Immigration Reform and Benefits Access as a Means of Keeping Families Together

On June 27^th, the Senate passed the Border Security, Economic Opportunity, and Immigration Modernization Act of 2013 (S. 744), a comprehensive set of reforms of federal immigration policy. Title II of S. 744 contains many provisions of significance to low-income immigrant families, including the creation of a new immigrant status, an overhaul of current family and employment visas, policy on benefits access, and the creation of new farm worker and temporary worker visas.

The bill creates a new status, registered provisional immigrant (RPI), for people who were physically present in the U.S. on or before December 31, 2011; have maintained continuous presence until the date of application; have paid all federally assessed tax liabilities, fees and penalties; and have not been convicted of certain criminal offenses. RPI status may be renewed in six-year periods. After 10 years, individuals in RPI status may apply to adjust to lawful permanent resident (LPR or “green card”) status. An additional three years in LPR status is required before people initially granted RPI status may apply for U.S. citizenship.

The bill allows undocumented farm workers who can demonstrate a minimum of 100 work days or 575 work hours in the two years prior to the date of the bill’s enactment to be eligible for an agricultural card (“blue card”). Workers who work at least 100 days a year for five years or workers who perform at least 150 days a year for three years can adjust to LPR status. To be eligible for LPR status, agricultural workers must show that they have paid all taxes and fees, and have not been convicted of any serious crime.

The bill goes on to describe the applicability of benefits programs for these new immigrant statuses. A person granted RPI status or a blue card will not be eligible for nonemergency Medicaid, the Children’s Health Insurance Program, Supplemental Nutrition Assistance Program, Temporary Assistance for Needy Families, or Supplemental Security Income for the duration of their provisional status. When they adjust to LPR status, they generally will be forced to wait at least five additional years before becoming eligible for these programs. A person granted RPI status or a blue card will be able to purchase private health insurance through the state Health Exchanges created by the Affordable Care Act (ACA). However, as a RPI they are not eligible for the ACA’s premium tax credits and cost-sharing reductions.

Immigration Policy’s Impact on Children and Families

The policies contained in this new Senate bill have important implications for keeping immigrant families together, because creating a legal means for families to remain in the U.S. will remove the threat of deportation, thereby preventing the children of immigrants from separation from their parents. Poor immigration policies and poor implementation and enforcement of policy can lead to severe consequences for immigrant families, in particular low-income undocumented children and families. In the first six months of 2011, the federal government removed more than 46,000 parents of U.S.-citizen children, and an alarming number of these children end up in foster care. Unfortunately, the exact number of children in foster care due to deportation of their parents is challenging to find because child welfare departments and the federal government do not document cases of families separated in this way. These children must wait months or years to see their parents, if they ever see them again at all.

The trauma of separation can be substantial for both immigrant parents and children. Parents are held in detention centers for an indefinite amount of time while their case is being reviewed, which leaves parents and children in the dark about when they will see each other again. Detention centers are on average 370 miles away from a detainee’s home, which can make visitation extremely difficult for families with limited resources. If the separation is long, the issue of language barriers can arise for infants and toddlers, who oftentimes must adjust to speaking English in their foster homes, and lose some of their native language. Loss of language can even become a major barrier to reunification, as some caseworkers and children’s attorneys deem communication between parent and child to be too difficult.

What Works

The Senate-passed bill would create new immigrant statuses that would bring millions of undocumented workers into more stability. While neither the Senate bill nor current federal policy extend public anti-poverty programs to families in RPI or LPR status, state policymakers have some leeway in supporting immigrant families’ ability to maintain their housing, meet their nutritional needs and support their ability to maintain consistent employment. Having access to these benefits can support families’ ability to maintain the extensive employment, income and fee requirements for RPI and LPR status, which would protect them from deportation, thereby preventing the devastating consequences of the separation of families, including trauma, parental alienation and loss of language and culture.

