Tag: undocumented immigrants

Immigrants and Health Insurance

California has made major strides in reducing the number of state residents without health insurance coverage. With the state’s Medicaid expansion and the creation of Covered California under the Affordable Care Act (ACA), the percentage of Californians without insurance dropped nearly 5 percentage points in 2014—the first year of ACA implementation. Declines occurred across all racial and ethnic groups, with Latinos registering the largest drop at 9 percentage points. Nevertheless, Latinos continue to experience the highest uninsured rate, in part because the ACA coverage expansions exclude California’s estimated 2.7 million undocumented immigrants.

But there is more to the story of insurance coverage and California’s immigrants: we also observe large declines in the uninsured rate among all noncitizens, a group that includes an estimated 2.6 million people who are legally residing in the state (with green cards, temporary visas, work visas, etc.), as well as those who are undocumented. When we look at uninsured rates across different citizenship categories, we see the drop was larger among noncitizens than among US-born and naturalized citizens—noncitizens had nearly a nine percentage point decline in their uninsured rate.

Noncitizens who legally reside in the state have access to ACA coverage expansions either through the Medi-Cal program—if their household income is below 138 percent of the federal poverty level, about $33,500 for a family of four—or through Covered California, with financial assistance available to help pay for coverage. Still, about 35% of California’s more than five million noncitizen residents currently lack comprehensive health insurance coverage—most are likely to be undocumented, with limited sources for affordable insurance coverage.

Undocumented residents sometimes have private health insurance, most often through their employers. National estimates suggest between 30–40% of undocumented immigrants have coverage. This number could grow if federal immigration reforms are implemented, by providing undocumented immigrants who qualify (between 1.1 and 1.3 million in California) with work permits and better job opportunities that could offer increased access to employment-based insurance.

Along with pending federal action on immigration reform, state legislative proposals are also focusing on expanding affordable insurance coverage options to the undocumented. In our new report, we discuss these potential options and provide new regional estimates of the undocumented population in California by income thresholds to assist policymakers in planning for potential coverage expansions to this group.

Video: Health Coverage & Undocumented Immigrants

Legislative efforts, executive decisions, and public opinion all suggest interest in expanding health coverage to California’s undocumented immigrants. The state’s decision to provide Medi-Cal benefits to undocumented children reflects that support. But the vast majority of undocumented residents in California are adults, and they make up a sizable share of residents without health insurance.

A new PPIC report finds that half of California’s undocumented immigrants—about 1.4 million—have incomes low enough to qualify for full Medi-Cal benefits should legislative proposals to offer coverage be enacted.

This week at a briefing in Sacramento, PPIC research associates Shannon McConville and Iwunze Ugo presented their report, which includes estimates of the number of undocumented immigrants across family income levels and the Covered California insurance regions. These estimates can help policymakers plan for the increase in Medi-Cal participants if coverage is expanded—which will depend on the legislature, governor, and federal courts.

Health Insurance for the Undocumented

California continues to have at least 3 million uninsured residents, even after the coverage gains from the Affordable Care Act (ACA). Estimates suggest that between 1 million and 1.5 million of them are undocumented immigrants who are not eligible for federally subsidized coverage.

But there may be two opportunities for California’s undocumented population to gain access to coverage – depending on the legislature, governor, and courts. We estimate that as many as half of the state’s undocumented immigrants have incomes that are low enough to qualify for Medi-Cal coverage—with some variation across regions. To qualify for Medi-Cal, household income must be below 138% of the federal poverty level (about $16,000 for a single person or about $28,000 for a family of 3). Those with higher incomes may gain access to insurance through a state exchange.

First, the governor’s recently released proposal for the state budget includes funding to provide full Medi-Cal coverage to low-income undocumented immigrants who register for the federal Deferred Action for Parental Accountability (DAPA) program, which offers protected status to undocumented immigrants who have resided continuously in the U.S. for the past five years and are parents of children who are either U.S. citizens or legal permanent residents. This proposal is dependent on DAPA surviving current legal challenges.

