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P O L I C Y k aios e ri s s i o n c mm medicaid and the on June 2007 Health Insurance Coverage and Access to Care for Low-Income Non-Citizen Adults by Karyn u n i nSchwartze d s u r and Samantha Artiga B R I E F June 2007 Recently, there has been interest at both the federal and state level in expanding health coverage, Health Insurance Coverage and Access to Care to expand coverage move forward, including several universal coverage plans. As efforts for Low-Income Non-Citizen Adults assessing the coverage needs of low-income non-citizen adults, who have a very high uninsured by Karyn Schwartz and Samantha Artiga rate due to limited access to both private and public coverage, will be an important consideration. Overall, non-citizenbeen interest at both theunder one quarter level in expanding health adults Recently, there has adults account for just federal and state of non-elderly uninsured coverage, (Figure 1). About universal coverage plans. As effortsadults are low-income (below 200% of the including several 73% of these uninsured non-citizen to expand coverage move forward, poverty level). Expanding coverage options non-citizen adults,key tohave a very high uninsured assessing the coverage needs of low-income for these adults is who assuring their access to necessary care and access to both private and financial security.will be an important consideration. rate due to limited protecting their families’ public coverage, Overall, non-citizen adults account for just under one quarter of non-elderly uninsured adults This brief analyzes health insurance coverage and access for low-income non-citizen adults and (Figure 1). About 73% of these uninsured non-citizen adults are low-income (below 200% of the provides insight into the obstacles they Figure 1 poverty level). Expanding coverage options for these adults is key to assuring their access to face in obtaining coverage and receiving Uninsured necessary care and protecting their families’ financial security. Nonelderly Adults by care.1 It finds that, largely due to their Citizenship Status, 2005 high brief analyzes health insurance coverage and access for low-income non-citizen adults and This uninsured rate, low-income nonNon-citizens, <5 years in U.S., 6% citizen adults have very poor access to provides insight into the obstacles they Figure 1 Non-citizens, 5+ care.in obtaining coverage and receiving Years in U.S., face Having insurance significantly 17% Uninsured Nonelderly Adults by improvesfinds that, largely due to their care.1 It their access to care and Citizenship Status, 2005 increases their likelihood of receiving high uninsured rate, low-income nonNaturalized Non-citizens, <5 preventive care, but, even with citizens, 6% years in U.S., 6% citizen adults have very poor access to Non-citizens, 5+ insurance, they continuesignificantly Native Citizens, care. Having insurance to face access Years in U.S., 71% 17% barriers. Although they have and more improves their access to care limited access to care, low-income nonincreases their likelihood of receiving Total Uninsured Adults: Naturalized 36 million citizen adults arebut, even with the preventive care, not relying on citizens, 6% emergencythey continue to face Instead, insurance, room for their care. access Native Citizens, 71% many rely on clinics andhave more barriers. Although they health centers. limited access to care, low-income nonTotal Uninsured Adults: CHARACTERISTICS OF IMMIGRANT ADULTS 36 million citizen adults are not relying on the emergency room for their care. Instead, adults in the United States. Immigrant adults are Immigrants make up 16% of all nonelderly many rely on in certain areas of the country, and over half of all immigrant adults resided in concentrated clinics and health centers. California, Texas, New York, and Florida in 2005. However, the areas in which immigrants CHARACTERISTICS OF IMMIGRANT ADULTS reside are changing. The states experiencing the highest growth rates of immigrants through the 1990s were make up historically had relatively few the United States. Immigrant adults Immigrants areas that16% of all nonelderly adults in immigrants, such as North Carolina, are 2 Georgia, Nevada, and areas of the concentrated in certainArkansas. country, and over half of all immigrant adults resided in California, Texas, New York, and Florida in 2005. However, the areas in which immigrants reside are changing. The states experiencing the highest growth rates of immigrants through the 1990s were areas that historically had relatively few immigrants, such as North Carolina, Georgia, Nevada, and Arkansas.2 Nonelderly adults includes all individuals age 18-64. SOURCE: KCMU/Urban Institute analysis of March 2006 CPS. Nonelderly adults includes all individuals age 18-64. SOURCE: KCMU/Urban Institute analysis of March 2006 CPS. A companion brief, Health Insurance Coverage and Access to Care for Low-Income Non-Citizen Children, is available at http://www.kff.org/medicaid/7643.cfm. 2 Urban Institute Immigration Studies Program, “The Dispersal of Immigrants in the 1990s,” November 2002. 