Immigrant families that live and work in the United States can be assisted in their stability and integration into the community with the help of public benefits. Federal statute limits the eligibility for essential means-tested social services, such as health insurance and food assistance, to non-citizens and legal residents who have lived in the U.S. for a minimum of five years. Under the Senate bill, an individual who began as a RPI would have to wait at least 15 years before becoming eligible to receive benefits from federal means-tested programs. However, states have the ability to use their funds to expand coverage to programs for low-income children and families who are not qualified for coverage under federal funding. States can:

• Elect to provide Medicaid and CHIP to lawfully present immigrant children and pregnant women who meet the Medicaid state residency requirement.
• Provide state-only food assistance to qualified immigrant families.
• Expand TANF coverage to some or all qualified immigrants during the five-year ban. This could include cash assistance, childcare, transportation and/or housing assistance.
• Implement welcome/outreach programs for new immigrants to assist with integration into society.
• Support programs that assist eligible immigrants through the process of naturalization and increasing their civic engagement.
• Support the policy force in addressing immigrant communities with proper communication and culturally sensitive measures.
• Support policies that protect immigrants from deportation.
• Create exceptions to the termination of parental rights timelines for incarcerated, detained and deported parents.
• Institute “time-of-arrest” protocols for local law enforcement agencies to enable parents to decide who should take custody of their children.

For more on how access to benefits can reduce child poverty and prevent child abuse and neglect, see Policyforresults.org.

To Block Grant Medicaid—A Potentially Heavy Burden for States

Medicaid, the federal health insurance program that largely serves low-income children, seniors and certain disabled adults, has been a vital component of the public safety net since its inception in 1965. Because children under Medicaid tend to be in poorer health than children in private insurance (they have a higher prevalence of asthma, autism, dental and vision problems, ADHD, developmental delays, depression, and seizure disorders), Medicaid’s benefits package was designed to meet the complex needs of low-income children. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) has been essential to ensuring that children continue to have a routine source of care and preventive screening for oral health, vision, mental health, developmental issues, and physical health.

In the last four years, people have enrolled into Medicaid at a higher rate than previous years as a direct result of the recession. With more people out of work, they lose access to their employer-based health insurance, their families become impoverished and they then become income-eligible for Medicaid. Furthermore, Medicaid’s enrollment has increased because of the aging population and because of the steady decrease in the number of employers who offer health plans to employees.

Since the federal government pays for the majority of the share of Medicaid spending, this increase in enrollment has led to an increase in the proportion of federal spending that goes to Medicaid. Although Medicaid costs less for the federal government than Medicare and Social Security, it often becomes the target of cuts because people with low-income are an easy target. Therefore, to control for the rising costs of Medicaid and to reduce the federal deficit, there are two very different opinions on the direction that Medicaid should now take: (A) expand Medicaid eligibility while creating cost-savings elsewhere or (B) block grant Medicaid.

Under the Affordable Care Act, Medicaid’s eligibility rules are set to expand in 2014 so that childless, non-disabled adults would be able to enroll if their income was up to 133% of the federal poverty level. The costs of this expansion are offset by revenues from the excise tax on high-premium insurance plans and net savings from other coverage-related effects, such that the Affordable Care Act produces a net reduction to the federal deficit of $124 billion.

On the opposite end of the spectrum is a proposal to change Medicaid from a defined entitlement program to a block grant. With a set amount of dollars and no mandates on coverage, states would have more autonomy and flexibility to design their Medicaid program to meet the specific needs of the state. Under this proposal, to encourage more enrollment into private insurance, premium supports or a refundable tax credit would help non-disabled adults and children to enter the private insurance market. States would be encouraged to use block grant dollars to pay for home-based care for the aged and disabled, rather than more costly institutional care.

As noted by First Focus in their analysis of the US House of Representative’s Budget Committee bill (which would block grant Medicaid), a Medicaid block grant would result in a loss of $810 billion over 10 years of federal investment in the program. About $162 billion of the total would come from investment in children’s services. While it would save money for the federal government, it would also shift the burden of costs to states, which would face a difficult decision in how to respond.

