Number and Cost of Immigrants on Medicaid, The: National and State Estimates

Number and Cost of Immigrants on Medicaid, TheNational and State EstimatesLeighton Ku, Bethany KesslerPresented to:Office of the Assistant Secretary for Planning and EvaluationDepartment of Health and Human Services This work was conducted under Subtask 2.2.12 of HHSContract HHS-100-94-1009. Many constructive comments were provided by staff of the Department of Healthand Human Services, including Linda Sanches, David Nielsen, Penelope Pine and Bob Tomlinson. We gratefullyacknowledge data and advice made available by Ron North and Roger Buchanan of the Health Care FinancingAdministration and Charles Scott of the Social Security Administration. Many colleagues at the Urban Instituteoffered useful advice or data, including Brian Bruen, Rebecca Clark, Teresa Coughlin, Linda Giannarelli, JeffPassel, Karen Tumlin and Wendy Zimmerman. All opinions expressed are the authors' and should not beinterpreted as opinions of the Urban Institute or the Department of Health and Human Services.The nonpartisan Urban Institute publishes studies, reports, and books on timely topics worthy of publicconsideration. The views expressed are those of the authors and should not be attributed to the UrbanInstitute, its trustees, or its funders.The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) made major changesin the eligibility of legally admitted immigrants for health insurance under the Medicaid program. In the past,immigrants were eligible for the full range of Medicaid benefits, like citizens.1 In contrast, undocumented(illegal) aliens were eligible only for emergency medical benefits, not full coverage. Under the new welfarereform law, with certain exceptions, noncitizen immigrants who arrive in the U.S. after August 1996 will bebarred from Medicaid, although they may still be covered for emergency services. Assessing the impact of this change has been problematic because there are few data about the number andcosts of immigrants on Medicaid. This report provides national and state-by-state estimates of the numberand cost of noncitizen Medicaid beneficiaries. Methods and Data. The analyses are based on the Medicaid Quality Control (QC) data base for the first halfof 1994, with additional information about Supplemental Security Income (SSI) participants from the SocialSecurity Administration (SSA). The QC data base includes verified data about 93,000 sampled Medicaidenrollees, roughly 2,000 per state, making it the largest known national sample of Medicaid beneficiaries. QCdata include relatively detailed information about immigration status, as well as medical expenditures paid byMedicaid in the sample month. The QC sample represents the great majority of Medicaid beneficiaries, but in31 states the QC sample excludes SSI recipients. Thus, SSA data are used to supplement information aboutelderly and disabled immigrants, although these data are more limited. Estimates of the number and costs ofaged, blind and disabled Medicaid beneficiaries who are noncitizens were generated by combining QC andSSA data. National Participation Estimates. Overall national estimates of the number of noncitizen immigrants onMedicaid, based on the combination of QC and SSA data, are presented in Table ES-1. About 2.4 million ofthe 32 million Medicaid enrollees in an average month in 1994 were noncitizens (including undocumentedaliens with emergency coverage only). This is 7.5 percent of the total caseload. Measured another way, about3.2 million immigrants were enrolled in Medicaid over the course of a year. Insofar as noncitizens are 12.6percent of the population under poverty, according to the 1996 Current Population Survey, the number ofimmigrants on Medicaid is less than might be expected given their poverty. Adult and aged beneficiaries weremore likely to be immigrants than were children or the disabled. A major reason for the low percentageamong children is that immigrants' children are often native citizens born in the U.S. The total Medicaidexpenditures for noncitizens (excluding Disproportionate Share Hospital or DSH payments) were $8.1 billion,or 6.9 percent of total expenditures. Table ES-1. National Estimates of Noncitizen Immigrants on Medicaid in 1994,Based on Combined QC and SSA Data TOTALChildrenAdultsAgedBlind &DisabledDocument date: December 16, 1997Released online: December 16, 1997 DisabledNumber of NoncitizenMedicaid Enrollees (in Avg. Month, in 1000s)2,415.5655.01,059.3262.1699.1Proportion of Enrollees inCategory Who AreNoncitizens7.5%4.1%16.0%13.0%4.9%Medicaid Expenditures forNoncitizens (in millions of $)$8,129.3$504.0$2,118.3$2,567.5$2,939.5Source: Urban Institute analyses of Medicaid QC and SSA data PRWORA and later legislation create a very complex set of rules for determining the Medicaid eligibility ofimmigrants. While legal permanent residents are barred from full Medicaid coverage for their first five years inthe U.S., refugees and asylees may participate in Medicaid for their first seven