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October 2003, Vol 93, No. 10 | American Journal of Public Health 1680-1682
© 2003 American Public Health Association

RESEARCH AND PRACTICE

Eligibility for Government Insurance if Immigrant Provisions of Welfare Reform Are Repealed

Olveen Carrasquillo, MD, MPH, Danielle H. Ferry, MS, Jennifer Edwards, DrPH and Sherry Glied, PhD

Olveen Carrasquillo is with the Division of General Medicine, College of Physicians and Surgeons, Columbia University, New York, NY. Olveen Carrasquillo, Danielle H. Ferry, and Sherry Glied are with the Department of Health Policy and Management, Mailman School of Public Health, Columbia University. Jennifer Edwards is with the Commonwealth Fund, New York, NY.

Correspondence: Requests for reprints should be sent to Olveen Carrasquillo, MD, MPH, 622 W 168 St, PH 9E Room 105, New York, NY 10032 (e-mail: oc6{at}columbia.edu).


   INTRODUCTION
TOP
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 References
 
The 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA; also known as the Welfare Reform Act) prevents states from using federal funds to provide Medicaid and State Children’s Health Insurance Program (SCHIP) coverage for most immigrants who have resided in the United States for less than 5 years.1,2 Some states currently use "state-only" funds to provide Medicaid and SCHIP to recently arrived immigrant children, but others do not.3,4 Furthermore, although expansions of Medicaid and SCHIP to cover parents of enrolled children have been widely touted,5,6 under PRWORA, recently arrived immigrant parents would be excluded. Currently, considerable bipartisan political support exists for the repeal of these immigrant provisions of PRWORA.2,7


   METHODS
TOP
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 References
 
To estimate the number of uninsured children currently barred from Medicaid and SCHIP programs and the number of parents who would be excluded from government insurance expansion programs because of PRWORA’s immigrant provisions, we analyzed data from the March 1999 and 2000 Current Population Surveys.8 We considered all persons born in the United States, foreign-born persons with at least 1 American parent, and those who had become naturalized as US citizens. All others were classified as noncitizens.

We assigned health insurance based on previously described methodology.9 We then used both person- and family-level sociodemographic information to model income eligibility for Medicaid and SCHIP. To the extent possible, we used state-specific qualification criteria appropriate for the survey year.10–14 State policies on coverage of immigrants at the time of our study were similarly compiled.4,15

We randomly assigned noncitizen immigrants the status of documented or undocumented at the state level based on 1996 Immigration and Naturalization Service estimates.16 Persons assigned undocumented status are ineligible for Medicaid or SCHIP. We also provide a sensitivity analysis in which we assumed that the undocumented population is ±50% of our baseline figure.

We derived population estimates with Current Population Survey weights based on independent estimates of the population, including Immigration and Naturalization Service data.8 We calculated standard errors for 2-year data according to methods developed by the Census Bureau8 and present all standard errors greater than 2% of an estimated percentage or greater than 5% of a population estimate. For population estimates less than 1 million, we used rounding, and sums may not total exactly.


   RESULTS
TOP
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 References
 
Among the 17.2 million immigrants who were not US citizens, 42.8% were uninsured, and 13.7% had public coverage (Table 1Go). Noncitizen immigrants made up 21.3% of the uninsured population in the United States. The majority of these uninsured immigrants, 64%, were Hispanic. Among the 4.9 million immigrants living in this country for less than 5 years, 50% were uninsured. However, even in states with large immigrant populations, recent immigrants made up only a small proportion of the uninsured: 8.8%, 9.2%, 5.9%, 8.7%, 7.0%, and 6.9% in California, New York, Texas, Florida, New Jersey, and Illinois, respectively.


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  		TABLE 1—— Sociodemographic Characteristics of US Citizens and Immigrants Who Are Not Citizensa,b
 
Among the newly arrived immigrants who were not US citizens, there were approximately 1.1 million children (SE = 80 000), of whom 43% (SE = 2.7%), or 460 000 (SE = 50 000), did not have health insurance. Of these uninsured children, 310 000 (SE = 40 000) were legal immigrants (Figure 1). We found that the majority, 230 000 (SE = 30 000), met income guidelines that would qualify them for Medicaid or SCHIP coverage, including 110 000 (SE = 20 000) who lived in a state that already allowed them to qualify for Medicaid and SCHIP coverage. In our sensitivity analysis, we found that the number of uninsured children living in a state barring SCHIP and Medicaid coverage because of their recent arrival ranged from 100 000 to 140 000 (SE = 20 000), depending on the number of undocumented children used in the models. Among the 250 000 (SE = 30 000) newly arrived legal immigrant children eligible for SCHIP or Medicaid (based on each state’s income and immigration criteria), 27% (SE = 5.0%) were covered by private insurance, 27% were covered by government programs, and 46% (SE = 5.5%) were uninsured.

