IMMIGRANT HEALTH CARE
Kristi
McDermott
Advanced
Topics in Health Economics
Professor
Gleason
December 11,
2002
I.
INTRODUCTION TO
IMMIGRANT HEALTH CARE
Immigrants come to
this country in search of better lives for themselves and their families; they
seek to achieve the “American Dream.”
They work hard, contribute significantly to our workforce and economy,
pay taxes, and obey their civic duties as residents of the United States of
America. However, their access to the
proper and necessary health care, among other public benefits, is quite
limited. In 2000 there were 8.3 million
uninsured non-citizen immigrants, which grew to 8.8 million by 2001. Greater
than two fifths of immigrants lack health insurance coverage.[1]
As of March 2000, there was an estimated foreign born population of 28.4 million, an increase of 44 percent from the 1990 census.[2] Given these statistics, this translates into a substantial number of uninsured persons. Lacking medical insurance coverage causes these individuals to refrain from the use of regular doctor’s office visits, and delaying care until illnesses become severe. They then utilize more costly emergency rooms and clinics to treat these progressed illnesses which could have perhaps been avoided had these individuals sought preventive care.
According to a brief by the National Immigration Law Center, there are a number of deterrents which keep immigrants from seeking public benefits such as health care coverage, including eligibility confusion and fear of deportation, among others. Consider that in New York City only eight percent of citizen children in immigrant families are uninsured, while twenty eight percent of non-citizen children lack insurance.[3] There is clearly a discrepancy between citizens versus non-citizens evident in these figures, which can be accounted for by several possible reasons. One cause is confusion regarding one’s eligibility. Eligibility tends to vary by state, one’s immigration status, and his or her date of entry into the United States. There are various different requirements which make it difficult for immigrants to determine whether they would be eligible or not. Immigrant families are often “mixed-status”, meaning different races and ethnic origins reside in the same households, which further confuses the matter. The limited knowledge which these immigrants possess regarding the American health care system leads them to seek poor quality alternatives. Another concern many immigrants have relates to the issue of confidentiality. Eligible individuals often have family members who are undocumented or awaiting resolution of their status. These eligible immigrants worry that agencies will share this information with the Immigration and Naturalization Service (INS), which causes them to avoid acquiring health care. The fear of deportation or denial of other family members leads these immigrants to refrain from taking the risks which may be involved.
Immigrants also worry that in using health care and benefits, they will be labeled a “public charge”, which could prevent them from becoming a lawful permanent citizen or from re-entering the country if they were to travel abroad. According to the INS, the use of health benefits does not cause immigrants to be considered a public charge, except in limited circumstances involving long term care. Immigration judges, however, can make discretionary decisions. The use of these benefits may also bar those that are HIV positive, because they are required to prove they will not be reliant on the government before they are permitted to enter the U.S. or become a lawful permanent resident.
Immigrants usually enter the country through a family member who acts as a sponsor and signs an “affidavit of support”, or a promise to support them. Immigrants worry that through the use of public benefits, they will somehow harm their sponsor. Sponsors who have signed this contract may be responsible for the repayment of public benefits. These particular immigrants may also be ineligible for Medicaid or SCHIP because their sponsor’s income is considered when determining if he or she meets the income requirements for these assistance programs. Immigrants also worry that they will not be able to later sponsor the entry of their family members if they are reliant on public benefits. However, as long as he or she can prove that he or she receives an income of 125 percent of the federal poverty level, acting as a sponsor is permitted. If this requirement is not filled, it is also possible to have joint sponsorship.
Language also acts as a deterrent because these immigrants have difficulties learning about the available benefits and programs, the application process, and other factors relevant to their healthcare. This barrier further limits their knowledge of the system, causing them to avoid health care until it becomes necessary through the use of emergency rooms. For these reasons, immigrants fear receiving public health benefits and refrain from applying, further increasing the difference between the United States’ foreign-born and native-born populations.[4] For many immigrants, perception remains reality. However, generally these concerns are unnecessary and could be avoided if these individuals had access to all of this information. However, it is easy to understand why an immigrant may wish to avoid these risks, especially when it relates to his or her family’s potential well being.