According to the non-partisan Congressional Budget Office, which also analyzed the bill, “states would face significant challenges in achieving sufficient cost savings through efficiencies to mitigate the loss of federal funding.” States could: (A) maintain current service levels, in which case they would need to reduce spending in other areas or raise revenues, or (B) reduce the size of their Medicaid program.

To adjust to the decrease in contribution from the federal government, states would likely have to tighten eligibility restrictions, ration care that children receive and lower payments to providers. Considering that Medicaid reimbursement rates are already lower than the reimbursement rates under Medicare and private insurance, this might discourage doctors from accepting Medicaid patients.

Whether Medicaid expands as an entitlement or is reduced via a block grant, states will have flexibility to design innovative programming to get services to their populations; it will be critical that state policymakers carefully consider their options (through state plans, waivers, demonstration programs, etc.) to provide quality, cost-effective care to children.For more on strategies to ensure that children are healthy, please visit PolicyForResults.org.

The Importance of Medicaid

Medicaid is crucial in supporting low-income households in obtaining healthcare coverage and provides health insurance to nearly 60 million children and families. Since Medicaid has strict rules for eligibility, the expansion of Medicaid benefits those who had not been previously eligible for any type of affordable health coverage. Under the current eligibility requirements, state Medicaid programs must cover children under the age of 6 living in families with incomes below 133% of the federal poverty level and children ages 6-18 with family incomes below 100% of the FPL. However, states can decide whether or not to extend eligibility further. For example, states must cover children up to 18 years of age, but have the option to cover 19 and 20 year olds. In addition, states must provide coverage to pregnant women with family incomes below 133% of the FPL and parents with incomes below 50% of the FPL, but have the option to provide coverage to these groups above the minimums.

Adults who are not disabled, pregnant, or elderly, and have no minor children generally have been excluded from Medicaid.  In the past, to extend Medicaid to these adults, states had to receive a waiver and could not receive additional federal Medicaid funds for this coverage; instead, states needed to redirect existing federal Medicaid funds or create program savings to offset the cost of the coverage.  As a result, the expansion of Medicaid will cover an additional 22.3 million uninsured individuals with incomes below 138% of the FPL.

Medicaid is jointly funded by the federal government and states. To finance the expansion, the federal government will cover 100% of the states’ cost in covering newly eligible Medicaid recipients, then phase down its federal contribution to 95% between  2014 and 2019, then again to 90% in 2020. Since April 2010, California, Connecticut, Minnesota, New Jersey, Washington, and the District of Columbia have expanded Medicaid to low-income adults and have been able to cover an additional 600,000 people.  These states were able to preserve, expand, and strengthen coverage for their low-income residents.

 According to The Urban Institute, if a state does not implement the expansion, some individuals would receive federal tax credits and other subsidies instead of Medicaid; however, cost-sharing requirements would be higher. Federal tax credits and subsidies would not be available for most people with incomes below the federal poverty line, which means uninsured individuals living above poverty can receive help, but those living below poverty would not. Rejecting federal funds and refraining from the expansion could have adverse impacts on more than 27 million uninsured Americans with incomes below 138 percent of the poverty level.

For state policymakers, it is important to consider the economic and societal benefits of providing healthcare to those who currently lack access to affordable coverage and to reduce coverage disparities.  

For state policy strategies to ensure that children are healthy, visit PolicyforResults.org. 

Healthcare Reform in the States

A study conducted by the Robert Wood Johnson Foundation found that the states with residents that have the most to gain from the Affordable Care Act – are also those who are the slowest to set up the insurance exchanges required under the health-care overhaul. The report, State Progress Toward Health Reform Implementation: Slower Moving States Have Much to Gain, outlines the projected impact for states as they implement the ACA. The report states that under the ACA, uninsurance rates will decrease in all 50 states and in Washington, D.C., contributing to a national decline of 24 million nonelderly uninsured individuals.

