immigration reform challenges and opportunitiescpac.berkeley.edu/sites/default/files/pb_49... ·...
TRANSCRIPT
ASSISTANCE FOR THIS BRIEFING PROVIDED BY THE OFFICE OF FEDERAL GOVERNMENTAL RELATIONS, UNIVERSITY OF CALIFORNIA, AND THE OFFICE OF CONGRESSWOMAN LUCILLE ROYBAL-ALLARD
WEDNESDAY, OCTOBER 2, 2013
1:30 – 3:00 PM UNIVERSITY OF CALIFORNIA WASHINGTON CENTER’S AUDITORIUM
1608 RHODE ISLAND AVE, NW WASHINGTON, DC
AGENDA
WELCOME AND OPENING COMMENTS:
Elena V. Rios, MD, MSPH, President and CEO, National Hispanic Medical Association Moderator: Xóchitl Castañeda, Director, Health Initiative of the Americas, School of Public Health, UC Berkeley
PRESENTATIONS:
IMPLICATIONS OF IMMIGRATION REFORM ON HEALTH AND ACCESS TO HEALTHCARE Virginia Ruiz, Director of Occupational and Environmental Health, Farmworker Justice
STATUS OF IMMIGRANT HEALTH COVERAGE IN THE UNITED STATES Jennifer Ng’andu, Director, Health and Civil Rights Policy Project, National Council of La Raza
BINATIONAL OPPORTUNITIES FOR IMMIGRANT COVERAGE Arturo Vargas Bustamante, PhD, Assistant Professor, Department of Health Policy and Management, UCLA Fielding School of Public Health
OPPORTUNITIES IN HEALTH CARE REFORM FOR IMMIGRANTS: A CALIFORNIA PERSPECTIVE Gilbert M. Ojeda, Director, California Program on Access to Care, School of Public Health, UC Berkeley
CALIFORNIA PROGRAM ON ACCESS TO CARE (CPAC) AND THE HEALTH INITIATIVE OF THE AMERICAS (HIA)
UC BERKELEY SCHOOL OF PUBLIC HEALTH
CO-SPONSORS: FARMWORKER JUSTICE, NATIONAL COUNCIL OF LA RAZA, & NATIONAL HISPANIC MEDICAL ASSOCIATION
IMMIGRATION REFORM: CHALLENGES AND OPPORTUNITIES
IMPLICATIONS OF IMMIGRATION REFORM ON HEALTH AND ACCESS TO HEALTHCARE
Virginia Ruiz Director of Occupational and Environmental Health Farmworker Justice
Farmworker Justice is a nonprofit organization
that seeks to empower migrant and seasonal farmworkers to improve their living and working
conditions, immigration status, health, occupational safety, and access to justice.
www.farmworkerjustice.org
Overview: Immigration Reform and Health
→ Overview:
Immigration Reform → Provisions that
affect health and access to healthcare
→ Indirect impacts of immigration reform on health
CURRENT LEGISLATIVE PROPOSALS
SENATE The Border Security, Economic Opportunity, and
Immigration Modernization Act of 2013, S.744; passed Senate June 2013
Path to citizenship for 11 million undocumented immigrants currently in the U.S. Registered Provisional Immigrant (RPI) status (10
year path to LPR with work/income requirement) Blue Card status for agricultural workers and their
families (5-8 year path to LPR with work requirement)
DREAMers Expanded guestworker program (W-visas)
HOUSE OF REPRESENTATIVES No comprehensive bill Agricultural Guestworker
“AG” Act (H.R. 1773) – Bob Goodlatte (R-VA) No path to citizenship Lowers wages and offers
fewer worker protections than notorious Bracero program
Guestworkers will be even more vulnerable to exploitation and will have extremely limited access to judicial relief and legal assistance
PROVISIONS THAT AFFECT HEALTH AND ACCESS TO HEALTHCARE
Eligibility for ACA programs
Individuals with provisional status will be eligible to enroll in
the health insurance marketplaces but would not be eligible for subsidies until they gain LPR status Will not be subject to the individual mandate 5-year bar still applies for Medicaid eligibility
H-category visas and low-skilled workers who obtain W visas
Eligible to enroll in the marketplaces and subsidies Subject to the individual mandate If they adjust to LPR status, the 5-year bar still applies for