II.
THE UNINSURED IN
AMERICA, SPECIFICALLY IMMIGRANTS
Nationwide, it is estimated that 41.2 million Americans are uninsured, as of 2001 statistics. This is an increase from about 39.8 million in 2000.[5] Preliminary data from the National Health Interview Survey also indicated that the number of uninsured Americans would continue to rise in 2002, for reasons such as growing unemployment and higher healthcare costs due to state Medicaid cutbacks. These general trends of an increasingly uninsured population do not indicate a positive outlook for legal immigrants, considering that non citizens are more than twice as likely to be uninsured than citizens.[6] The number of immigrants who actually have insurance or coverage has been steadily declining since Congress terminated Medicaid and SCHIP for recently admitted legal immigrants under the 1996 law. The latter point will be discussed more thoroughly later in the paper.
Among adults in families below 200 percent of the federal poverty level, only 26% of non-citizens have job-based health insurance, versus 42% of US born adults.[7] This statistic implies that low income immigrants and their US born children are less likely to be covered by job-based health insurance than other low-income workers. The increase in healthcare costs has led to a decline in the number of insured people, which in turn continues to drive up the cost of job based insurance. Small businesses have stopped offering this insurance while other companies have increased the costs to workers. According to estimates from the CPS report in March of 2000, foreign born individuals typically earn less than natives.[8] This makes it more difficult for low wage employees to afford job-based insurance for themselves and their dependents, while still affording the basic necessities. Given their difficulty in paying the current costs of this insurance, rapidly increasing insurance costs will only make it more difficult for these low wage earners to afford coverage going forward.
Connecticut’s Office of Health Care Access (OHCA) 2001 Household Survey[9] suggests a number of factors which influence the likelihood of one being uninsured, which can be correlated with specific U.S. Census data[10] regarding the foreign born population to make relevant conclusions. The survey indicated that there are discrepancies between age groups, race and ethnicities, employment status, income levels, levels of education, and gender, among others. For example, males were more likely to be uninsured than females. Individuals in their twenties and thirties were recorded as having the greatest proportion of uninsured persons. In using specific data from the U.S. Census, approximately forty three percent of foreign born individuals of the U.S.’s total population were ages twenty five to forty four while only twenty eight percent of the native population was in this age group. One could infer from this information that immigrants account for the majority of the uninsured, given that they make up most of the age group which has the highest rate of uninsurance.
Other factors mentioned in OHCA’s 2001 Household Study which affect the likelihood of one being uninsured include employment status, income levels, and education. According to the census data, the foreign born population was also found to be more likely to be unemployed than those born in the U.S, which affects the rate of job based health insurance coverage. More specifically, foreign born individuals are more likely to be in service occupations as opposed to managerial or professional positions which are held more often by the native born population. This fact implies a difference in income levels, which strongly affects one’s ability to pay for health insurance. This finding was expanded upon in noting that foreign born U.S. residents are more likely to live in poverty. The Household Study also pointed out that there are noticeable discrepancies between education levels, which affects the likelihood of being insured. As indicated in the census, foreign born populations were less likely to have graduated from high school. Greater than one fifth of foreign born individuals had less than a ninth grade education, compared with one twentieth of the native population.
As OHCA’s Household Study recommends, further studies must be conducted to break down each factor in order to identify the exact nature of each characteristic which makes it vulnerable to being uninsured or underinsured. However, current studies have identified the existence of a correlation between these factors and uninsured populations. In further identifying the specific problems, perhaps the case of legal immigrants could become more recognized allowing more attention and resources to be allocated toward it. Future studies would assist policymakers to pinpoint and implement the appropriate policy changes and coverage expansion programs.
III.
