National debates over health care reform and immigration reform contribute to a fair amount of confusion about who, in fact, is eligible for what.
In general, permanent resident immigrants (green card holders) are eligible for Medicaid and CHIP after five years of residence on the same basis as U.S. citizens and must meet all other program requirements.
Unauthorized immigrants are not eligible for federal health insurance programs, and are only eligible for more discrete programs like emergency medical assistance under Medicaid, services in federally qualified health centers and certain public health programs.
The Affordable Care Act (ACA) program established marketplace health care benefits and extended eligibility to lawfully present immigrant populations.
This issue brief attempts to lay out the main federal programs that offer health care coverage and services to low income populations, including legal permanent immigrants, temporary immigrants, humanitarian immigrants and unauthorized immigrant populations residing in the United States.
Medicaid, established in 1965, is a federal- and state-funded insurance program offered to low-income individuals. Prior to the establishment of the ACA, to qualify for Medicaid an individual had to meet financial criteria and fall into a category that is eligible for the program, including children, parents of dependent children, pregnant women, people with disabilities and the elderly. Federal law set the minimum requirements for eligibility and benefits. However, states had the authority to extend Medicaid beyond these minimum standards using their own funds, leading to variations in Medicaid coverage throughout the states. The ACA allowed states to use federal money to cover all individuals up to 138 percent of the FPL, regardless of whether they fit into one of the categories.
The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 added restrictions on legal immigrants’ eligibility for Medicaid. Prior to this law, most immigrants were eligible for public benefits, including health care, on much the same basis as citizens. PRWORA created the qualified immigrant standard and the five-year bar, when applicable, for immigrants who enter the United States on or after Aug. 22, 1996. Certain groups are exempt from the five-year bar, such as refugees and veterans. States can choose whether to provide or limit public benefits to immigrants.
Since 1996, non-emergency Medicaid has been generally limited to citizens and “qualified immigrants.” This limited eligibility standard includes people who are lawful permanent residents, also known as green card holders, and humanitarian forms of relief, such as asylum-seekers and refugees, victims of domestic violence, and trafficking victims. Qualified immigrants are subject to a five-year waiting period before obtaining Medicaid coverage, unless they hold a status that is exempt from the waiting period, which is generally the humanitarian forms of relief. Since 2009, states can also elect to use federal matching funds to cover all lawfully present children and pregnant women without a waiting period. Read more about Immigrant Eligibility for Federal Programs.
Children’s Health Insurance Program (CHIP)
The Children’s Health Insurance Program (CHIP), established in 1997, offers low-cost health coverage for children in families whose household income is higher than the standard to qualify for Medicaid. CHIP provided health insurance coverage to low-income children under age 19 based on their household income, at household levels set by the state. States could choose to administer CHIP as an expansion of the state Medicaid program, as a standalone insurance program or as a combination of these approaches. Eighteen states operated separate CHIP programs, 11 states and the District of Columbia implemented CHIP by expanding Medicaid and 21 states used a combination approach. States that implemented CHIP through Medicaid expansions received federal funding at the lower Medicaid matching rate if they exceeded their federal CHIP allotment.
Immigration-related eligibility for CHIP mirrors that of Medicaid, meaning that generally it covers qualified immigrants, with the five-year bar when applicable, but states can elect to cover all lawfully present children and pregnant women.
The Affordable Care Act (ACA)
The Affordable Care Act (ACA), enacted in 2010, aimed to expand affordable coverage for many Americans through access to insurance, consumer protections, prevention and wellness, quality, an expanded health workforce, and curbing the rise of health care costs (The Affordable Care Act: A Brief Summary). The ACA is actually a combination of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010; which together, were able to extend Medicaid coverage to adults whose income was below 138 percent of the Federal Poverty Line ($16,643 for individuals) for states that chose to expand.
The ACA created new marketplaces for health care insurance and allowed states to expand Medicaid to cover new populations; covered those with preexisting conditions; extended coverage for children up to age 26, removed the waiting period for enrolling in state insurance exchanges, and extended eligibility for basic health plans, premium tax credits, and lower copays.
The ACA also expanded which categories of immigrants were eligible for comprehensive health insurance programs by using the standard of “lawfully present” for eligibility, which is broader than the qualified immigrant standard for Medicaid established as part of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. The term lawfully present includes “qualified” immigrants, humanitarian entrants, victims of trafficking, and certain immigrants with permission to live and work in the U.S. Deferred Action for Child Arrivals are not considered lawfully present for marketplace coverage.
