the impact of health care reform on immigrants
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The impact of health care reform on immigrants
Steven P. Wallace, PhDUCLA Center for Health Policy Research &
UCLA School of Public Healthswallace@ucla.edu
Percent Residents Born Abroad
6.6 7.4
13.4 11.78.8 7.5
4.8 6.2 811 12.4 12.510.4 10.8
19 18.4
12.8 10.9
22.124.8
36.436.1 35.6
15 15.3
22.719.6
13.510.7 8.9 15.1
21.726.3 27.3 26.9
1900 1910 1920 1930 1940 1950 1970 1980 1990 2000 2005 2009
Source: U.S. Census and ACS
US
CA
LA
Age-adjusted total per capita health spending, 2008 dollars
Stimpson, Wilson, Eschbach, Health Affairs 2010.doi: 10.1377/hlthaff.2009.0400
Odds ratios*, health care access vs. U.S.-born Mexican Americas, CA
1.00
0.82 0.75 0.700.83
1.00
1.28
0.830.73
1.061.00
0.70
0.52 0.50
1.00
US Born MexicanAm
Naturalized Green card Undocumented US Born NL white
Usual source of care MD visit ED visit* Adjusted for sex, marital status, health insurance, age, education, employment, federal poverty level, location of residence, and self-reported health status. Source: CHIS 2003 in Arch Intern Med, Vol 167, Nov 26, 2007, p 2354
No Usual Source of Care, California, 2009
7.7% 9.0%
21.6%
43.4%
36.4%
47.4%
US Born Naturalized citizen Noncitizen
Insured Uninsured
Source: California Health Interview Survey, 2009
Percent Uninsured Ages 0-64, Calif. 2009
14.8%
25.2%
41.9%
11.9% 12.9%
31.3%
US Born Naturalized citizen Noncitizen
Mexican
All others
Source: California Health Interview Survey, 2009
Uninsured in CA by Documentation Status, 2005
21.0%
3.0%
76.0%
Undoc adultsUndoc kidsCitizens/LPR
Most insurance from work, California 2009
58.5% 61.8%
32.3%
6.7% 7.8%3.4%
US Born Naturalized citizen Noncitizen
Employment
Private purchased
Source: California Health Interview Survey, 2009
Calif. any insurance 2008:Employed Mexican-born noncitizens ages 25-49
73.9
47.7
65.3
45.7
32.8 33.6
48.6
41.8 43.3
34.663,344
73,336 68,40783,291
288,449
143,157
198,821
151,963
51,339
125,120
Prof-Exec Sales Admin Priv HH-Prot Sgv Farm Repair Mach opr Trans Labor
% insured
# employed
Source: Current Population Survey, 2009Overall 42.7% have any coverage
Work coverage has declined:Employed all noncitizens in U.S. ages 25-49
52.7 51.449.8
46.8 46.9 46.945.3 46.1 44.8
2000 2002 2003 2004 2005 2006 2007 2008 2009
Perc
ent
Source: Current Population Survey
Percent with health insurance from job
Work coverage has declined:Employed Mexican-born noncitizens in U.S., 25-49
37.5 37.9 36.5
32.3 31.2 31.728.9
30.4 29.3
2000 2002 2003 2004 2005 2006 2007 2008 2009
Perc
ent
Source: Current Population Survey
CA work coverage declined:Employed all noncitizens ages 25-49
51.3
45.948.6
45.8
42 43.441.9 42.8
38.52000 2002 2003 2004 2005 2006 2007 2008 2009
Perc
ent
Source: Current Population Survey
CA work coverage declined:Employed Mexican-born noncitizens ages 25-49
40.437.2
40.5
36.3
31.8 33.2 32.2 32.830
2000 2002 2003 2004 2005 2006 2007 2008 2009
perc
ent
Source: Current Population Survey
Main Elements of the Reform Legislation affecting Working-Age Population*
*Most go into effect in 2014
Insurance Coverage
Will reduce uninsured from 48 million to 21 million through :
• Employer mandate• Individual mandate• Medicaid (Medi-Cal) expansion• + Community health center expansion
Coverage (Employer Mandate)
• Employers with more than 50 employees must provide coverage or pay penalty of $2000/employee.• Tax credit to small employers that pay
at least 50% of health insurance costs; <25full-time workers
• average annual wage < $50,000
Uninsured employees by company size & citizenship, Calif. 2009
20.5%
7.4%14.6%
8.3%
20.9%
11.2% 12.9%
4.3%
50.9%
26.7%21.6%
14.9%