CONNECTICUT IN PARTICULAR
The Office of Health Care Access (OHCA) aims to ensure that citizens of Connecticut all have access to quality health care, and performs various studies to identify important problems and shortfalls in the system. OHCA’s 2001 Household Survey[11] found that 5.6 percent of its respondents were uninsured, which are 185,201 civilian non-institutionalized Connecticut residents. The state’s uninsured rate was 8.3 percent.[12] Although this percentage is one of the lowest in the country, Connecticut still needs to create new methods of expanding coverage. The graph in Appendix I illustrates the uninsured rate by citizenship in Connecticut in 1995.[13] This identifies the disparity that exists between citizens and non-citizens within the state. The U.S. Census notes two important reasons, which pertain particularly to immigrants, as to why individuals do not receive care, enroll in insurance plans, or apply for public funding. One which was previously mentioned, but ought to be re-emphasized, is the fear that getting Medicaid, SCHIP, or other public benefits will negatively affect the immigrant’s ability to become permanent residents or may even result in deportation. Another reason relates to the cost of healthcare. Policies can range from one hundred dollars per month, which would provide basic coverage, to four hundred dollars or more per month for benefits similar to those contained in employers’ packages.
There are a number of examples of legal immigrants in Connecticut who live in poor conditions and lack the access to the proper health care that they need and deserve. One prime example is of the migrant workers in the Connecticut River valley, consisting of towns such as Middlefield and Enfield. This area has approximately 7,000 migrant workers from countries such as Jamaica and Mexico, and from Puerto Rico, among others. Dr. Bruce Gould, associate dean for primary care at University of Connecticut, along with students of the UConn School of Medicine, have formed a mobile migrant worker health clinic. The migrant farm workers rely on these makeshift clinics to treat their ailments which range from sunburns and strained muscles to allergies. More severe cases such as diabetes and heart disease, however, get referred to community health centers. The clinic has evolved from using picnic tables behind farm buildings to pop up tents and tarps. The clinic operates annually on $10,000 which comes from federal grants, private donations, and the Hartford County Medical Association. This money is enough to pay stipends to the three students in charge and to cover supplies and equipment. Because the workers lack insurance coverage, this is the manner in which they are forced to receive treatment.[14] If this migrant clinic was not available, it is questionable as to where these individuals would or could go to seek medical attention, if at all.
IV.
THE 1996 “PERSONAL
RESPONSIBILITY AND WORK OPPORTUNITY ACT” (PRWOA)
This 1996 federal
welfare reform law, PRWOA, was designed to change the nation’s welfare system,
but in doing so, also became one of the most detrimental acts against
immigrants’ access to health care. As President Clinton stated, the bill
represented “an historic chance to make welfare what it was meant to be: a
second chance, not a way of life.”[15] However, this bill also affected most
non-citizens’ access to federal assistance programs. Clinton did go on to criticize the bill for “hurt(ing) legal immigrants”
and vowed to propose legislation which would counteract some of these
restrictions, although this was never done. Non-citizen immigrants have historically had similar rights and
responsibilities that citizens possess.
They have always paid taxes and had similar responsibilities as citizens
of this country. Upon the enactment of
this bill, restrictions were placed on non-citizen immigrants, and their
eligibility for public benefits such as Medicaid was limited. Under PRWOA, states were given the right to
provide or deny Temporary Assistance for Needy Families (TANF) and Medicaid to
qualified aliens residing in the U.S. before the date of the enactment of the
welfare reform law, August 22, 1996.
New arrivals, with the exception of refugees, were barred from benefits
such as TANF and Medicaid, as well as food stamps and SSI, for the first five
years of their residence in this country.
This welfare law included a provision attempting to restrict the states’
ability to use their own funds to provide public benefits to immigrants. Immunizations and testing and treatment for
communicable diseases were permitted, but Medicaid funding was not
provided. Emergency medical assistance
was to be made available for both qualified and non-qualified aliens, but as
will be discussed later, reliance on this type of care can become quite costly.[16]
Advocates of this bill expressed discontent towards immigrants prior to the
passing of this act. Some felt that
immigrants used welfare disproportionately and that this use was increasing at
a rapid rate, further stressing the welfare system and raising its cost. These individuals were also frustrated at
the number of immigrants that received public assistance despite being admitted
under the provision of receiving financial support from his or her sponsor.[17]
This general discontent toward immigrants increased support for the passage of
PRWOA.
