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Access to Health Care After Immigration Reform--Recommendations for Policymakers

Access to Health Care After Immigration Reform--Recommendations for Policymakers

Thursday, March 13, 2008

Health Care Options for Participants in Comprehensive Immigration Reform:
Recommendations for Policymakers

Prepared by Adam Gurvitch
Director of Health Advocacy
New York Immigration Coalition

On behalf of the Migration Policy Institute’s
National Center on Immigrant Integration Policy

March 2, 2007

This paper presents realistic alternatives for achieving varying levels of access to health care under immigration reform, with the goals of maintaining a healthy workforce and protecting public health and the financial soundness of the US health care system.

The analysis assumes that immigration reform could create new categories of temporary workers, increase the number of lawful permanent residents, and change the treatment of unauthorized residents. Foreign-born residents who are permitted to live and work in the United States must have access to affordable health care in order to avoid circumstances of extreme inequity and exploitation. Public health is safeguarded only when all members of a community are willing to come forward for screening and treatment in the event of an epidemic. Currently, residents who cannot afford health care avoid seeking it until faced with an emergency, resulting in a less healthy, less effective population; immigration reform should enable something better.


Ensuring parity in access to health programs for taxpayers regardless of how long they have been lawfully present in the US is essential, and immigration reform will be fundamentally unworkable unless this policy is rationalized.

Medicaid, SCHIP, and Medicare
The federal government should eliminate the five-year bar from the Medicaid and SCHIP programs for participants in immigration reform and other lawfully present immigrants, reinstating similar access to programs that such immigrants enjoyed prior to August 22, 1996. Existing policies prevent lawfully present immigrants from accessing safety net supports during times of hardship: Most legal immigrants arriving in the United States since August 22, 1996 are categorically barred for five years from accessing the Medicaid and SCHIP health programs, as well as Medicare. Lawful permanent residents and others who are authorized to work, reside, and pay taxes must have access to health benefits that their contributions support.

Public Health Services
Participants in immigration reform should be treated at least as favorably as H-1 visa holders for the purposes of participating in programs and services that currently impose a requirement of residency in a state or locality, independent of immigration status. Examples of these programs include public health services, federally qualified health centers, hospital reimbursement for the treatment of an emergency medical condition through “emergency Medicaid,” and free or subsidized insurance for children, pregnant women, and individuals living with HIV and AIDS.

Access to Emergency Care
Emergency medical transportation and emergency health care are generally extended to all persons in the United States experiencing an emergency medical condition, upholding our long-standing respect for basic human decency; immigration reform should affirmatively retain this most essential commitment to all US residents.

Stop-Loss Protection for Catastrophic Care
Medical care is extremely expensive for the vast majority of Americans and is distinct in nature from other types of expenses and debts because medical care is often incurred involuntarily. US citizens gain access to Medicaid if they have limited income and exhaust their disposable resources. Migrants admitted under immigration reform will need some form of stop-loss protection against catastrophic medical costs; options include Medicaid, Medicare, or restricted scope Medical Assistance for an emergency medical condition (“emergency Medicaid”). This protection will also ensure that safety net health providers are reimbursed, at least in part, for the costs of treating low-income patients.

Key Considerations
1) Workers who reside in the United States and pay federal income taxes should be able to access federal means-tested public benefits on the same basis as any other American if they fall on hard times.
2) The parity option does not grant the immigration reform population special rights, just the same rights other Americans currently share.
3) This option opens the door to existing programs and services for a deserving population, and would generate significant savings at the state and local levels by standardizing and greatly simplifying public benefit eligibility determinations. No new programs or administrative structures would be created.
4) Federal immigration reform policies should assure that states do not create more restrictive policies with regard to access to health care and public programs for participants.

Eliminating the five-year bar for all lawfully-present individuals and the other parity measures are essential health policies that must be addressed through immigration reform. Lifting the restrictions that prevent low-income, lawfully present immigrants from accessing medical care will significantly promote immigrant integration, and will reinstate a crucial reimbursement for safety-net health providers.

Option One is the essential foundation; it should be augmented with one of the following options.

Participants in immigration reform programs who do not receive insurance through their employers would be matched with safety net health care providers. The providers would bid to serve as the ‘medical home’ for immigration reform participants, and selected providers would receive an annual fee (like a capitation rate in managed care) in exchange for providing comprehensive health services.

Each participant would receive a clinic card and be required to have an initial health screening; then could obtain care as needed from the provider with no out-of-pocket costs. As a concrete example, New York City’s Health and Hospitals Corporation (HHC, the public health care system) currently operates MetroPlus, a health plan that charges roughly $2,200 annually for an adult to access comprehensive health services through HHC. For that charge, individuals receive culturally and linguistically accessible comprehensive health, diagnostic, and mental health services in the most expensive health care market in the country, with no additional charges, no prior approval, and no claim forms.

The annual fee could come at least in part from an assessment paid by immigrants. Government would identify immigration reform participants residing in a geographic area, select providers through a competitive bid process, and create a ‘connecter’ to ensure that comprehensive health services are available to immigrants. Federally qualified community health centers (FQHCs), FQHC look-alikes, rural and migrant health centers, and public and private hospitals and clinics comprise a health care safety net in the communities where participants in immigration reform are likely to be concentrated, and could compete or enter into consortia to deliver cost-effective, comprehensive care.

The pre-paid medical program will be attractive to any provider that currently serves uninsured individuals, assuming modest annual payments per participant in the range of $2,000, because providers today generate almost no revenue from self-pay patients. Because some individuals utilize less care each year, providers can serve other individuals with high medical needs at no additional cost to the patient.