We found that 3.8 million noncitizen adults in the United States had less than 5 years of residency. Two million lacked insurance coverage. We estimated that 1.4 million (SE = 80 000) of these uninsured adults were here legally, and 330 000 (SE = 40 000) had children. Among these parents, 50 000 (SE = 14 000) already qualified for Medicaid based on their incomes but lived in a state barring recent immigrants from public coverage. Another 90 000 (SE = 20 000) had children who were eligible for Medicaid or SCHIP and lived in a state that used its own funds to cover recent immigrants. Finally, 100 000 (SE = 21 000) qualified only if immigration restrictions were repealed in conjunction with a SCHIP expansion to parents. A negligible number (< 20 000) of childless adults would qualify for Medicaid if the ban on recent immigrants were repealed. Altogether, 250 000 immigrant parents (SE = 40 000; sensitivity analyses = 200 000–310 000) would benefit from a policy simultaneously expanding SCHIP to parents of eligible children and repealing immigration restrictions.


   DISCUSSION
TOP
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
References
 
Lack of insurance among immigrants remains a major public health problem.17 Half of the quarter million legal recently arrived children who were SCHIP and Medicaid eligible and lived in states allowing coverage were uninsured. However, despite numerous concerns that PRWORA would worsen this crisis,18,19 we found that only 110 000 children are barred from SCHIP and Medicaid because of the immigrant provisions of this legislation. Other studies have also shown that PRWORA had a limited effect on Medicaid participation in this population.3 Thus, the primary result of PRWORA’s immigrant provisions has been to shift the costs of this coverage to states. Given the current fiscal condition of states,20 particularly those with large immigrant populations, the wisdom of such policies needs to be reconsidered.

Among adults, we found that if SCHIP programs were expanded to parents of eligible children, only about 250 000 recently arrived uninsured immigrant adults would become eligible for coverage. Unfortunately, with the budget deficits many states are facing, it is unlikely that many states will continue to push for SCHIP expansions for low-income parents, immigrant or otherwise.

Caveats apply. First, we used Immigration and Naturalization Service data to assign undocumented status. These figures may be conservative.21 Given the inherent uncertainty in estimating this population, we thought it more appropriate to provide a sensitivity analysis. Second, state Medicaid and SCHIP policies are in a constant state of flux, and readers should be aware that our analysis was based on policies during 1998 and 1999.

Even after the events of September 11, 2001, support for legislation beneficial to immigrants continues.22,23 Compelling social justice arguments and our findings support legislative initiatives to repeal PRWORA provisions preventing federal funding of insurance programs for recent immigrants.



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  		FIGURE 1—— Number of uninsured immigrant children and adults currently and potentiallya excluded from Medicaid and State Children’s Health Insurance Program (SCHIP) coverage because of immigrant provisions of the Welfare Reform Act.

Note. aFor adults, our estimates show the number of uninsured adults that would be excluded from coverage by immigrant provisions of the Welfare Reform Act, if Medicaid and SCHIP were expanded to parents of eligible children.

bWe randomly assigned noncitizen immigrants the status of documented or undocumented at the state level based on 1996 Immigration and Naturalization Service estimates. Such persons are ineligible for Medicaid or SCHIP.

cNumbers may not add up because of rounding.

dIn a sensitivity analysis (assuming that the undocumented population is ± 50% of estimate), we found that this estimate of immigrant parents could range from 200 000 to 310 000 (SE = 40 000).

eIn a sensitivity analysis (assuming that the undocumented population is ± 50% of estimate), this estimate of the number of uninsured immigrant children living in a state barring SCHIP and Medicaid coverage because of their recent arrival ranged from 100 000 to 140 000 (SE = 20 000).

 

   Footnotes
 
Contributors
O. Carrasquillo co-developed the idea for the brief; assisted with the data analysis; wrote numerous drafts, including the final draft; and discussed the ideas at scientific meetings. D. H. Ferry conducted the data analysis, co-wrote the initial drafts of the manuscript, and provided articles and expertise concerning Medicaid and SCHIP eligibility issues. J. Edwards co-developed and refined the intellectual content, extensively edited the final drafts of the brief, and provided expertise concerning immigration, Medicaid, and SCHIP issues. S. Glied co-developed the idea for the brief, assisted with the data analysis, refined the intellectual content, contributed extensively to all drafts of the brief, and provided editorial expertise.

Human Participant Protection
This study was a secondary analysis of a publicly available data set without patient identifiers and thus was exempt from review.

Peer Reviewed

Accepted for publication April 25, 2003.


   References
TOP
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 
1. Bachrach D, Lipson K. Health Coverage for Immigrants in New York: An Update on Policy Developments and Next Steps. New York, NY: The Commonwealth Fund; July 2002. Commonwealth Fund publication 546.