V.
ALIESSA V. NOVELLO:
TAKING PRWOA TO COURT
Aliessa v. Novello 2001 was a crucial New York case which ruled that the state violated both the U.S. and state constitutions when it denied state-funded Medicaid to immigrants who lost their eligibility due to the 1996 welfare reform law. More specifically, it ruled that there was a violation of the equal protection clauses of the federal and state constitutions, along with a specific violation of the New York constitution’s requirement that the state and its subdivisions provide for the needy. The court found that “To allow a serious illness to go untreated until it requires emergency hospitalization is to subject the suffering to the damage of a substantial and irrevocable deterioration in his health,” thus violating the state’s duty to provide for the “aid, care, and support of the needy.” The court also concluded that PRWOA’s delegation to the states the ability to differentiate between different classes of legal immigrants in allocating their benefit programs was in violation of Congress’s constitutional obligation to establish a uniform, national system for the regulation of immigration.[18] The results of this case, particularly the violation of the U.S. Constitution, should lead other states to scrutinize their own immigration programs and policies. This decision will probably act as a catalyst to cause more states to extend benefits to all legal immigrants. It should also promote increased federal funding to restore benefits which were lost due to the installation of the five year bar. In the next section there will be discussion of important legislation which has proposed such measures and is in the process of being reviewed.
VI.
PROPOSED
LEGISLATION TO COUNTERACT PRWOA’S
EFFECTS
Much legislation has been proposed in order to counteract the negative effects that PRWOA had on legal immigrants within the United States as a whole and within individual states. For example, the recent Connecticut state bill titled “An Act Concerning State Support for Legal Immigrants”, number SB-444, was created with the intent to insure that immigrants who legally reside in Connecticut will remain eligible for state benefits. It seeks to restore medical assistance for legal immigrants. This bill was raised on February 14, 2002, and after approval by the Human Services Committee, it reached the Appropriations Committee on March 19, 2002. As of April, this bill had not passed through the Appropriations Committee, although the budget does contain funding for continued applications for medical assistance.[19]
Ellen Andrews, Executive Director of the Connecticut Health Policy Project, made a solid argument in her March 7, 2002 human services committee testimony as to why legal immigrants deserve access to health care and, more specifically, why the passage SB-444 ought to be passed. She argues that legal immigrants have come to America, specifically the state of Connecticut, to find better lives. They make important contributions to our economy and culture, follow the rules, and pay taxes. It is therefore unfair to deny them proper health care and basic human needs. It is also counter productive because these individuals will not seek health care services until their illnesses are more difficult and costly to treat. Those increased costs will mean higher premiums and taxes for the rest of the community. She clearly feels that this existing situation is neither optimal nor desirable.[20]
Other people have shown similar feelings of support for SB-444. Katharine Carlino of the Connecticut Children’s Health Project also expressed her support for the bill. She mentioned that unless this bill passes, many of these legal immigrant families residing in this state will not be eligible for health coverage through the HUSKY program. Marie Hillard of the Connecticut Catholic Conference points out the need for these rights to exist for legal immigrants since they would otherwise be eligible if they were citizens. Sister Suzanne Brazauskas, the Advocacy Coordinator for the Collaborative Center for Justice, took the issue even further in stating that not allowing assistance for people who are contributing to the welfare of the state and society through taxes and the workforce raises the possibility of discrimination. These were just some of the testimonies of those in support of the bill “An Act Concerning State Support for Legal Immigrants.”[21]
“The Immigrant Children’s Health Improvement Act of 2001” (ICHIA) is another one of the several legislative attempts to counteract the 1996 passing of the welfare reform act. As was previously stated, the welfare reform act was intended to make adults more self sufficient, but unfortunately ended up affecting children by eliminating government supported health care for all legal immigrants regardless of age. ICHIA would allow the states the decision to provide Medicaid and CHIP to eligible immigrant children and pregnant women arriving legally to the U.S. after August 22, 1996, lifting the five year bar. Consider that one in five children in America live in immigrant families, but many are unlikely to receive coverage because of federal restrictions on the immigrants who live in their households.[22] It is very common to have this intermixing where legal and/or undocumented immigrants from varying countries live in the same household with US-born children. Again, the parents in these situations may have issues of confusion or have concerns and fears of jeopardizing their immigration status that keep them from seeking health coverage for themselves and their children. In PRWOA’s attempt to encourage self-sufficiency and independence among adults, children have unintentionally been punished.