1330 G STREET NW, WASHINGTON, DC 20005 PHONE: (202) 347-5270, FAX: (202) 347-5274 1 A B SI T E : W W W . K F F . O R G / K C M U W E companion brief, Health Insurance Coverage and Access to Care 1 for Low-Income Non-Citizen Children, is available at http://www.kff.org/medicaid/7643.cfm. 2 Urban Institute Immigration Studies Program, “The Dispersal of Immigrants in the 1990s,” November 2002. About 18 million of the total 29 million immigrant adults were non-citizens in 2005. These include legal permanent residents (immigrants with green cards), refugees, temporary immigrants, and undocumented immigrants. The majority of non-citizen adults are Hispanic (61%), 18% are Asian/Pacific Islander, Figure 2 15% are white and 6% are black. Six in Family Work Status and Income of Nonelderly ten (60%) non-citizen adults come from Adults by Citizenship Status Mexico, Central America, or the Citizen Non-Citizen, 5+ Years in US Non-Citizen, <5 Years in US Caribbean; 11% from Asia; 7% from South America; and the remaining 22% 84% 81% 78% come from other regions. Non-citizens are about as likely as citizens to live in a family with a fulltime worker, with over three-quarters in working families. However, a much higher percentage of non-citizen adults are in low-income families (Figure 2). HEALTH COVERAGE Low-income non-citizen adults are much more likely to be uninsured than their citizen counterparts. Low-income non-citizens who have been in the U.S. for less than five years are the least likely to have health coverage, with two in three (67%) uninsured (Figure 3). The high uninsured rate among low-income non-citizen adults is driven by low rates of both public and private coverage. Low-income non-citizen adults have very limited access to Medicaid coverage. Overall, Medicaid eligibility for low-income adults is restricted. Low-income parents are much less likely to be eligible for Medicaid than their children due to low income eligibility levels for parents. Further, adults without dependent children generally are not eligible for Medicaid regardless of their income. Low-income non-citizen adults face additional restrictions on their eligibility for Medicaid coverage. Figure 3 Following the 1996 welfare reform law, Health Coverage of Low-Income Nonelderly almost all legal immigrants became Adults by Citizenship Status, 2005 ineligible for federally-matched Medicaid Uninsured Medicaid/Other Public coverage during their first five years of Private 36% residence in the United States. After five 60% 67% years, they become eligible if they meet 27% the program’s other eligibility requirements. Undocumented immigrants 16% 10% 38% and temporary immigrants are generally 24% 23% ineligible for Medicaid regardless of their Citizens Non-Citizens, 5+ Non-Citizens, <5 length of residence in the country, a Years in U.S. Years in U.S. restriction that had been in place prior to Total: 49.2 M 7.6 M 2.3 M welfare reform. Nonelderly adults includes all individuals age 18-64. Low-income is defined as twice the federal poverty level, which was $2,600 per month for a family of three in 2005. SOURCE: KCMU/Urban Institute analysis of March 2006 CPS. 53% 30% 60% 1 or More Full-Time Workers Low-Income Nonelderly adults includes all individuals age 18-64. Low-income children are defined as those living in families below 200% of the federal poverty level, which was about $2,600 per month for a family of three in 2005. SOURCE: KCMU/Urban Institute analysis of March 2006 CPS.  00 Under federal law, immigrants, both legal and undocumented, who meet all of the Medicaid eligibility requirements except for the immigrant restrictions, are eligible to receive Emergency Medicaid. However, this coverage is limited to treatment for medical emergencies not preventive or routine services. Additionally, federal law requires hospitals to screen and stabilize all individuals, including immigrants, who seek care in their emergency room, but again this law does not provide for any preventive and routine services. To help address these prohibitions on federal matching funds for coverage of immigrants, some states provide coverage with state-only funds. As of 2007, 17 states provided fully state-funded coverage to cover at least some non-pregnant adult immigrants who are not eligible for Medicaid due to the immigrant eligibility restrictions. However, in some cases, this coverage is only available to limited groups of immigrants and/or the benefits provided are more limited than Medicaid. In the absence of these state-funded programs, recent legal immigrants and undocumented immigrants have few if any public coverage options, regardless of their income. Few low-income non-citizen adults have access to employer-sponsored coverage. Figure 4 The majority (71%) of low-income nonIndustry and Firm Size of Low-Income citizen adults live in families with at least Nonelderly Adult Workers by Citizenship one full-time worker. However, they tend Status to work in low-wage jobs and in firms and Citizen Non-Citizen, 5+ Years in US Non-Citizen, <5 Years in US industries that do not offer health insurance. Low-income non-citizen 54% 49% 48% 48% workers are more likely than their citizen 36% counterparts to be self-employed or work 32% in small firms, which are less likely to offer health