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CHIP and the Immigrant Community:
Getting Out the Word on 'Public Charge'
State Health Notes, Vol. 20, #308, 9/13/99
by Ann Morse
Over the last three years, Congress and the Clinton Administration have moved to restore many of the vital safety net benefits that the 1996 welfare reform law took from immigrant families, including food stamps, Medicaid and Supplemental Security Income. Uncertain of their rights and fearing penalties associated with applying for assistance -denial of citizenship, for example, or of a "green card" to work in the U.S. -however, many immigrants continue to forego benefits to which they are legally entitled.
On May 22, the administration took a major step to allay the fear factor, issuing a rule clarifying a longstanding "public charge" policy designed to keep immigrants from becoming dependent on government aid by denying them admission into the country, for example, or threatening to deport them. Specifically, the rule said the Immigration and Naturalization Service and the State Department may not consider Medicaid or the Title XXI Children's Health Insurance Program (CHIP) in deciding public charge status.
Worried about public health implications, states have already commited to serving the 2.8 million uninsured kids under 18 who are either noncitizens or members of noncitizen families. By law, so-called pre-enactment children-those in the U.S. legally as of Aug. 22, 1996, the date the federal welfare law took effect-are automatically eligible for CHIP and may be covered by Medicaid at the option of individual states. Currently, all states but Wyoming exercise that option, which brings with it the federal match, and a dozen or so also use their own funds, with no match, to cover some post-enactment pregnant women and kids, who are barred from CHIP and Medicaid for their first five years in the U. S. (Two bills before Congress would let states provide Medicaid and CHIP coverage to pregnant women and children who entered the U.S. after the cutoff.)
The public charge rule will be a critical tool in states' outreach and enrollment arsenal, giving them a way to assure the parents of immigrant children that they won't suffer negative repercussions by applying to CHIP or, for those with lower incomes, to Medicaid. But while the rule "has done a great deal" to make federal policy "less hostile" to immigrants, Richard Brown of the Center for Health Policy Research at the University of California Los Angeles said there is much work to be done. The information must be disseminated "in a very credible way," involving schools, churches and other community groups. And although the rule makes clear that government-subsidized health programs "don't constitute public charge" and by extension, aren't a handout, he said there is still "a legacy of the welfare origins of Medicaid"-and the stigma that carries-to overcome.
Into the Breach: States Target Outreach
Welfare reform has already had a measurable impact on immigrants' use of public benefits. A 1998 Urban Institute report on Los Angeles County, for instance, said "fear and confusion" about the changes have had a "chilling effect" on use of benefits for which immigrants remain eligible. From 1996-98, 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. Another institute study issued last March found much the same: use of public benefits, including Medicaid, by noncitizen households fell 35 percent from 1994-97 versus 14 percent for citizens.
Besides being unaware or unsure of their eligibility, immigrant families often face language and cultural barriers, including a dearth of interpreters and translated materials, that deter them from applying for health coverage for their children. To focus outreach and enrollment in nontraditional ways to diverse ethnic populations, states are developing a variety of methods to get the word out to families, providers and service agencies and to make it simpler to apply. Some examples:
• In California, home to about a third of the nation's immigrants, the Department of Health Services (DHS) has forged partnerships with community-based groups (schools, day care centers, clinics) to do education and outreach for Healthy Families, the state-sponsored CHIP program, and Medi-Cal. This year, the budget for those activities was $1 million; next year , the legislature has raised that to $6 million.
The balance of DHS' $21 million education/outreach budget goes to radio, TV and billboard ads-the focus increasingly is on local ethnic news and talk shows-and to a program to train 15,000 people in 3,000 community-based groups as application assistants. The groups get a $50 'bonus' (up from $25) for every approved application.
Responding to critics, DHS in April also shortened its 28-page application form to four pages and now translates it from English into nine languages: Spanish, Korean, Vietnamese, Cambodian, Hmong, Cantonese, Armenian, Russian and Farsi. A hotline dispenses application aid, with a multilingual staff to field eligibility questions and address public charge concerns.
Local coalitions of schools, public health and social services agencies, providers and others, are also filling gaps. Earlier this year, for example, 13 community groups in the San Francisco Bay area held a "Healthy Families Day," hoping to reach 150 or so families. By day's end, Glenda Arellano, chief of DHS' Medi-Cal eligibility branch, said they'd enrolled 489 kids in 209 families. To boost turnout, volunteers supplied child care and school buses ferried folks to and from the event. What's most important, Arellano said, "is for people to talk to someone they know and trust" who can convey that the new public charge rule "makes it safe to apply for health coverage."
In addition to the state efforts, the California Primary Care Association has spearheaded a statewide education campaign on the public charge issue. Among other things, it developed an outreach worker guide, held training workshops for clinics and produced a public service ad publicizing a toll-free number for clinic referrals and listing services and languages available at clinics.
• New Mexico is also relying heavily on community involvement to get the word out on eligibility for its CHIP program, SALUD!, which is a Medicaid expansion, and Medicaid itself. Matching a $1 million grant with state Medicaid dollars, it has begun a project to train "promotoras," or lay health education volunteers, on informing immigrant families about the change in public charge and about the availability of services. In October, the project will also hold a workshop to give state workers who process applications for food stamps, Medicaid and public assistance information on the public charge issue, as well as cultural sensitivity training.
Carla Chavis of New Mexico Advocates for Children and Families, said lessons learned from the immigrant project may improve outreach to other populations, like Native Americans and migrant workers. Annual Medicaid recertification notices go out by mail, for example, but often, migrant families have changed residences, "don't receive the notices and automatically fall off the rolls." Better communication with those communities could perhaps avoid disruptions in coverage, she suggested.
• In Texas, which has the largest number of uninsured children in the nation after California, more than half of them Hispanic, the Legislature met in January for the first time since the enactment of Title XXI (it approved an administrative structure for a Medicaid-expansion CHIP plan in June 1997, before Title XXI passed) and voted to offer coverage via a program that mirrors CHIP to post-enactment kids affected by the five-year prohibition. The program will be financed by $35 million in tobacco settlement funds. If Congress approves the bill allowing coverage for those children, program officials will apply for federal CHIP and Medicaid matches.
Jason Cooke of the state's Health and Human Services Commission said outreach "is being informed by focus groups, with a strong emphasis" on the Spanish-speaking population, citizens and immigrants alike. To the extent the public charge issue stands as an impediment to immigrant families, outreach will "tackle it head-on," working with groups with "a reservoir of trust in the community" that can communicate the message that applying for benefits will not be detrimental to their status.
Despite the progress, the Urban Institute's Michael Fix, who's written extensively on immigration issues, said that the federal government must become more involved in informing the community on public charge. Outreach efforts in the states have been "uneven," he said. "We need a more uniform and concentrated public information campaign to get the word out."
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