According to a 1999 U.S. General Accounting Office Report, one third of all low-income children who were eligible, but not enrolled in Medicaid, were children of immigrant families. Nearly half of low-income immigrant children had no health insurance coverage although seventy eight percent of the children of immigrants were born in the U.S., making them eligible for Medicaid and SCHIP.[23] In passing ICHIA, states would have the option of providing coverage to these affected children and pregnant women. It is estimated that by giving the states this option and eliminating the arbitrary decision of August 22, 1996 as the cutoff date, more than 200,000 people would be covered per year. As U.S. Senator Bob Graham stated in his introduction of the bill on March 21, 2001, “legal immigrant children are, as much as citizen children, the next generation of Americans” and it is therefore critical to ensure that they are healthy and productive members of our country.[24] In considering this, it is important to consider that increasing state’s health coverage among adults implies an increased number of parents providing coverage for their children.
On the federal level, in May of 2002, a group of U.S. senators introduced the “Federal Responsibility for Immigrants Health Act” (FRIHA), which would also increase access to health care for low income immigrants. Prior to the enactment of such an act, states can only get federal Medicaid reimbursement for emergency medical services extended to ineligible immigrants. FRIHA would expand the definition of “emergency Medicaid exception” to provide reimbursement for pregnancy related services, and the testing and treatment of communicable diseases. This act would also include the following in the definition of an emergency: chemotherapy, dialysis, and services necessary for the prevention of an emergency. One provision of the welfare reform law was a requirement that state legislatures pass laws stating their intentions to provide benefits to undocumented immigrants. This requirement further limits the states’ fiscal abilities to provide such benefits due to budget constraints at the state level. FRIHA would react to this limitation by exempting all state and local benefits from this provision, meaning these laws would not have to be passed in order to provide benefits. This bill would also expand federal funding for emergency services provided to undocumented persons outside the realm of the Medicaid program. In order to accomplish this, funding between 1998 and 2001, provided by the Balanced Budget Act of 1997, would be reauthorized for the years 2003 through 2007, as well as increasing the appropriation from twenty five million to fifty million dollars per year.[25]
VII.
THE DIFFICULTIES OF
CHANGING PUBLIC POLICY
It is important to consider some of the difficulties involved in changing public policy, particularly given the circumstances of a legal immigrant. The average citizen trying to make a change generally has other duties and aspects of their life which take priority. For example, he or she may have a job or children to care for which restrains the amount of time he or she has available to lobby for a particular issue. This limitation becomes especially relevant in the case of legal immigrants. Immigrants generally spend much of their time trying to establish themselves and provide for their families, whether they be in the U.S. or their native country, which results in a restraint on the time that they have to lobby for their rights. These rights many immigrants may not even realize that they have.
Another problem is that they may not have the strongest voice in the community. Compared to an established citizen, a migrant worker or other immigrant does not have as much political power. As Jane Murphy, Government Affairs Consultant, stated during her talk on Saturday October 19th, legislators do not want to meet with the average citizen. This setback makes it more challenging for the already busy immigrant to assume a more powerful role.
