. The Number and Cost of Immigrants on Medicaid: National and State Estimates: Executive Summary. Washington, D.C.: The Urban Institute, December 16, 1997.

Morse, Ann; Jeremy Meadows; Kirsten Rasmussen; and Sheri Steisel. America's Newcomers: Mending the Welfare Safety Net for Immigrants. Denver: National Conference of State Legislatures, 1998.

Ross, Donna Cohen. Community-Based Organizations; Paving the Way to Children's Health Insurance Coverage. Washington, D.C.: Center on Budget and Policy Priorities, March 1999.

Zimmermann, Wendy, and Karen C. Tumlin. Patchwork Policies: State Assistance for Immigrants Under Welfare Reform. Washington, D.C.: The Urban Institute, Occasional Paper No. 24, May 1999.

NCSL's SCHIP information: www.ncsl.org/programs/health/chiphome.htm and www.stateserv.hpts.org

NCSL's Immigrant Policy Project: www.ncsl.org/programs/immig/ and www.stateserv.hpts.org

NCSL's welfare page: www.ncsl.org/statefed/welfare/welfare.htm

For information about language and cultural access to health care: www.diversityrx.org/

For links to state information on health insurance, sponsored by NGA:

www.insurekidsnow.gov

For information on Covering Kids, a national health access initiative for low-income, uninsured children, sponsored by The Robert Wood Johnson Foundation: www.coveringkids.org

The UCLA Center for Health Policy Research: www.healthpolicy.ucla.edu

The Urban Institute: www.urban.org

Florida's website: www.floridakidcare.org

Information on Florida's outreach is also available at www.hcfa.gov/init/outreach/factfl.htm

Texas: http://main.org/txchip/

California: www.childrenspartnership.org and Medicaid Managed Risk Medical Board at www.mrmib.ca.gov/

New Mexico presentation at HCFA meeting: www.hcfa.gov/init/outreach/tap5nm.htm

U.S. Census: www.census.gov

U.S. Health Care Financing Administration/CHIP: www.hcfa.gov/init/children.htm

U.S. Immigration and Naturalization Service: www.usdoj.gov/ins/

Notes

1. Donald J. Hernandez and Evan Charney, eds., From Generation to Generation: The Health and Well-Being of Children in Immigrant Families (Washington, D.C.: National Academy Press, 1998), 10.

2. E. Richard Brown, Roberta Wyn, and Victoria D. Ojeda, Access to Health Insurance and Health Care for Children in Immigrant Families (Los Angeles: UCLA Center for Health Policy Research, June 1999).

3. Ibid.

4. Ibid.

5. Ibid, p. 24

6. Wendy Zimmermann and Michael Fix, Declining Immigrant Applications for Medi-Cal and Welfare Benefits in Los Angeles County (Washington, D.C.: The Urban Institute, July 1998).

7. Peter Feld and Courtney Matlock, Global Strategy Group, Inc., and David Sandman, The Commonwealth Fund, Insuring the Children of New York City's Low-Income Families: Focus Group Findings on Barriers to Enrollment in Medicaid and Child Health Plus (New York: Commonwealth Fund, December 1998) Available at www.cmwf.org/programs/newyork/feld_insuring_children_nyc_305.asp

8. New York Task Force on Immigrant Health, Child Health Insurance for Immigrants: Overcoming the Barriers, (New York: New York Task Force on Immigrant Health, January 1999.)

9. Michael Fix and Wendy Zimmermann, All Under One Roof: Mixed-Status Families in an Era of Reform (Washington, D.C.: The Urban Institute, June 1999.)

10. NCSL Immigrant Policy Project, "Medical Assistance and Health Benefits", (Washington, D.C.: NCSL, July 1997), available at www.StateServ.hpts.org. See also Karen C. Tumlin, Wendy Zimmermann, and Jason Ost, State Snapshots of Public Benefits for Immigrants: A Supplemental Report to "Patchwork Policies" (Washington, D.C.: The Urban Institute, August 1999.)

11. New York Task Force on Immigrant Health, Child Health Insurance for Immigrants: Overcoming the Barriers, (New York: New York Task Force on Immigrant Health, January 1999.)

12. The INS is required to determine whether a noncitizen is likely to become a public charge 1) when he or she seeks admission to the United States, including lawful permanent residents who are re-entering the United States after a six-month absence, and 2) when the person applies within the United States to adjust status to permanent resident. The State Department makes the determination for persons applying for visas overseas. In extremely rare instances, a noncitizen is deportable if he or she has become a public charge within the first five years after entry to this country if the causes leading to public charge arose before entry.

13. See the Immigration and Naturalization Service guidance and fact sheets online at www.ins.usdoj.gov, including "A Quick Guide to 'Public Charge' and Receipt of Public Benefits" published by the INS on October 18, 1999. The Federal Register Notice of Proposed Rulemaking was published on May 26, 1999.

14. A national of the United States is a person who is not a U.S. citizen but owes permanent allegiance to the United States. At present, noncitizen U.S. nationals are essentially limited to American Samoans.

15. Health Care Financing Administration Letter to State Health Officials, September 10, 1998.

16. See the U.S. Department of Justice interim guidance published in the Federal Register on November 17, 1997, and the Proposed Rule published in the Federal Register on August 4, 1998, pp. 41622-41686.

17. Ibid.

18. Sarah C. Shuptrine and Kristine Hartvigsen, The Burden of Proof: How Much is Too Much for Child Health Coverage? Report on Verification Issues Meeting with State and Federal Officials, Southern Institute on Children and Families, December 1998. http://www.coveringkids.org/verification.html

19. "The Henry J. Kaiser Foundation Forum: Language Barriers to Health Care", Journal of Health Care for the Poor and Underserved (Volume 9, Supplemental 1998), p. S6.

20. Julia Puebla Fortier, "Why Language and Culture Are Important", (Silver Spring, MD: Resources for Cross-Cultural Health Care), www.DiversityRx.org.

21. Title VI of the Civil Rights Act of 1964: "No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance." HHS requires linguistic accessibility to health care. The Office of Civil Rights (OCR) has interpreted Title VI to require qualified interpreter services and translated materials at no cost to patients. See also Jane Perkins, Harry Simon, Francis Cheng, Kristi Olson, and Yolanda Vera, Encouraging Linguistic Access in Health Care Settings: Legal Rights and Responsibilities, January 1998.

22. For additional information on language and cultural access to care, see www.DiversityRx.org and www.healthlaw.org.

23. Victoria Pulos, Deep in the Heart of Texas: Uninsured Children in the Lone Star State, (Washington, D.C.: Families USA, 1999), available at www.familiesusa.org/kidtex.htm

24. U.S. General Accounting Office, "Children's Health Insurance Program: State Implementation Approaches Are Evolving, May, 1999, p. 70.

25. Health Care Financing Administration letter to state officials, January 14, 1998.

26. Health Care Financing Administration letter to state officials, August 6, 1998.

27. Sheri Steisel, "Taking Advantage of the New Flexibility of Temporary Assistance to Needy Families Funds and State Maintenance of Efforts Funds: A Checklist for State Legislators" (Washington, D.C.: NCSL) July 25, 1999.

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