insurance. Further, one half of low-income non-citizen workers are Small Firm or Self-Employed Agriculture, Construction and Services employed in agriculture, construction or service industries, compared to about one third of low-income citizens (Figure 4). These three industries have the lowest rates of employer-sponsored coverage. Only about one quarter of low-income workers in agriculture, construction or service industries have employersponsored coverage, compared to about 35% of all low-income workers and 70% of workers overall. Nonelderly adults includes all individuals age 18-64. Low-income is defined as twice the federal poverty level, which was $2,600 per month for a family of three in 2005. Small firm is defined as having fewer than 25 employees. SOURCE: KCMU/Urban Institute analysis of March 2006 CPS. ACCESS TO CARE A sizable body of research shows that health insurance improves adults’ access to care, which ultimately impacts their health and their families’ financial security. This section analyzes the impact of insurance on access to care for low-income non-citizen adults.3 3 Access data is from NHIS and all differences discussed in the text are statistically significant at p<0.05, except where noted.  Insured low-income non-citizen adults were more likely to have a usual source of care than those who were uninsured. Among low-income adults, non-citizens were more likely than citizens to lack a usual source of care. Insurance dramatically improved the likelihood that a low-income adult had a usual source of care, with about two in three uninsured low-income noncitizen adults lacking a medical home compared to only 16% of those with insurance (Figure 5). Although low-income non-citizen adults were less likely to have a usual source of care, they had lower rates of emergency room use than did citizens. Regardless of insurance status, low-income non-citizens were less likely than lowincome citizens to report an emergency room visit in the past year. Uninsured lowincome non-citizens were the least likely to use the emergency room with only about one in ten reporting a visit in the past year. Emergency room use was higher for those with coverage, but insured non-citizens were still less likely to use the emergency room than citizens (Figure 6). Uninsured low-income non-citizen adults primarily relied on clinics or health centers for their care. Among adults with a usual source of care, low-income non-citizens were significantly more likely than low-income citizens to depend on a clinic for that care. Clinics and health centers were a particularly important source of care for uninsured low-income non-citizens, as six in ten relied on them as their medical home (Figure 7). In contrast, the majority of insured low-income noncitizen adults relied on a doctor’s office or HMO. However, still more than one in Figure 5 Percent of Low-Income Nonelderly Adults with No Usual Source of Care, 2004-2005 Insured Uninsured 65% 50% 10% 16% Citizen Non-Citizen Nonelderly adults includes all individuals age 18-64. Low-income is defined as twice the federal poverty level, which was $2,600 per month for a family of three in 2005. Source: KCMU analysis of 2004-2005 NHIS data. Data analyzed using multiple imputation methodology. Figure 6 Percent of Low-Income Nonelderly Adults with an Emergency Room Visit in the Past Year, 2004-2005 Insured Uninsured 29% 24% 18% 11% Citizen Non-Citizen Nonelderly adults includes all individuals age 18-64. Low-income is defined as twice the federal poverty level, which was $2,600 per month for a family of three in 2005. Source: KCMU analysis of 2004-2005 NHIS data. Data analyzed using multiple imputation methodology. Medical Home for Low-Income Nonelderly Adults with a Usual Source of Care , 2004-2005 4% 15% 5% 11% 29% Other Doctor's Office or HMO Clinic or health center Figure 7 73% 49% 59% 60% 23% Insured 36% Uninsured 36% Insured Uninsured Nonelderly adults includes all individuals age 18-64. Low-income is defined as twice the federal poverty level, which was $2,600 per month for a family of three in 2005. Other includes the emergency room, hospital outpatient department or some other place. Only adults who identified a single source of usual care were included in this analysis. Source: KCMU analysis of 2004-2005 NHIS data. Data analyzed using multiple imputation methodology. Citizens Non-Citizens  00 three of those with coverage had a clinic or health center as their medical home, suggesting that clinics remain an important source of care for insured low-income non-citizens. Insured low-income non-citizens were more likely to receive preventive care and to have seen a health provider in the past two years than those without coverage. Low-income non-citizen adults were more than twice as likely as low-income citizens to report going without preventive care.4 Having health insurance dramatically increased the likelihood that an adult received preventive care. While more than half of uninsured low-income non-citizens did not receive preventive care, that proportion dropped to 15% among those with coverage ((Figure 8). However, insured non-citizens remained more likely than their citizen counterparts to go without preventive