Medicaid eligibility Employers required to carry workers compensation insurance
INDIRECT IMPACTS OF IMMIGRATION REFORM ON HEALTH & ACCESS TO HEALTHCARE Valid work authorization = more opportunities for
employer-provided insurance
Fewer barriers to access healthcare Transportation (esp. drivers’ licenses) Ability to travel outside of US to home countries Residents of border states can access care in Mexico &
Canada
Better working and living conditions More willing to speak out about hazardous working conditions
Lower stress and anxiety
Status of Immigrant Health Coverage in the United States
Policy Briefing October 2, 2013
Jennifer Ng’andu, @CanDoNgandu
MARCH 21, 2010 - Inside the Capitol The Final Vote on the Historic Affordable
Care Act
MARCH 21, 2010 - Outside the Capitol
Nearly 1 Million Gather in the Name of Fair, Comprehensive Immigration Reform
Presentation Overview
• Immigrant Coverage and the Affordable Care Act
• Briefly, Affordable Care Act Coverage Opportunities
• Options for Those Left Behind
Coverage Status
The Big Picture
According to the most recent annual Census figures, immigrants comprise 13% of the
population, but represent 20% of the uninsured.
Coverage for the Unauthorized
According to the Migration Policy Institute’s May 2013 brief:
• Seven in ten (71%) of unauthorized workers and nearly half (47%) of unauthorized children are uninsured.
• Of those unauthorized and uninsured, just under one in
three (29%) of adults receive coverage through an employer and negligible numbers (estimated at 0%) receive public coverage. One in five (21%) unauthorized children receive coverage through an employer; 32% of children receive coverage through public programs.
THE ACA: Current Eligibility
Eligibility: U.S. Citizen
• Employer-Sponsored Coverage – Employers with more than 50 employees responsible
for providing affordable insurance options • Medicaid
– Current Medicaid program continues to operate – Blanket expansion for new Medicaid package for all
persons with annual income* under 133% of the federal poverty level ($30,700 per year for family of 4)
• New Health Insurance Marketplaces, “Exchanges” – Tax credits for individual coverage – SHOPs for small businesses
Eligibility: Lawfully Present Immigrant • Employer-Sponsored Coverage remains unrestricted
– Seasonal workers are not counted towards employer responsibility requirements
• New Health Insurance Marketplaces, “Exchanges” available to all defined as lawfully present.* – Protects low-income immigrants ineligible for Medicaid – Administration inserts a partial rollback, denying coverage
to DACA recipients. • Medicaid
– Unchanged, with continued legal immigrant restrictions. – “Qualified” immigrants barred for five-years – “Not-Qualified” barred indefinitely unless status changes – Emergency Medicaid available to those who would
otherwise qualify
Eligibility: Undocumented
• Employer-Sponsored and Private Market Coverage Outside Exchanges – No explicit ban
• New Health Insurance Marketplaces, “Exchanges” are restricted to individuals – SHOPs have no explicit ban
• Medicaid – Explicit bar from full-scope Medicaid dating prior to
ACA enactment – Emergency Medicaid available to those who would
otherwise qualify
Core Enrollment Challenges
IMMIGRANT HOUSEHOLDS
LOW-INCOME FAMILIES
LANGUAGE BARRIERS
Common Questions • Can I enroll a child or another family member if I
am not eligible?
• Can DHS access this information for immigration purposes?
• Will using the Affordable Care Act hurt my chances to become a legal permanent resident or a citizen?
• What are the options for the remaining uninsured?