A simple ‘connector’ system would match participants with providers, and issue health access cards. As the federal government collects fees from individuals and employers participating in immigration reform, these could be transferred to the connector, which in turn would contract with providers, and pay the annual charge for each participant. Health providers must demonstrate that participants were provided access to medically necessary care with no additional charges; existing health care reporting mechanisms can be tapped for performance measurement.

As is current practice with refugees, the government could require newly minted immigration reform participants to obtain an initial medical screening, which would establish a medical home for each, and enable early detection and management of chronic health conditions.

Key Considerations
1) The pre-paid medical program could be extended to any uninsured resident willing to pay into the system.
2) This option is distinguished by eliminating insurance industry administrative overhead, profiteering, and rationing. Decisions about what medical care was needed would be made by health care providers, rather than by managed care administrators, whose profit motives and duties to shareholders come into tension with the fundamental aim of providing appropriate medical care to patients.
3) Establishing a “medical home” would greatly increase the likelihood that health care would be accessed in the most timely and cost-effective way through preventive and primary care. It would strategically utilize existing capacity in the health care system. This option would provide access to comprehensive care in most regions in the United States.
4) Maintenance of effort by employers that provide coverage to their workers must be ensured; this is commonly accomplished by establishing enrollment waiting periods for individuals who have employer-sponsored coverage. A mechanism could be established to bring employers into the finance system.
5) Children cost considerably less to serve, while people in long-term care cost much more; it will be important to minimize complexity by setting rates for broad categories of immigration reform participants (eg, child, adult, over-65) and avoiding actuarial fragmentation of the population.
6) Some form of wrap-around coverage might be necessary to reimburse providers for catastrophic health care expenses; the federal government’s Medicaid and “emergency Medicaid” programs currently serve this function.
7) Some critics are ideologically opposed to directing individuals towards particular health providers. However, the reality for most uninsured US residents is that health care is unaffordable and inaccessible. The advantages of assuring access to comparatively low-cost comprehensive health care for every uninsured participant far outweigh principled arguments about limiting choice of providers. In fact, participants would not be limited in their freedom to seek care from other providers – they could negotiate access to providers outside their pre-paid network in the same way any currently uninsured individual would. The only limitation is that pre-paid services would only be available from designated providers.
8) Portability should be addressed — an individual who relocates would need to establish a relationship with a new provider. One possibility would be health access cards that entitle a participant to receive care without additional charges from any provider in the US that is part of the immigration reform program’s pre-paid medical care system.

Pairing Options One and Two constitutes the ideal health access policy for immigration reform.

Individuals who participate in an immigration reform program would be required to enroll in one of the following health coverage programs by paying a group-rated premium: employer-based insurance, state employee health insurance plans, Medicaid, or Medicare.

Under the health insurance buy-in option, both employers and participants in immigration reform could be assessed a fee or would pay a group-rated “premium,” with additional contributions required on behalf of any dependents. Employers’ contributions would receive the same favorable federal and state tax treatment currently in place, constituting a government subsidy of health benefits provided by private-sector employers.

Key Considerations
1) The insurance buy-in option could be extended to any uninsured resident willing to pay into the system.
2) Health providers could adapt their existing billing and claims systems, and new administrative and information technology requirements would be minimized.
3) The buy-in option would utilize existing insurance infrastructure and administrative mechanisms, which, in the case of the private market, results in up to 30 cents of each dollar being lost to administrative costs and profits, while participants face bureaucratic complexity maintaining their enrollment and having services approved and claims paid.
4) A mechanism will be needed to create portable health coverage so that individuals do not become uninsured if they change jobs or move to a different community. Participants should be protected from enrollment and re-certification barriers that result in churning and disrupt care; this poses significant challenges in our current health care system.
5) It is crucial to ensure that employers who already provide health insurance benefits maintain that effort.
6) This option would subsidize US-born individuals who are insured by adding significantly younger and healthier participants to existing insurance pools and would favorably distribute risks.
7) Opponents of government program expansion need to be reminded that direct transfers from the government are minimized when costs are covered by employers and participants themselves. Additionally, significant offsets will be achieved by reducing current federal spending on programs such as “emergency Medicaid” and section 1011 of the 2003 Medicare Reform Act.
8) A significant proportion of immigrants have difficulty navigating managed care, and they consequently under-utilize health care that is delivered in this way. Further, the ongoing erosion of benefits and continued cost-shifting to enrollees could limit the attractiveness of an insurance buy-in option, depending on which type of insurance participants are permitted to purchase.

Options One and Three could be paired to assure access to health care for immigration reform participants. Most states do not cover single or childless adults in Medicaid, and therefore a buy-in to Medicaid would be useless to many people. A buy-in to Medicare would be desirable but could be very costly for participants, leaving a buy-in to the state employee health benefit program as perhaps the most attractive buy-in option. Such a buy-in could be significantly more costly than Option Two – pre-paid medical care; and would share all the disadvantages inherent in the current system of private insurance.


All three policy options are consistent with the following key principles:
· Do not add to the ranks of the uninsured. By taking the immigration reform population out of the ranks of the uninsured, significant savings would be achieved for all Americans who have private insurance, because each private premium contains more than $900 in extra cost each year attributed to higher prices providers charge insurance companies to offset financial losses from caring for the uninsured.
· Strengthen the health care safety net for everyone in the community and promote access to cost-effective preventive and primary care. Consider the interests of both healthy individuals and those who have medical needs.
· Do not weaken employer-based health insurance coverage. Any employer that provides prevailing health insurance benefits to a worker who is a participant in immigration reform could be granted an offset or credit against the employer’s assessed cost of participating in the immigration program.
· Favor the simplest, least costly administrative structures.
· Promote stakeholder investment: Employer and employee assessments or contributions are assumed to be a significant source of funding for access to health care.

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