care, suggesting that they may continue to face increased barriers to care even when they are insured. Percent of Low-Income Nonelderly Adults Who Do Not Receive Preventive Care, 2004-2005 Insured Uninsured 55% 43% Figure 8 15% 7% Citizen Non-Citizen Nonelderly adults includes all individuals age 18-64. Low-income is defined as twice the federal poverty level, which was $2,600 per month for a family of three in 2005. Source: KCMU analysis of 2004-2005 NHIS data. Data analyzed using multiple imputation methodology. Low-income non-citizen adults were also Percent of Low-Income Nonelderly Adults more likely than low-income citizens to go Going More than Two Years Since Contact for more than two years without seeing or with a Health Professional, 2004-2005 talking to a health professional. Among Insured Uninsured non-citizens, those with health insurance were much more likely to have seen a doctor 44% in the past two years (Figure 9). Uninsured low-income non-citizens fared very poorly, 29% with more than four in ten going for two or 16% more years without contact with a health 6% professional. Even among those with a Citizen Non-Citizen chronic condition, 25% of uninsured lowincome non-citizens had gone for more than two years without seeing or talking to a health professional.5 However, insured low-income non-citizens remained about three times as likely as insured low-income citizens to go for two or more years without contact with a health professional. Language and cultural barriers may make it more difficult for these adults to connect with a provider even when they are insured. Nonelderly adults includes all individuals age 18-64. Low-income is defined as twice the federal poverty level, which was $2,600 per month for a family of three in 2005. Source: KCMU analysis of 2004-2005 NHIS data. Data analyzed using multiple imputation methodology. Figure 9 Adults reported to not receive preventive care are those adults who responded “doesn’t get preventive care anywhere” when asked where he or she usually goes for preventive care. 5 Adults with chronic conditions include adults who had ever been told they had diabetes, cancer, hypertension, a heart condition, a stroke, emphysema, or still have asthma. 4  IMPLICATIONS Low-income non-citizen adults are at particularly high risk for being uninsured due to very limited access to both private and public coverage. Even though they are as likely as lowincome citizens to be in a working family, low-income non-citizens are more likely to work in jobs and industries that do not offer health coverage. Public coverage could help fill this gap, but low-income non-citizen adults have very limited access to Medicaid due to overall limited eligibility for adults and specific eligibility restrictions for immigrants that bar most recent immigrants from Medicaid. In an effort to address the federal restrictions on Medicaid eligibility for recent immigrants, currently, 17 states provide state-funded coverage to at least some recent immigrant adults who are excluded from Medicaid. However, some of these programs only cover limited groups of immigrants and/or provide limited benefits. Further, the stability and financing of these programs is compromised in times of fiscal stress. Largely as a result of their high uninsured rates, low-income non-citizen adults have very poor access to care. Having insurance significantly improves their access to care, but, even with insurance, it appears they continue to face other access barriers, which may include language and cultural differences. Although they have more limited access to care, low-income non-citizens are not relying on the emergency room for their care. Instead, many rely on clinics and health centers, particularly those who are uninsured. With the goal of improving health, access to care and reducing the stress and financial risks of being uninsured, proposals and plans are emerging at both the state and federal level to expand health insurance coverage. Most recently, a few states have moved forward with coverage expansion proposals that would provide new opportunities for immigrants to obtain health insurance. Addressing the health coverage needs of low-income non-citizens will be an important piece of future efforts to expand coverage and reduce the number of uninsured.  00 1330 G STREET NW, WASHINGTON, DC 20005 PHONE: (202) 347-5270, FAX: (202) 347-5274 WEBSITE: WWW.KFF.ORG/KCMU Additional copies of this report (#0000) are available on the K a i s e r F a m i l y F o u n d a t i o n w e b s i e t w w w . k f f . o o n t h e Kaiser Family Foundation’s’ swebsitet at awww.kff.org. r g . Additional copies of this report (#7651) are available The Kaiser Commission on Medicaid and the Uninsured provides information and analysis on health care coverage and access for the low-income population, with a special focus on Medicaid's role and coverage of the uninsured. Begun in 1991 and based in the Kaiser Family Foundation's Washington, DC office, the Commission is the largest operating program of the Foundation. The Commission’s work is conducted by Foundation staff under the guidance of a bi-partisan group of national leaders and experts in health care and public policy.