Miss Murphy also emphasized the need for persistence when dealing with legislators. Most people do not have the necessary time to allow for such persistence, regardless of how important and crucial the issue is to him or her. The average advocate must match their availability with that of their legislator. They must also be available for the process necessary to change public policy, including public hearings and meetings. Rank and file members generally are unaware of which topics or bills will be discussed until the day before any scheduled meeting. The agenda for public hearings is printed only five days prior. This leaves little time to organize people and prepare the necessary information. It is challenging to follow each step closely and easy to fall behind. Access to a computer allows one to more easily and readily access the relevant schedules and information, but this sort of technology is often limited, particularly in the case of a low income immigrant. These all contribute to the restricting circumstances of both the average citizen and, more specifically, the immigrant.
VIII.
RECOMMENDATIONS:
THE COST EFFECTIVE SOLUTION: FEDERAL AND STATE ROLES
The current recession has increased state budget deficits and many states have cut back Medicaid expenditures while contemplating further cuts. Medicaid spending constitutes a large share of a state’s budget. The growth of Medicaid expenditures due to increased enrollment from high unemployment and increased health care cots has put a significant strain on the state’s budgetary abilities. Consider that Medicaid costs for prescription drugs have increased annually over the past three years at a rate of 18%.[26] Medicaid is reliant upon both state and national funding. In the area of funding, Congress has avoided the issue by passing the responsibilities of funding along to the states. The states do not have the tax base to make up these costs which have been passed to them.
An example of recent federal cuts is the SCHIP program. The State Children’s Health Insurance Program (SCHIP) is a federal program which gives states grants in order to provide health insurance coverage for uninsured children. This program has the potential to be very helpful for uninsured children of immigrant families. Cutting federal funding undermines the importance and impact of SCHIP when considering that the implementation of SCHIP has resulted in the largest expansion of health insurance in over the last three decades. However, the “SCHIP dip” involves a one billion dollar decrease in SCHIP funding per each fiscal year from 2002 and 2004 resulting in an estimate that the number of children helped by SCHIP will drop by 900,000 between 2003 and 2006.[27]
This limit in federal funding comes at a very bad time as states are in need of an increase in funding for programs such as SCHIP due to increased enrollment and the generally poor market due to the recession. In order to assist the states, Congress must consider this and increase federal funding for both Medicaid and SCHIP along with providing fiscal relief to states in order to reduce state budget problems.
State healthcare coverage of immigrant families is cost-effective. Without coverage, ineligible immigrants are not likely to get primary and preventive care and will most likely rely on emergency rooms as their primary source of care. If immigrants are forced to remain uninsured they will seek healthcare at public hospitals and clinics, (such as the UConn one) which ultimately costs more. Providing these individuals with insurance would promote more preventive care, while delaying services until emergencies only drives up the costs for everyone.[28] Therefore, providing aid for these immigrants would be more productive and sensible financially in the long term.
Connecticut is a good example. As OHCA’s study found, uninsured adults were
almost three times more likely as insured adults to have no regular source of
medical care, other than the emergency room.
Uninsured children were found to be almost four times as likely as
insured children to have no usual source of care such as a doctor’s office.[29]
As was stated in specific reference to New York by Karen Davis, the president of the Commonwealth Fund, a private foundation dedicated to improving care for various groups including the uninsured, “New York’s economy will clearly reap benefits by providing health care coverage to its immigrant population, in terms of improved health for vital members of the workforce and more efficient use of the resources of New York’s health care system”[30] This statement, although made in reference to New York, applies to every state with an immigrant population. In increasing health care for immigrants, the general population would become healthier. Promoting the use of doctor’s offices and preventive measures would result in less use of costly emergency care, and therefore more efficient use of medical resources.
