How Will Immigrants Fare Under Health Reform? Encouraging Enrollment

By Dinah Wiley

Immigrants who are eligible for Medicaid and CHIP, compared to their citizen counterparts, are less likely to sign up for health coverage.  Why is this so?  It’s true that newcomers to the U.S. are more healthy than native-born Americans, for a few years at least.  Yet when immigrants are offered private insurance at the workplace, their take-up rates are as high or higher than those of their citizen colleagues.

So why are immigrants more reluctant than their citizen counterparts to get coverage at a government agency?  Do their concerns apply to Marketplace agencies as well as Medicaid and CHIP agencies?  To discuss the answers to these questions, let’s return to the examples of our hypothetical mixed-status immigrant family discussed before:  undocumented Mom and Son, lawfully present Dad (who is an LPR with a green card) and Uncle (who is an asylum seeker), and little citizen Daughter.  Though Mom and Son are ineligible for the programs, Dad and Daughter are eligible and Uncle may also be eligible depending on particular circumstances.

Will Mom, who handles health care decisions for her family, be likely to apply for insurance?  Research tells us that to do so, she will need to overcome many concerns.  First, she likely knows she and Son will not qualify, and unless she is an expert in the ACA or has expert assistance, she may be unsure if Dad and Uncle will be eligible; she may wonder if Daughter is even eligible given Mom and Dad’s immigration status.  She wonders if the family’s search for insurance will doom her young brother-in-law’s application for a green card after he receives asylum; will the government regard him as a “public charge”?

Most compelling will be her fear that the health insurance agency will identify her and her son as undocumented and report them to immigration enforcement authorities.

The government has long recognized the chilling effect of this last, compelling concern in discouraging participation of immigrant families in health insurance programs and activities.  To respond, the ACA statute and regulations feature robust privacy and confidentiality protections.  Prohibitions against unlawful and inappropriate use and disclosure of personally identifiable information (PII) apply to agency policies and workforce training, issuers, and contractors including Navigators, agents, brokers, and other assisters.

The privacy protections cover a number of different scenarios of concern to immigrants.  For example, agencies should not ask persons such as our Mom, who will complete an application for others but not apply for herself, to provide information about her own immigration status.  Agencies cannot allow the absence of immigration status and Social Security number information about non-applicants, even if the non-applicant is the application filer for the family, to affect the eligibility of applicant family members.  Agencies cannot use PII for a purpose other than health coverage enrollment.  They cannot disclose PII to an individual who is not authorized to have the information.  And they must ensure compliance with these protections on the part of their employees and contractors.

These federal provisions go a long way to help prevent separation of families and reassure immigrants that it is safe to apply. To comply with new rules, states may need to change some past policies or practices that failed to protect privacy or to provide reassurances of confidentiality of PII, creating roadblocks for immigrants, often inadvertently.  The next blog in this series will address other barriers, including “public charge” concerns, verification issues, confusion about eligibility rules, and discrimination and a hostile “climate.”

Please see resources about “Health Insurance for Immigrant Families,” including presentation slides of a September webinar co-sponsored by CCF and the National Immigration Law Center (NILC).  The last slide includes a list of relevant materials available from NILC (