IMMIGRANTS: Face Unique Barriers to Health Care
Noting that immigrants comprise a considerable portion of America's uninsured population, health policy experts gathered at an Alliance for Health Reform-Kaiser Family Foundation briefing on Aug. 2 to discuss immigrants' insurance levels and access to care. Leighton Ku, a senior fellow with the Center on Budget and Policy Priorities and co-author of the June 2000 Urban Institute report "Immigrants' Access to Health Care and Insurance on the Cusp of Welfare Reform," presented some demographics for the immigrant population. Immigrants constitute 10% of the U.S. population, he said, and one-third of these immigrants are naturalized citizens. One-quarter are illegal or undocumented aliens and the remainder are legal immigrants. Immigrants generally experience high rates of employment, but typically earn low wages. At the same time, employers seldom offer immigrants insurance and immigrants cannot afford private insurance, Ku said. Steven Camarota, resident scholar at the Center for Immigration Studies, said that immigrants represent 26% of the 44 million uninsured. Furthermore, immigrants who have arrived in the United States between 1994 and 1998 account for 59% of the growth in the uninsured population. According to Ku, 19% of noncitizens whose incomes were below 200% of the federal poverty level had Medicaid coverage in 1995, but that figure dropped to 14% in 1998. The number of noncitizens with private insurance increased 1% (from 25% to 26%) between 1995 and 1998, while the number of uninsured also increased from 54% to 59% during the same time period. Latino immigrants account for the largest portion of uninsured immigrants.
Ku said that some recent "anti-immigrant" policy changes have affected how immigrants access health care, pointing in particular to California's Proposition 187 and 1996 changes in federal welfare laws. Prop. 187, which was passed in 1994, took public benefits such as health care away from California immigrants. It was overturned by a U.S. District Judge in 1999. As a result of the 1996 welfare reforms, immigrants entering the United States after August 1996 are not eligible for Medicaid benefits for five years. In 1997, HCFA made the same restrictions for CHIP, but some states, including California, have used their own funds to provide health care to immigrants.
Declining Medicaid Participation
Since 1996, immigrants' participation in public assistance programs such as Medicaid has declined, even for legal immigrants, according to Yolanda Vera, a lawyer with the Western Center on Law & Poverty. Between January 1996 and January 1998, approved applications of legal noncitizen families for Medicaid and Temporary Assistance for Needy Families dropped 71% in Los Angeles County, but there was no decline among citizen families during the same time period. Vera attributed the decline in applications by immigrants to their fear that using public assistance will damage their chances of obtaining a green card. Immigration and Naturalization Services has clarified that using public assistance such as Medicaid and CHIP does not disqualify immigrants from obtaining green cards, but INS agents often gauge immigrants' income levels by whether they receive Medicaid or CHIP assistance. Consequently, some immigrants incorrectly conclude that they might have been denied a green card because of their participation in Medicaid or CHIP, Vera said, adding that burdensome applications, complex Medicaid rules and language barriers also contribute to immigrants' lack of participation in public assistance programs.
Access to Care
Because they lack insurance, Ku said that immigrants and their children are less likely to see a health care provider or visit an emergency room. On the other hand, having insurance "substantially" increases noncitizens' medical and dental access. But even with insurance, immigrants' access to health care is not on par with native citizens because of "non-financial barriers," including language and discrimination, Ku said. Ku added that Latinos specifically cite language barriers as the No. 1 problem in getting health care for their children. Dr. Peter Morris, medical director and public policy director for Wake County Human Services in Raleigh, N.C., echoed Ku's calls for dismantling language barriers. He advocates increased "bicultural care," saying that even if immigrants receive care now, it is "inadequate" because of cultural barriers.
Vera, Ku and Morris all called for Medicaid and CHIP coverage of immigrants to be restored -- a policy idea that has been proposed in both the House and Senate. Vera noted that, for those states currently providing health care to immigrants out of their own budgets, legislation restoring immigrants' access to public assistance will not increase the population that receives health care; however, she said such bills will shift the monetary burden of caring for immigrants away from local and county governments. Morris added that preventive health care should be part of any insurance coverage immigrants receive, pointing out that many immigrants disproportionately face certain chronic conditions. Taking a different policy approach, Camarota called for changes in immigration policy, saying, "Does it make sense to invite so many people in [the United States] who will need welfare?" He said that unless policies are altered, 11 million immigrants will enter the United States in the next 10 years, adding between four and six million to the uninsured population. Significantly increasing the number of immigrants does not seem logical, considering the problems the United States now faces, Camarota said (Amanda Wolfe, California Healthline, 8/3).