1-49 50-99 100-999 1000+
Firm Size
US-bornNaturalizedNoncitizen
Source: California Health Interview Survey, 2009
Coverage (2)
Individual mandate• Everyone w/o employer insurance must
buy coverage or pay a penalty ($700/individual, $2100/family), unless insurance cost exceeds 8% of income
• Income-based subsidies to uninsured• sliding scale up to 400% poverty level
% uninsured among Californians <age 65 with incomes133-400% FPL
15.4%19.0%
39.6%
US-born Naturalized Noncitizen
8.7 million 1.7 million 1.3 million
Source: California Health Interview Survey, 2009
Coverage (3)
• Medicaid (low-income coverage) expansion• everyone covered whose income is less
than 133% of poverty level• eliminates link to families with
children, i.e. singles & couples w/o kids will qualify
% uninsured among Californians <age 65 with incomes <133% FPL
20.8%
30.8%
43.8%
US-born Naturalized Noncitizen
1 million 273,000 1.1 million
Source: California Health Interview Survey, 2009
Health Insurers…
• Cannot turn away those w/a history of illness• Cannot charge more to those w/a history of
illness (older people can be charged maximum of 3 times that of younger person)
• Cannot terminate coverage• Must renew coverage• Return at least 80% of premiums in the form
of health service benefits24
Other access issues
• Significant increase in funding for community health centers (primary care)
25
8.5 Million in CA Use Clinics as Usual Source of Care, 2009
5,506, 65%
1241, 15%
1717, 20%
US-bornNaturalizedNon-citizen
% using clinics among those with a usual source of medical care, Calif.
59.5%45.4%
35.4%
12.9%
79.2%
60.4% 57.6%
41.9%
Imm MexAm, in US <10 yrs
Immg MexAm, in US 10+ yrs
US Born MexicanAm
US Born NL White
insured uninsured
Source: California Health Interview Survey, 2009
Other issues?
• Undocumented residents• Mixed status families• Definition of “emergency” for Medicaid
Senate bill p. 292
• (d) NO FEDERAL PAYMENTS FOR INDIVIDUALS NOT LAWFULLY PRESENT.—Nothing in this subtitle or the amendments made by this subtitle allows Federal payments, credits, or cost-sharing reductions for individuals who are not lawfully present in the United States.
Undocumented Immigrants, U.S. = 11.2 million, 2010
State Estimated #California 2,550,000Texas 1,650,000Florida 825,000New York 625,000New Jersey 550,000Illinois 525,000Georgia 425,000Arizona 400,000North Carolina 325,000Maryland 275,000Washington 230,000
Source: http://pewhispanic.org/files/reports/133.pdf
Mixed status families complicate equitable health care, U.S.
14.9%
25.3%59.8%
Citizen parents1-citizen parentNoncitizen parents
Children of Mexican immigrants
47.1%
27.3%
25.7%
Citizen parents1-citizen parentNoncitizen parents
Children of NonLatino immigrants
Senate bill p. 126
• (c) APPLICATION OF EMERGENCY SERVICES LAWS.— Nothing in this Act shall be construed to relieve any health care provider from providing emergency services as required by State or Federal law, including section 1867 of the Social Security Act (popularly known as ‘‘EMTALA’’).
But each state defines “emergency” -Georgia does not cover dialysis
Adequate use of health care
• Availability – are services located in the community where immigrants live
• Accessibility – can immigrants afford the care; are the hours of service appropriate
• Acceptability – do the immigrants have confidence in the provider, can they communicate
Summary
• Health Care Reform (ACA) will greatly improve access to care to immigrants• More insured @ work, subsidies, Medicaid• Improved access to community health
centers• Availability & acceptability changes
unclear• Undocumented immigrants remain vulnerable
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