There are resources available that offer information on Affordable Care Act implementation providing both practical guidance as well as information about what is happening in states across the country. These resources are important tools because the successful implementation of the Affordable Care Act is instrumental in the policies effectiveness. One such resource, KidsWell is a state and national effort aimed at ensuring the successful implementation of health care reform on behalf of children. The goal of the KidsWell campaign is to sustain a multi-tiered, highly coordinated network of national, state and local partners working collectively to represent the perspectives of children. KidsWell has tools for successful state implementation of the ACA, state specific and national resources, state profiles, updates on what’s happening at the federal and state level and funding information.

Promoting Job Growth

While the economic recovery began- though slowly - in 2009, the employment rate has lagged behind. This makes it incredible difficult for families who are unable to secure work - and it makes it critical for policy to be focused on initiatives that lead to increased opportunities for employment.

The American Recovery and Reinvestment Act was created to increase the demand for goods and services - above what it would normally be - in order to preserve jobs during the recession and to create jobs during the recovery. The non-partisan Congressional Budget Office recently released a report regarding the number of jobs that were created by ARRA - between October and December of 2011. The report states that ARRA created and protected up to 2 million jobs as well as boosted the number of hours that people worked. A related brief by the Center on Budget and Policy Priorities, addressing ARRA's success in creating jobs, states that:

"Among ARRA's most effective provisions for saving and creating jobs, according to CBO's estimates, are direct purchases of goods and services by the federal government, transfer payments to states (such as extra Medicaid funding), and transfer payments to individuals (such as increased food stamp benefits and additional weeks of unemployment benefits). CBO's estimates indicate that tax cuts are less effective job producers, and tax cuts for higher-income people have very low bang for the buck."

In times of high unemployment considering strategies that will successfully produce jobs is an important aspect of promoting broader economic growth in your state and meeting the needs of the families in your constituency. For additional strategies to promote employment and to support working families visit the PolicyforResults fact sheet series - Policymakers' Corner.

The Affordable Care Act: Costs and Savings for States

The Patient Protection and Affordable Care Act (ACA) has many provisions that will affect State budgets. In a research report by the Urban Institute, Net Effects of The Affordable Care Act on State Budgets, the authors address the new costs and savings for states. The report asserts that between 2014-2019 states will increase Medicaid spending for low-income individuals by between $21.1 billion and $43.2 billion. However, during the same time period, the ACA will save states significantly by allowing them to shift higher-income adults from Medicaid into coverage where subsidies are funded entirely by the federal government; as well as to substitute newly available federal Medicaid dollars for prior state and local spending on uncompensated care and mental health services. Those provisions will save states between $83.8 billion and $153 billion. In total, these provisions will lead to net state and local gains of between $40.6 billion and $131.9 billion.

In their conclusion the report states that throughout Medicaid’s history smart and creative state officials have responded to changes in the federal law, which often have allowed for maximizing fiscal gains and minimize losses for their state. However, even without any state-level creativity, the straightforward implementation of the ACA’s coverage expansion is likely to yield state savings that greatly exceed net state costs resulting from increased coverage of low-income adults.

This report is a good resource for learning about the costs and savings that states will experience through the ACA. The report address the above mentioned factors in detail as well as provides information on potential savings under CHIP, the possibility to integrate Medicaid and Medicare funding and services for the duel eligible, and the changing cost of health insurance coverage for public employees and retirees.

For a Framework for Policy Success.

The ACA and Community Health Centers

In March of 2010 Congress passed, and the president signed, the Affordable Care Act (ACA). Provisions of the ACA reform the health insurance industry and expand coverage to more Americans. However, with this change, there will be an increased need for community health care centers and a well-trained health care workforce. A new issue brief by the Kaiser Commission on Medicaid and the Uninsured addresses the opportunities and challenges presented by health reform for community health centers. The brief, Community Health Centers: Opportunities and Challenges of Health Reform, states that health reform is going to usher-in important changes to the American health care system and that community health centers will be central to providing care to millions of Americans, particularly those in underserved areas.