Second, the Senate Appropriations Committee has approved state legislation that proposes to expand insurance coverage options to undocumented immigrants not eligible for DAPA. The bill (SB 4) would extend Medi-Cal to low-income undocumented immigrants under age 19. The number of adults who are eligible would depend on the state budget. The bill also includes provisions to allow those with higher incomes to purchase coverage through a state-based insurance exchange.

How many undocumented immigrants might be affected by these actions? Estimating the number is not straightforward. To help in the policy and planning process, we have recently updated our county estimates of undocumented immigrants for 2013 using zip code level tax records (filed with Individual Taxpayer Identification Numbers, or ITINs) and the analytic methods we have used in past work. We extend our earlier analysis to estimate how many undocumented immigrants might be eligible for insurance coverage based on family income for the pricing regions used by Covered California. To do this, we rely on information available from tax filings—we estimate income levels from adjusted gross income groupings and family size from tax filing status and the use of the federal child tax credit. PPIC expects to publish more results based on these analyses in the near future.

Statewide, our preliminary estimates indicate that just over half of undocumented immigrants (51%) are likely to be under the 138% poverty threshold used for Medi-Cal income eligibility. This share varies widely across regions. Nearly 60% in Los Angeles County and the Central Valley have incomes below the 138% threshold. Most Bay Area counties have lower shares below this threshold—from 36% in Santa Clara County to 44% in Contra Costa County. These findings are generally consistent with other work that uses different methods to profile California’s undocumented immigrants (MPI (2014), Marcelli and Pastor (2014), Warren (2015)).

We also estimate shares, by region, of undocumented immigrants that fall between 138% and 400% of the federal poverty level, the income range used by Covered California for its current enrollees to receive premium subsidies. Across most regions, between 40% and 60% of the undocumented population falls within this range, potentially making them eligible to purchase coverage through a state insurance marketplace.

Finally, about 85,000 undocumented have incomes above 400% of the federal poverty level – with most residing either in Bay Area counties or the coastal Southern California counties of Orange and San Diego.

Regional differences in health plans, provider capacity, and insurance costs make information on the size and distribution of the state’s undocumented population by income level crucial to planning effectively for coverage expansions. We expect to contribute regularly to the discussion as these planning efforts unfold.

Table source: Author’s analysis of tax data.
Table note: Counts are rounded to the nearest 500 and may not add to the statewide total as a result. Regions correspond to the insurance pricing regions used by Covered California, with one exception. Region 15 in the table includes all of Los Angeles County.

Undocumented Immigrants and Health Care

On the heels of President Obama’s recent executive actions on immigration, state senator Ricardo Lara has reintroduced legislation (SB 4) to provide access to affordable health coverage and care to all Californians, regardless of immigration status. The details of SB 4 have not been spelled out, but Senator Lara’s previous bill called for the state to offer the coverage available under the Affordable Care Act (ACA) to undocumented immigrants: Medi-Cal coverage to those below 138% of the federal poverty level (annual income of about $16,000 for a single person) and subsidies to purchase coverage to individuals earning up to 400% of the poverty level (about $46,700 annually).

As PPIC pointed out in a recent blog post, while the ACA excludes undocumented immigrants from the coverage expansions, President Obama’s executive order could pave the way for immigrants in California who are eligible for the Deferred Action for Parental Accountability program (and who meet income eligibility requirements) to get Medi-Cal coverage. Under current Medi-Cal eligibility rules, immigrants with deferred action status—meaning that their presence is known to the government and there are no plans to deport them—can receive full coverage under a benefit category known as PRUCOL (Persons Residing Under Color of Law). Some states, including California and New York, provide full Medicaid coverage for the PRUCOL group. This coverage is financed entirely by the states—the federal government funds only emergency medical treatment for undocumented immigrants.