Local public health directors who serve the increasing number of immigrant families note that there is a risk to the general public health if these children and adults do not receive the proper care. For example, these children attend public schools, interacting with a number of other children. This is a reason to incorporate undocumented children of immigrants into HUSKY coverage which has been recommended by the Children’s Health Council. HUSKY is a Connecticut program which helps uninsured children. It provides services under the traditional Medicaid program as well as new health services for children of higher income families. What it boils down to, if states are not helping legal immigrants whether they be children or adults, they are increasing health risks along with using the most costly and least effective method for health care- the emergency room. “The consequences of being uninsured are devastating for immigrants, their families, providers, and the health system,” according to Karen Davis.[31]
As some economists would argue, many people would not be willing to bear a higher cost in order to provide coverage for others. For example, in Philipson’s discussion of infectious diseases in his article “Economic Epidemiology and Infectious Diseases,”[32] he makes the argument that people will not be willing to bear extra costs. Self-interested people have already protected themselves and therefore have nothing to gain from assisting others. This is evident in the example of the New Jersey KidCare program, which was designed under the assumption that all children ought to have health insurance coverage and that higher income families should bear some of the responsibility of the extra costs. With this in mind, the state developed a tiered benefit program that provided different levels of benefits to different income groups, with the highest incomes having the most responsibility for the costs. In other words, the plan was designed to be partially self-funded. Higher income individuals or families would pay a disproportionate cost for their service, effectively funding the program. The example of New Jersey brings into question of whether people would be willing to pay more to help those that are less fortunate and whether this is an equitable approach. In the case of New Jersey, plans with little or no cost sharing had approximately 76 percent enrollment compared with 22 percent in plans with higher cost sharing requirements. This suggests that even if premiums and cost sharing requirements are below market rates, they still have the potential of being significant deterrents to enrollment.[33] People generally work hard for their money and are very conscious as to its proper uses.
Although some argue that people would not be willing to pay a higher price in order to assist others, there are other factors which imply that the opposite it true. According to a W.K. Kellogg Foundation poll, seventy seven percent of Americans felt that legal immigrants deserved to have the same access to benefits as American citizens.[34] However, perhaps the results would differ if the poll had directly addressed the issue of those Americans paying extra in order to provide those benefits. Simply because people agree with the moral side of this issue does not mean they will be willing to bear the costs.
IX.
FOLLOWING OTHER
STATE’S INITIATIVES
In determining what the “optimal” situation would be, it is useful to consider other states’ health care situations. For example, New Jersey has been said to have been at the forefront of healthcare reform for over a decade. New Jersey considered research which indicated that children were more likely to receive immunizations and regular checkups if parents were insured. The state devised a strategy to extend coverage to parents, in the hopes of increasing access to care for both parents and their children. It is particularly important to note about the case of New Jersey that they opted not to design a unified comprehensive approach at inception, but instead incrementally develop an integrated series of programs. As the programs incrementally grew, it became comprehensive. “New Jersey’s comprehensive yet incremental approach to health care coverage, focusing on maximizing access to private insurance while building a base of subsidies for public coverage, offers lessons for other states.” It offered reforms in the individual and small-group markets which made coverage available to poorer families. It also subsidized coverage for low income individuals who were not eligible for Medicaid, incorporating legal immigrants. Other states should notice that New Jersey built on its existing infrastructure while simplifying the process. Standardization of benefit packages and amending current Medicaid contracts significantly simplified their reform process. States must adopt a gradual approach in determining their resources and the demand which must be met. Another crucial aspect of New Jersey’s reform relates to the development process. Before determining whether funds were available, an interdepartmental group met very frequently, obtained planning grants, and developed the plan. Other states must realize the importance of having strong organization and a strong “plan of attack,” and take the necessary time to deliberate rather than rushing into an unclear process.
Although New Jersey demonstrated success in their reforms, there are also concerns which emerged that other states must consider and solve. Equity is one major concern. Families in similar economic situations must be treated fairly. Non-citizens and citizens with similar incomes must be offered similar options. Budgetary restraints also proved to be a limitation. The state focused largely and perhaps too much on subsidies, which had budgetary drawbacks.
In assessing New Jersey’s actions and results, there are several important concluding notes which states ought to consider. It is likely that problems will arise or that one particular aspect of the plan will fail. However, rather than disregarding the plan altogether, amending specific aspects of it and building new alternatives may be the solution. New Jersey’s success has been attributed to strong and consistent leadership. States must consider this when determining who ought to be in charge of this reform. Overall, New Jersey may be one state which could serve as a model for others to follow.[35]
X.