ALTERNATIVES TO COVERAGE
Solutions to Implement Now
Emergency Medicaid
Basic Health Plans
Community Health Centers/Free Clinics
Charity Care
State-Funded Programs
Potential Solutions Moving Forward?
• Binational Health Insurance • Non-Insurance Health Products • Uncompensated Care Pools (e.g. Improved
Section 1011 legislation) • Health Insurance Buy-Ins and External Co-op
Plans • Immigration Reform Related State Impact Aid
RESOURCES
Critical Resources
Enrollment • www.healthcare.gov (Enrollment on October 1st) • www.cuidadodesalud.gov (Enrollment mid-
October) • 1-800-318-2596 (150 Languages, including
Spanish)
General Policy Information • www.nclr.org/healthcareforall
– Basics of Health Care Reform Subpage
AND FINALLY
My Contact Information
Jennifer Ng’andu
Director, Health and Civil Rights Policy National Council of La Raza (NCLR)
Email: [email protected] Twitter: @CanDoNgandu
(202) 785-1670 www.nclr.org/healthcareforall
Arturo Vargas Bustamante, PhD, MPP
Assistant Professor of Health Policy & Managemnt UCLA Fielding School of Public Health
Binational Opportunities for Immigrant Coverage
Immigration Reform: Challenges and Opportunities
Outline
Overview of Mexican Immigratns in the U.S.
Experience of Californa: Binational Health Coverage
Options in Mexico: Mexican Institute of Social Security,
Seguro Popular, Private Sector
Outlook: healthcare and immigration reforms
Mexicans in the U.S. 33.7 million individuals of Mexican origin resided in the U.S. in
2012 (U.S. Census).
11.4 million immigrants born in Mexico + 22.3 million born in
the U.S. who self-identified as Mexican Americans
In 1970, fewer than 1 million Mexican immigrants lived in the
U.S. By 2010, immigrants accounted to 9.8 million.
Mexicans in the U.S.
Previous research shows that Mexicans living in the U.S. go back
to Mexico to receive some health care
Since NAFTA was signed, economic and social integration
between the U.S. and Mexico has accelerated
US-Mexico border is the busiest international border in the
world. 350M people cross it legally each year
Mexicans sent $23 billion last year as remittances. Almost half
of recipient families (46%) used a share for health spending
Motivations for binational health coverage
Access to care challenges for Mexicans in the U.S.
Cultural familiarity with the health system in Mexico
Geographic proximity
Lower costs of care in Mexico (50% - 90%)
California’s experience
In 1998, California enacted legislation allowing
binational health coverage in Mexican border cities. In
2001 Texas tried to introduce a similar law but failed.
Three private plans were licensed to provide services
in California and Mexico. Enrollment is ~20K individuals
California’s experience
According to the California Health Interview Survey an
approximately 800K California adults use medical,
dental, and/or prescription services in Mexico
Approximately 50% are Mexican immigrants
California’s experience
Mexican immigrants >15 years 225,000
Mexican immigrants <15 years 263,000
US-born Non-Latinos 89,000
US-born Mexican Americans 232,000
Source: Wallace, Castañeda et al
California’s experience
Among Mexican immigrants the main predictors of use
are: need, no insurance, delay seeking care, more recent
immigration and limited English
Living closer to the border increased use, although half
of immigrants seeking services lived more than 120 miles
from the border
Options in Mexico
Program Share of population
Health Coverage
Responsibility
Social Security (e.g. IMSS)
52% comprehensive Federal government
Seguro Popular 48% 284 services Federal and state governments
Private 2-3% varies Private insurers (FFS)
IMSS-Social Security Institute
Mexican immigrants can enroll since 1997
Now they should enroll in Mexico
Different fees according to age of enrollees
No co-payments or deductibles. Excludes pre-existing conditions
Seguro Popular
99% enroll for free
No co-payments or deductibles. Covers pre-existing conditions
Seguro Popular enrollees can include their relatives in the U.S.