2. Immigrant’s Health Care: Coverage and Access. Washington, DC: The Kaiser Commission on Medicaid and the Uninsured; August 2000. Kaiser Family Foundation publication 2203.

3. Fix M, Passel J. The Scope and Impact of Welfare Reform’s Immigrant Provisions. Washington, DC: The Urban Institute; January 2002. Discussion Paper 02–03.

4. Zimmerman W, Tumlin KC. Patchwork Policies: State Assistance for Immigrants Under Welfare Reform. Washington, DC: The Urban Institute; May 1999. Occasional Paper 24.

5. Dubay L, Kenney G. Covering Parents Through Medicaid and SCHIP: Potential Benefits to Low-Income Parents and Children. Washington, DC: The Kaiser Commission on Medicaid and the Uninsured; October 2001. Kaiser Family Foundation publication 4022.

6. Kennedy EM. Introduction of the bipartisan Familycare Act of 2001 [press release]. Washington, DC: Office of Senator Edward M. Kennedy; July 25, 2001.

7. 108th Congress expected to address immigrant health benefits. Kaiser Daily Health Policy Report. December 10, 2002. Available at: http://www.kaisernetwork.org/daily_reports/rep_index.cfm?hint=3&DR_ID=15017. Accessed December 12, 2002.

8. Source and Accuracy of the Data for the March 2000 Current Population Survey Microdata File. Washington, DC: US Census Bureau; September 2000. Available at: http://www.bls.census.gov/cps/ads/2000/ssrcacc.htm. Accessed July 10, 2001.

9. Ferry DH, Garrett B, Glied S, et al. Health insurance expansions for working families: a comparison of targeting strategies. Health Aff (Millwood). 2002;21:246–254.[Abstract/Free Full Text]

10. Ku L, Ullman F, Almeida R. What Counts? Determining Medicaid and CHIP Eligibility for Children. Washington, DC: The Urban Institute; 1999. Discussion Paper 99-05.

11. State Policy Documentation Project. Medicaid: 50 State Policy Comparison. Washington, DC: The Center for Law and Social Policy and the Center on Budget and Policy Priorities; September 2000. Available at: http://www.spdp.org/medicaid.htm. Accessed August 2, 2001.

12. Smith VK. Enrollment Increases in State CHIP Programs: December 1998 to June 1999. Washington, DC: The Kaiser Commission on Medicaid and the Uninsured; July 1999. Kaiser Family Foundation publication 2153.

13. Center for Best Practices, Health Policy Studies Division. States Have Expanded Eligibility Through Medicaid and the State Children’s Health Insurance Program. Washington, DC: National Governors Association; February 1999. Available at: http://www.nga.org/cda/files/19990210MCHUPDATE.PDF. Accessed August 2, 2001.

14. State Children’s Health Insurance Program (SCHIP) Aggregate Enrollment Statistics for the 50 States and the District of Columbia for Federal Fiscal Year (FFY) 2000. Baltimore, Md: Health Care Financing Administration; August 15, 2001. Available at: http://www.hcfa.gov/init/fy2000.pdf. Accessed September 5, 2001.

15. Tumlin KC, Zimmerman W, Ost J. State Snapshots of Public Benefits to Immigrants: A Supplemental Report to Patchwork Policies. Washington, DC: The Urban Institute; May 1999. Occasional Paper 24, supplemental report.

16. Statistical Yearbook of Immigration and Naturalization Service 1998. Washington, DC: US Immigration and Naturalization Service; 2000.

17. Carrasquillo O, Carrasquillo A, Shea S. Health insurance coverage of immigrants living in the United States: differences by citizenship status and country of origin. Am J Public Health. 2000;90:917–923.[Abstract/Free Full Text]

18. Ku L, Matani S. Left out: immigrants’ access to health care and insurance. Health Aff (Millwood). 2001;20:247–256.[Abstract/Free Full Text]

19. Lewin J. Protecting the health of children of immigrants: innocent victims of adult policy. JAMA. 1997;277:672.[Medline]

20. Lav IJ, Johnson N. State Budget Deficits for Fiscal Year 2004 Are Huge and Growing. Washington, DC: Center on Budget and Policy Priorities; 2003.

21. Fix M, Zimmerman W, Passel JS. The Integration of Immigrant Families in the United States. Washington, DC: The Urban Institute; July 2001. Available at: http://www.urbaninstitute.org/pdfs/immig_integration.pdf. Accessed September 5, 2001.

22. Hulse C. Gephardt is preparing a measure to legalize illegal immigrants. New York Times. July 23, 2002:A13.

23. Pear R. Bush plan seeks to restore food stamps for non-citizens. New York Times. January 10, 2002:A1.




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This Article
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