CONCLUSIONS
Since the founding of this nation, greater than 55 million immigrants from every continent have settled here. Other than Native Americans, everyone is either an immigrant or a descendant of one. It is easy for citizens of this country to criticize use of substantial funds to provide benefits to immigrants, as many view these individuals as welfare reliant, therefore using our hard earned tax money. People may tend to overlook the difficulties that these immigrants face upon arriving in a new country, often coming from conditions of poverty, with little to show for themselves. American citizens must realize that these immigrants could have been their ancestors or even themselves arriving to the country in search of a better life. Placing such restrictive provisions such as those enacted in 1996 greatly limit an immigrant’s health care access, and even potentially endanger their overall health and well-being.
Health issues exist in the general population. They are not going away and in fact, it is logical to assume that they will grow as the population ages. The legal immigrant population in this country also continues to grow with the natural health issues arising from that population growth. Preventive medicine is ultimately cheaper to provide than emergency or catastrophic health care by its very nature. Restricting preventive care to legal immigrants by limiting their access to health insurance is ultimately a more costly approach to the rising public cost of health care. Americans effectively pay that cost through higher insurance premiums and taxes. By not addressing the issue directly, Americans also expose themselves to the health issue of exposure to a growing population that could carry or spread disease, since they have never been part of the U.S. health care umbrella (vaccines, etc.).
Whether Americans address the issue on moral ground or from self interest, legal immigrants deserve public benefits such as access to health care and coverage. Moral reasons aside, it is in America’s financial and health self interest that these services by equitably provided to legal immigrants through both national and state funding.
Appendix A
Appendix B
Aliessa V. Novello
NY court case which ruled violations of both the U.S. and state constitutions when New York State denied state-funded Medicaid to immigrants who lost their eligibility after the 1996 law.
FRIHA: “The Federal
Responsibility for Immigrants Health Act”
Introduced in 2002, this federal act would expand the definition of “emergency” to include Medicaid reimbursement for pregnancy related services, testing and treatment of communicable diseases, chemotherapy, dialysis, and services necessary for the prevention of an emergency. It would also rescind the requirement that states pass a law if they intended to provide benefits to undocumented immigrants.
HUSKY:
Healthcare for UninSured Kids and Youth
A Connecticut program which is designed to help children without health insurance, broken down into three categories: HUSKY A, B, and Plus.
ICHIA: “The Immigrant
Children’s Health Improvement Act of 2001”
The passage of this act would allow the states the decision to provide Medicaid and CHIP to eligible immigrant children and pregnant women arriving legally to the U.S. after the August 22, 1996 date, thus lifting the five year ban.
Medicaid
A health insurance program for certain low-income and needy people which is funded by both federal and state means.
OHCA: The Office of
Health Care Access for the state of Connecticut.
This office aims to ensure that all citizens of Connecticut are afforded access to quality health care.
PRWOA: The
“Personality Responsibility and Work Opportunity Act” of 1996,
Commonly referred to as the federal welfare reform law, this federal act was enacted August 22, 1996. Designed to change the nation’s welfare system, but in doing so, placed restrictions on legal immigrants. States were given the ability to deny benefits such as TANF and Medicaid, among others, to aliens residing in the U.S before August 22nd. New immigrants were denied public for the first five years of residence.
SB-444: “An Act
Concerning State Support for Legal Immigrants”
A Connecticut bill aimed to insure that immigrants legally residing in the state would remain eligible for state public benefits.
SCHIP:
State Children’s Health Insurance Program
A program which provides federal matching funds in order to help states expand health care coverage to uninsured children.
TANF: Temporary
Assistance for Needy Families
A national program created by the welfare reform law of 1996 which provides assistance and work opportunities to needy families by granting states the federal funds and ability to create their own welfare programs.
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