The brief is a useful tool for policymakers because it includes information on the way that provisions of the health care law intersect with the role of community health centers. This information is important in considering the opportunities for states that are available through the Affordable Care Act. For example, the ACA includes several provisions aimed at expanding the health care workforce in order to ensure that people have access to health care in addition to health insurance. Some of the strategies to accomplish this include increasing funding aimed at the National Health Services Corps and funding for community-based training programs. States considering new workforce development strategies that also have areas with health access concerns would certainly benefit from considering this opportunity.

Other intersections between the ACA and community health centers include:

• Increased funding for health centers
• Insurance expansion
• Medicare payment reform
• Delivery system reform

The brief includes detailed information on the way that community health centers will play a key role in these, as well as other, aspects of comprehensive health care.

For more on funding opportunities available through health reform.

For more on creating jobs through community health centers visit our Financing Community Change blog.

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Medical Homes: A Look at Illinois Health Connect

State Medicaid programs have the potential to conserve taxpayers’ money while providing families with more personalized care. The Robert Graham Center recently published a study that highlights the success of Illinois Health Connect, which saved the state $140 million in 2009. The initiative assigns Medicaid recipients in Illinois to primary care doctors, who are responsible for coordinating all of the families’ healthcare needs. The arrangement, better known as "medical homes," centralizes patient care; one physician is responsible for treating, referring, and continually following up on a particular patient. Such an approach minimizes costs by eliminating administrative expenses, improving the health of patients, and subsequently by the decline in hospital visits (doctor’s offices provide specialized care at a lower cost than most hospitals).

A recent news report characterizes medical homes as the future of national healthcare reform. The efficiency and affordability of Illinois Health Connect could serve as a model for policymakers reforming their State Medicaid programs.

For more on the relationship between increased healthcare access and improving a child’s performance in school.

Poverty Reduction in the Short and Long Term

The American Recovery and Reinvestment Act has mitigated some of the effects of the recession by expanding and extending the supports available through food stamps, unemployment benefits, and health insurance, and by providing states with general purpose aid. While federal assistance has helped states support the growing numbers of residents who are unemployed or who are living in poverty, ARRA is due to expire long before the recession stops impacting the labor market and state budgets. The Urban Institute brief, Reducing Poverty and Economic Distress after ARRA: Next Steps for Short-Term Recovery and Long-Term Economic Security, outlines key goals for federal antipoverty policy. Goals include:

• Provide jobs and income support as well as other services to reduce the short-term distress over the next 3-5 years.
• Prepare policy responses that might lessen the next economic downturn.
• Make sensible long-term investments in reducing poverty by extending certain provisions of ARRA and creating additional measures (such as investing in education and post-secondary credential programs aimed at low-income youth).

For more information on Family Economic Success.

While the brief discusses the antipoverty policy goals for the federal government, several of their suggestions are also relevant to state governments. With state budget cuts likely to be even deeper in 2011 than they were this year, it is critical that policy and program level strategies support the families most in need now as well as ensure greater economic security for all families in the future.

For more information on place-based strategies to reduce poverty and economic distress after ARRA. (For other results-based financing posts visit our financing community change blog).

New Report on Health Reform Shows that the Cost Burden Will Be on the Feds, Not the States

A new report by the Kaiser Family Foundation shows the impact of the new health reform law on both the number of uninsured and new enrollees.  The report also shows that the federal government will pick up the overwhelming majority of the cost. "Health reform will offer Medicaid coverage to millions of low-income adults for the first time and help establish a national floor for Medicaid eligibility that contrasts sharply with the wide variation in eligibility across state Medicaid programs today. ... "For a relatively small investment of state dollars, states could see huge returns in terms of additional coverage for their lowest income residents -- with federal dollars covering the bulk of the bill," said Diane Rowland, executive vice president of the Foundation." (from the press release)

WIC Eligibility by State: A New Interactive Report

This year Congress will reauthorize the Child Nutrition and WIC Reauthorization Act, which authorizes all of the federal school meal and child nutrition programs. These programs provide the funding necessary to ensure that low-income children have access to healthy and nutritious foods. One of the components of this act, the Special Supplemental Nutrition Program for Woman, Infants, and Children (WIC) provides nutritious foods, health care referrals, and education about nutrition to families with incomes under 185 percent of the federal poverty level and who are found to be at nutritional risk.

