California’s Implementation of the Affordable Care Act: Implications for Immigrants in the State

Julia Gelatt, Heather Koball, and Juan Manuel Pedroza October 2014 The Immigrant Access to Health and Human Services project maps and describes the legal and policy contexts that govern and affect immigrant access to health and human services. Through a synthesis of existing information, supplemented by in-depth visits to purposively selected sites, the study aims to identify and describe federal, state, and local program eligibility provisions related to immigrants; major barriers (such as language and family structure) to immigrants’ access to health and human services for which they are legally eligible; and innovative or promising practices that can help states manage their programs. Introduction This brief examines how the implementation of the Patient Protection and Affordable Care Act of 2010 (ACA) in California might affect immigrants’ access to health care in the state.1 We first describe the implementation of the ACA in California generally, and then turn to implications for immigrants (particularly low-income immigrants) in the state. We highlight promising state-specific policies that may increase the share of immigrants with some form of health insurance coverage. We also describe ongoing challenges in connecting immigrants to insurance for which they are eligible. We conclude by highlighting areas where California’s experience could provide useful approaches for other states to consider as they implement the ACA and work to improve health insurance coverage of all residents in their state. Background Across the United States, approximately 15 percent of the population had no form of health insurance as of 2012 (DeNavas-Walt, Proctor, and Smith 2012). Immigrants make up a disproportionate share of C E N T E R O N L A B O R , H U MA N S E R V I C E S , A N D P O PU L A T I O N B R I E F California’s Implementation of the Affordable Care Act Implications for Immigrants in the State 2 CALIFORNIA’S IMPLEMEN T A T I O N O F T H E A F F O RD A B L E C A R E A C T the uninsured population: they were 20 percent of the uninsured population in 2012, but only 7 percent of the US population overall (DeNavas-Walt, Proctor, and Smith 2012).2 As states across the country begin implementing the ACA, they face many policy choices within the provisions of the law. The choices states make may affect whether and how immigrants are able to find new sources for health insurance coverage. In this brief, we examine one state—California—as a case study to help better understand how state decisions may affect immigrants’ access to health insurance under the ACA. Nationwide, immigrants are less likely than citizens to have health insurance. For example, among nonelderly immigrants, about 51 percent of adults had no health insurance in 2009, compared with 17 percent of US-born citizen adults (Kenney and Huntress 2012). This gap in insurance coverage is driven by lower rates of both employer-sponsored insurance coverage and public coverage for immigrants. Lower rates of public health insurance coverage stem, in part, from Medicaid and Children’s Health Insurance Program (CHIP) eligibility criteria that generally exclude recent legal permanent residents (LPRs) for their first five years in the country and exclude unauthorized immigrants for as long as they are unauthorized. However, there is some state flexibility regarding providing public health insurance to lawfully present immigrants, particularly pregnant women and children, within their first five years of legal residence. And states are free to use state funding to provide public insurance to immigrants regardless of legal status, though few do so and such insurance is generally provided only to children. The share of the uninsured population who are immigrants is expected to rise as ACA implementation progresses. While many US citizens and a substantial share of LPRs gain new access to Medicaid under the ACA, most new LPRs and unauthorized immigrants do not. California has more immigrants than any other state, so its policies affect the lives of many immigrants. About one-quarter of the foreign-born population in the United States, or 10 million foreign-born people, live in California. While 13 percent of the US population is foreign born, in California this share is 27 percent (Migration Policy Institute 2013). It is also estimated that more unauthorized immigrants live in California than any other state: about 2.6 million, or just under a quarter of the estimated 11.2 million national total (Passel and Cohn 2011). Half of all children (49.6 percent) in California have at least one foreign-born parent (Migration Policy Institute 2013). This brief is based on a site visit to California in February 2013 and publicly available information. The site visit included discussions with state and local government agencies, nonprofit service providers, advocacy organizations, professional organizations for health care workers, public-private servi