Under the ACA, lawfully present immigrants are eligible to enroll in health insurance plans from either the federal or state insurance exchanges. This eligibility standard is used throughout the ACA-created structures, including premium tax credits, cost sharing reductions, and Basic Health plans, although it did not change the eligibility for Medicaid for states that expanded their program. The chart below lists the services that are offered to lawfully present immigrants under the ACA. The law did not make substantive changes in health access for people who are not lawfully present.
Immigrants’ Access to Care
Aside from the federal program restrictions on healthcare for immigrants, other factors hinder immigrants from seeking health care services. Immigrants face difficulties around limited English proficiency, familiarity with the U.S. healthcare system, cost and concern about immigration enforcement.
Language is a huge barrier for immigrants and health care access. In 2015, 41percent of people in the United States were considered Limited-English Proficient. Title VI of the Civil Rights Act of 1964 has been used to require health care providers and insurance providers to provide translation and interpretation services so that those with limited English proficiency, or else violate the civil rights of patients.
The complexity of the health care system makes it difficult for the average health care consumer to understand, and even more so for immigrants, or non-English speakers. To effectively combat challenges in accessing healthcare, certain states have provided health care service information sheets to help immigrants better understand the health care options for which they are eligible. For example, North Carolina has fact sheets available for immigrants that list immigration statuses, examples of acceptable verification documents, and the varying levels of health insurance eligibility. These documents show the health insurance eligibility chart and makes it very easy to find the type of insurance a person may qualify to receive based on their specific immigration status.
Minnesota, Illinois and Arizona have implemented community health outreach programs specifically for underserved, low-income immigrants to provide access to preventive care services. Illinois, for example, has an Immigrant Health Access program that assists with communicating with various health care providers, scheduling appointments, accessing available financial assistance and providing basic health education programs for underserved populations. Phoenix Allies for Community Health is a nonprofit organization that provides free health care services to those that are uninsured, catering to the unauthorized immigrant, refugee and working poor populations. Their services help to educate patients on various community health issues and offers certain services (such as bloodwork and EKGs) onsite, to save patients from taking time off from work to obtain these services at separate facilities.
Additionally, California, Illinois, Massachusetts, New York, Oregon, Washington and The District of Columbia have expanded their Medicaid programs to provides insurance to all income-eligible children, regardless of immigration status. These programs include services such as regular check-ups, immunizations, sick child doctor visits, prescriptions, vision and dental care, hospitalization, mental health and substance abuse services. For unauthorized immigrants (also known as undocumented or illegal immigrants), few options are available, usually limited to emergency services, charity care, or community health centers.
Health Reforms 2017
Medicaid and CHIP provide health coverage to 74.5 million Americans as of April, 2017 and are the largest source of health coverage in the United States. About one-half are children, one-fourth are adults, and one-fourth are seniors or disabled.
In 2017, the House and the Senate each proposed a revision to the ACA through the H.R. 1628 bill. The House proposed American Health Care Act (AHCA); and the Senate proposed The Better Care Reconciliation Act (BCRA). The House passed the American Health Care Act (AHCA) on May 4, 2017, with a 217-213 vote. Both the AHRA and the BCRA would significantly reduce Medicaid expansion that is in place under the ACA, by requiring a per capita cap on Medicaid or a specific spending/block grant of funds to states. The two bills also change eligibility requirements for tax credits. Tax credit eligibility would be based on age and income under the BCRA, while the AHCA would base its eligibility largely on age. These adjustments would make some lawfully present immigrants ineligible for tax credits and Marketplace coverage that they are currently offered under the ACA.
In both the revised BCRA and AHCA bills, specific changes are in the language used in the ACA that would ultimately limit eligibility for some benefits that immigrants had under the current law. The AHCA would establish eligibility for its tax credits using the qualified immigrant standard from PRWORA, while the BCRA would use the standard for both tax credits and enrollment under federal and state marketplaces. Because PRWORA’s standard is more restrictive than the ACA’s lawfully present standard, many immigrants who were able to buy insurance through the Marketplace exchanges would be either ineligible or unattainable under both bills.
Prepared by: Amanda Salami, NCSL Immigrant Policy Project Summer Fellow, 2017.