A new interactive report by the Urban Institute shows the number and portion of children by state (and congressional district) who are eligible for WIC based on their family’s income. This is a great tool for policymakers to see how many children in their states are growing up in low-income families and who are potentially at nutritional risk. The report also serves as a useful tool for policymakers as they consider the importance of policies that contribute to the healthy development of children in their states. According to the report, in 14 states 45-54 percent of children ages 0-4 were income-eligible for WIC. In another 19 states 37-44 percent of children were income-eligible. These numbers do not include children who are adjunct-eligible (eligible automatically through TANF, SNAP or Medicaid), therefore, the Urban Institute estimates the number of eligible children would actually increase by approximately 2.8 million children if those who were adjunct-eligible were included in the report.

To see the Urban Institutes full interactive report.

For policies to ensure that Children are Healthy and Prepared to Succeed in School.

Improving Dental Policies for Low-Income Children

In honor of National Children’s Dental Health Month, Pew Center on the States has released The Cost of Delay: State Dental Policies Fail One in Five Children. Pew graded states’ policy responses to the challenges in dental health among America’s low-income children, scoring all 50 states and the District of Columbia on whether and how well they are employing proven policy solutions—all related to cost-effective prevention, Medicaid improvements, new workforce models, and data collection—to ensure dental health and access to care for children. The report and accompanying state fact sheets detail such policies and states’ efforts, highlighting and recommending low cost solutions with high return on investment for children and taxpayers.

Policies to expand health insurance and policies to help children be healthy and prepared to succeed in school.

How States Can Use Automation to Increase Health Coverage for Children

The Urban Institute has a very useful report out on how states can increase enrollment of children in health insurance programs. The report details automated strategies that have

achieved remarkable results with many public and private benefit programs, dramatically increasing program participation while lowering administrative costs and reducing erroneous eligibility determinations. The recently passed Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) should make such steps much easier for states to take in covering eligible but uninsured children. Following CHIPRA's enactment, states have both new tools and new incentives to use automated strategies in fulfilling four key functions: identifying uninsured children; determining their eligibility for health coverage; enrolling eligible children into coverage; and retaining eligible children.

For policies to increase access to Medicaid and SCHIP.

A Guide for States to Maximize Enrollment for Uninsured Children

The National Academy for State Health Policy has issued a new brief that

reviews literature and expert opinions to elaborate on seven strategies states can implement to maximize enrollment for uninsured children eligible for public coverage. From simplifying the enrollment process to implementing the latest technology and urging political leaders to make enrollment a priority, the report lays out key steps that states may consider when tackling the difficult issues of making sure the pathways for enrollment and renewal for all eligible children are as efficient as possible. The seven strategies states can pursue are:

• Keeping enrollment and renewal procedures simple
• Reaching out through community-based organizations and institutions
• Using technology to coordinate programs and reduce administrative burdens
• Changing agency culture to promote enrollment
• Engaging leaders to champion the goal of enrolling children
• Engaging partners to help reach enrollment goals
• Using marketing to promote enrollment in public programs

For policies to maximize medicaid and SCHIP

How States Can Take Advantage of the New Medicaid Performance Bonus

The Kaiser Commission on Medicaid and the Uninsured is issuing a series of briefs on how states can be eligible for the

new "performance bonus" available to states that do an especially good job of signing up eligible children for Medicaid. The bonus, created by a provision in the Children's Health Insurance Program Reauthorization Act of 2009 (SCHIP), is designed to help states cover the added costs that result when states are very successful in enrolling eligible children in Medicaid above target levels specified in the law. It reflects an understanding that aggressive state outreach efforts for CHIP tend also to drive up enrollment in state Medicaid programs.

For more information on state policies to maximize medicaid and SCHIP.