Enrollment in Mexico
Private Sector
Approximately 52% of health spending in Mexico is private
and most of it is out-of-pocket
Private health insurance is underdeveloped
Medicare in Mexico has produced high expectations
Increasing consolidation of services
Outlook: ACA
If HC reform is effective:
Binational health utilization could decrease among currently
uninsured Mexicans who are ACA eligible
Uncertain among those who currently have insurance and still prefer
to purchase care in Mexico
Outlook: ACA
Opportunities to expand binational health coverage:
ACA pilot programs to cut Medicare costs could consider Medicare in
Mexico
Health plans in the exchanges will compete based on cost. Binational
coverage could take advantage of lower-cost Mexican providers.
Potential partnerships between Medicaid and FQHCs and Mexican
providers
Outlook: Immigration reform
More than half (55%) of the 11.1 million Mexican immigrants in the
U.S. live are undocumented
Granting legal status to this population could make them eligible for
health coverage and would allow them to receive care in Mexico
Potential guest worker program could consider low-cost binational
health insurance coverage.
Mexican plans lack coverage in the U.S.
U.S.-Mexico cooperation could ease the flow of
transnational populations
ACA and immigration reform opportunities
Next steps
Idea Policy Paper Pilot Legislation Implementation Evaluation
Arturo Vargas Bustamante, PhD, MPP
Assistant Professor of Health Policy & Managemnt UCLA Fielding School of Public Health
Binational Opportunities for Immigrant Coverage
Immigration Reform: Challenges and Opportunities
UC Berkeley School of
Public Health A Publ ic Ser v ice Program of UC Of f ice of the
Pres ident Gilbert Ojeda, Director
California Program on Access to Care. UC Berkeley School of Public Health
UC Forum-- Immigration Reform:
Challenges & Opportunities October 2, 2013
Opportunities in Health Care Reform for Immigrants: a California Perspective
Established in 1997 by University of California Office of President at request of CA Legislature
Mission as set by UC & the Legislature is to promote access to health care for farmworkers, immigrants & the “working poor”
Has assisted multiple State initiatives to maintain & expand
health coverage to low-income populations during a tight fiscal period
Supported start-up of Health Initiative of the Americas which established Latin American migration & health programs with focus on US-Mexico health & public health (beginning in 2001)
Has implemented grant programs, coverage initiatives & Technical Assistance projects with CA’s decision makers
THE CPAC PERSPECTIVE
Largest Medicaid program- 7.2 million persons; approximately 50% Latino; over 60% in managed care plans (largely private sector); soon over 80%
Eligible but not enrolled- 1 million; almost 60% Latino & partly immigrant-based
Child Health/CHIP- CA’s program for under age 19 (Healthy Families): 900K enrollees; 60% Latino, with many in “mixed-status” families; integrated into Medi-Cal by January 2014
Medicaid Childless Adults- expansion adopted in CA; about 55% Latino; 1.4 million in total by end of 2014
MEDICAID/MEDI-CAL: CORE ELEMENT OF HEALTH REFORM
Board of Covered CA only 5 members; in place since Jan 2011; five advisory bodies reflecting CA’s diverse population & complex health industry A staff of over 800 including service centers reflects state’s diversity
13 health plans, including state’s 4 largest health plans
(which serve 80% of commercial market), selected as Qualified Health Plans (QHPs) for state’s 19 regions Most plans commercial; other plans are public, county-based or
multi-county. All have experience with Medicaid/Medi-Cal
CA HEALTH INSURANCE EXCHANGE: THE STRUCTURE
Safety net providers- depending on region & its responsible health plans, community clinics, traditional Medicaid docs & public hospitals have dif ficulty securing contracts
No wrong door entry (Single Portal)- premise of system is entry into Medicaid & Covered CA through plans, counties, State service centers, providers & CBOs
Markets for individuals & businesses- through Covered CA in individual insurance marketplace and small business marketplace (SHOP); only undocumented are not eligible
COVERED CA: THE STRUCTURE
13 Qualified Health Plans & State’s Medicaid plans beginning
enrollment on October 1st