The president’s action could also have implications for county programs that are required by state law to provide medical care to indigent residents. Currently, counties have considerable latitude in determining eligibility criteria for their indigent care programs, and many exclude undocumented immigrants. When state officials decided to expand Medi-Cal eligibility under the ACA, they reduced the funding provided to county indigent care programs because many of the people served by these programs would become eligible for Medi-Cal. The legislation (AB 85) that redirected state funds for county health programs included a provision to review this funding shift if there was federal action on immigration reform, but it’s not clear if that will happen in this case.

What is clear is that options for providing access to insurance coverage and health care for the more than 2.5 million undocumented immigrants in the state is a policy topic under consideration by policymakers at local and state levels.

Immigration: What’s Next in California?

More than one million Californians could be affected by President Obama’s executive order on immigration. Undocumented immigrants who have resided continuously in the U.S. for the past five years and are parents of children who are either U.S. citizens or legal permanent residents will be eligible for work permits. They will also be relieved from the threat of deportation. In addition, the executive order increases the number of people eligible to register as “Dreamers” because they were brought to the U.S. as children.

Undocumented immigrants who qualify under the president’s order will likely be able to provide more stable homes and increase their connection to their communities. Californians have already demonstrated that this is what they want for undocumented immigrants. More than 80% of Californians favor providing undocumented immigrants with a pathway to citizenship if they meet background checks, pay back taxes and penalties, and learn English—according to each of the three PPIC Statewide Surveys that asked about this issue in 2014.

California legislators have been leaders in setting policy that helps integrate the undocumented immigrants already in our communities by passing legislation that allows undocumented immigrant youth to pay in-state tuition at our colleges and universities, qualify for state financial aid, and obtain driver’s licenses. Low-income Californians registered as “Dreamers” also qualify for state Medi-Cal.

What happens next depends in large part on the reaction of state and local governments. Knowing where qualified undocumented immigrants live is essential to realizing the potential gains both to the state and to the immigrants themselves. This is challenging. Surveys don’t generally ask about immigration status, so most of what we know about this population derives from complicated estimates of immigration status.

Here, we present counts of undocumented immigrants who have filed federal tax returns without social security numbers (instead using Individual Taxpayer Identification Numbers, or ITINs) and with wage forms (W-2s) attached. We believe this is a reasonable way to broadly determine who will be affected by President Obama’s executive order. Undocumented immigrant tax payers are more likely to have been in the U.S. longer and are likely to be the most intent on making the U.S. their permanent home. By filing taxes, they have already taken steps to identify themselves as contributing members of their communities and the economy.

A few caveats—while we are certain that each of the immigrants we identify in this fashion are undocumented, this method probably does not count all undocumented immigrants who may be eligible for the order. Probably not all undocumented immigrant tax payers use ITIN numbers, and not all undocumented immigrants file tax returns. Further, not all undocumented immigrants using ITIN numbers will be eligible for the order.

We find that California has over 900,000 undocumented immigrants filing federal tax returns for the 2012 tax year, the most recent year data is available. These undocumented immigrants live in 55 of our 58 counties, with large numbers in Los Angeles, the Bay Area, the Sacramento region, the Central Valley, coastal California, and the Inland Empire. This information can be useful to local legal service providers and local governments to help plan for the registration of eligible undocumented immigrants, the most critical first step in implementing the president’s order.

Of course, county populations are not homogeneous—a closer look reveals sharp differences in the number of ITIN filings by zip code, even within counties. The map below shows high numbers of undocumented immigrants in rural regions (large-area zip codes), as well as in city and suburban centers (small-area zip codes). In Riverside County, for instance, undocumented workers are found in high numbers in the urban areas in the west, as well as in the agricultural region around the Coachella Valley.

President Obama has made it clear that those eligible for deportation relief under this new executive order are ineligible for health care subsidies under the Affordable Care Act. But, as in the past, California may wish to do more—for example, providing Medi-Cal coverage to qualifying adults and doing more to reach out to their already eligible children. In addition, upward mobility is most likely for immigrants obtaining work permits if they make investments in English language acquisition. NGOs, community college districts, and school districts that still provide adult education could use the information about where undocumented immigrants live to plan course offerings in the years to come.