Outreach & Education (O&E) contracts (almost $60 mill ion & 60 contractors) star ted in August after training period (public & foundation funding) Priority focus on young adults & populations of color, including Latinos &
other immigrant populations O&E materials developed to support O&E contracts & over $100
mill ion media campaign just beginning, including balanced use of Latino and Asian-based broadcast media
Certification of Certified Enrollment Entities proceeding apace; over
10,000 Certified Enrollment Counselors (CECs) in training or cer tified by early next year
HEALTH BENEFITS EXCHANGE: STATUS
California, one of 14 states, supporting State-only Medicaid & CHIP programs for immigrants under 5-year immigration bar (Legal Permanent Residents)
State budget maintains existing State-only programs for Medicaid & a State-only component for new Childless Adult expansion as well
Prenatal Limited Scope Medi-Cal program covering almost a third of Medicaid births annually also maintained Program has served all immigrant mothers without legal restriction
for 25 years
STATE-ONLY & STATE-DRIVEN PROGRAMS
Consistent with State’s administration of EMTALA, State provides an Emergency Medicaid component without concern to immigration status
State also administers other residency-based health programs
including: family planning (Family PACT) & Child Health Development Program (prevention screening to age 20)
STATE-ONLY AND STATE-DRIVEN PROGRAMS, Cont’d
State-only programs enacted when Legislature was responding to deficiencies in federal coverage resulting from Welfare & Immigration reforms of 1995-96 Outcomes have been positive & withstood efforts initiated by Proposition
187 to eliminate numerous immigrant protections
Section 17000 of State’s Health & Welfare Code designates counties as “providers of last resort” More liberal counties have provided coverage to indigent including
undocumented Some counties have limited coverage to legal residents only
Through initiatives over last 20 years, State has supported through direct funding indigent care at county level
14 counties operate public hospitals & others contract with
hospitals & clinics (including CHCs); counties have been fiscally challenged in last decade from State budget deficits & the Great Recession to lower county funding for indigent care
THE STATE’S SAFETY NET PROGRAMS
Need program to address health & human services at state level similar to SLIAG program under 1986 IRCA Models to address these needs, in the face of restrictions for federally means-
tested benefits, would address needs of Republican and Democratic led states
I f Federal legislation passes, as many as 6 mill ion immigrants nationwide are projected to become “newly legal” as Registered Provisional Immigrants (RPIs). These immigrants could assume such status star t ing as early as 2015 into early 2016
These numbers could reach 1 .5 mill ion in Cal ifornia alone
Amendment to recent CA State budget requires Health Department to
conduct study as early as Spring 2014 of implications to state’s health & human service network for such a newly legal population
Designation of over a mill ion immigrants to of fer avenue for legal action against counties resist ing care to their newly legal immigrant populations & for any ef forts to withdraw State indigent funds from counties due to coverage for indigent population through ACA
IN THE SHADOW OF IMMIGRATION AND HEALTH REFORM
Medicaid Expansive benefits & income
groups Private plan participation Integrate large CHIP component Compact w provider community Broad support for higher rates Childless Adult expansion
brought provider, public, advocate support Expansion of immigrant
coverage through State-only, “mixed” families efforts
Covered CA (Exchange) Administer portion of State-only Conduct aggressive outreach to
non-Medicaid eligible immigrants e.g., multi-language broadcasting
Supporting a culture of insurance for small business employing millions of immigrant workers
Immigrant Postures Under Review Maintain State-funded indigent $’s Study impact of RPI’s on county
indigent programs Review, enhance resident-based
programs
SUMMARY FOR CALIFORNIA: THE ROADS TAKEN & UNDER REVIEW
b
FOR ADDITIONAL INFORMATION:
Gilbert Ojeda Director
California Program on Access to Care UC Berkeley School of Public Health
Phone: 510-643-3140 [email protected] http://cpac.berkeley.edu