California is Covering the Undocumented – What About New York?

In a climate of relentless attacks on immigrants, including as to their right to quality health care, it’s easy to get discouraged. But California has recently provided us with a ray of hope.

In July, California’s Democratic governor, Gavin Newsom, signed legislation to cover (with state funding) an estimated 90,000 low-income undocumented young adults aged 19 to 25 through that state’s Medicaid program. California is the first state to cover some young adults through Medicaid. Coverage will begin in 2020. California immigration advocates had originally hoped to cover far more of the undocumented, including older adults.

The Affordable Care Act — while in many ways a big step forward — failed undocumented immigrants  by excluding them from the major benefits of the law, including the right to enroll in Medicaid, to receive subsidies, to purchase qualified health plans (QHPs), or even to enroll in QHPs without receiving a subsidy.

Denying health coverage to the undocumented is punitive, bad health policy and bad health policy. People without health coverage often delay care or go without necessary care, often leading to more severe problems that are ultimately more expensive to treat. And hospitals are required to provide emergency care to everyone, including the undocumented, which means those who disproportionately treat immigrants get an unfair share of the costs.

HCFANY and Coverage4All, a HCFANY project, are campaigning for comprehensive coverage for undocumented New Yorkers through our state’s Essential Plan, which covers people up to 200 percent of the federal poverty line for no or a minimal premium and minimal cost-sharing.  We estimate that over 100,000 additional New Yorkers would get coverage. The passage of “Green Light” legislation in 2019 (driver’s licenses for undocumented New Yorkers) and New York City’s creation of NYC Care to provide care to the undocumented gives us reason to hope that we can see action on health coverage. In the 2020 session, we’ll be campaigning for New York to follow California and provide comprehensive coverage for those now denied coverage due to their immigration status.  

The Trump Administration’s public charge rule was finalized today despite nearly 270,000 comments describing the harm it could cause to health and public welfare. The rule is yet another Trump action that de-values and de-humanizes immigrants (read the final rule here, and read our comments against it here).

Immigrant New Yorkers should know that they have support. The rule is very complicated and only applies to some immigrants and some circumstances. No one should disenroll from a program that is helping them, like Medicaid or SNAP, without talking to an expert first. For example, Medicaid enrollment does not count under the final rule for people under the age of 21. If you have questions about your specific status or a specific program, call the Office for New American’s Hotline (1-800-566-7636). The rule will not go into effect until October 15, 2019 – it will not apply for green card applications sent in before that.

This rule is a drastic change in American immigration policy that will result in rampant discrimination. Being a child under 18 years of age, or an adult over 61, could weigh heavily on a public charge determination. Having a disability or any documented health problem could likewise be a negative consideration. And using programs like SNAP, Medicaid, or public housing for longer than the Trump Administration’s arbitrary threshold means being potentially considered a public charge and thus not able to access a green card. Some experts estimate that one in three native-born Americans would not pass this test.

People fought back when the rule was proposed and they’ll keep fighting back now. There are sure to be many legal challenges to the rule – including court cases about whether the Administration really addressed all the concerns raised in those hundreds of thousands of comments. Congress can also pass new laws that stop the rule from being implemented – the executive branch can only take these types of action within parameters set by Congress. In the meantime, HCFANY will keep tracking the impact of health coverage and access to care. To keep track of other developments related to public charge, follow Protecting Immigrant Families (link).

On Tuesday we released an agenda for achieving racial justice in health care in New York. Today we’ll take a closer look at one factor that contributes to inequities in health care – white New Yorkers are more likely to have health insurance than others.

The most recent data on health coverage in the United States comes from the Census Bureau’s Small Area Health Insurance Estimates (SAHIE) for 2017. Right off the bat there are a couple missing pieces. The only racial and ethnic categories available for analysis are White alone, Black alone, and Hispanic (of any race). For one, what about people of Asian descent or who are mixed race? And second, people who say their ethnicity is Hispanic may have very different health care experiences depending on their race. We can’t pick up on something like that using this data-set.

We also can’t look at race and ethnicity at the county level, something that the SAHIE does provide for some other categories. It is especially challenging to get data by race and ethnicity at local government levels because in many counties of New York, the populations are too small to allow enough data points to meaningfully analyze trends.

Examining the available data shows some interesting differences in health insurance coverage depending on race and ethnicity. At every income category, people who said they were Hispanic are much more likely to be uninsured. Overall, about 9 percent of Hispanic people were uninsured, compared to 5.7 percent of people who reported their race as Black and only 3.5 percent of people who reported being White.

Looking at the data by income reveals some interesting differences:

Below 138% of the Federal Poverty Level:

People who reported their race as Black alone and White alone have almost the same likelihood of being uninsured (7.4 percent and 7.8 percent respectively). But for Hispanic (any race), the percent of uninsured at this level is shocking: 14.5 percent.

At this income, most New Yorkers are eligible for Medicaid. Some immigrants are eligible for the Essential Plan, which was created through the Affordable Care Act (ACA). The ACA excludes fewer immigrants from coverage than the Medicaid statute. That means New York was able to use the Essential Plan to cover many immigrants who would be income-eligible for Medicaid otherwise. But there are still many immigrants with very low-incomes who are not allowed to participate in public health programs because of their immigration status.

Between 138 and 400% of the Federal Poverty Level:

At this level there is more of a gap between the Black alone and the White alone categories: 8.2 percent of people who said their race was Black alone were uninsured, compared to 6.3 percent of people who said their race was White alone. People who said they are Hispanic were still uninsured at shockingly high rates: 14.5 percent.

At this income level, people move from eligibility for public coverage through Medicaid to public coverage for the Essential Plan and then into the private market. Essential Plan eligibility goes up to 200 percent of the federal poverty level. Above that, most uninsured New Yorkers can use the New York State of Health to purchase insurance and will be eligible for some level of premium subsidy. There are some glaring exceptions: depending on their type of immigration status, many immigrants are not allowed to purchase insurance on the New York State of Health, even if they use their own money and chose not to receive any assistance.

Above 400% of the Federal Poverty Level:

At this income level the gaps between Black alone and Hispanic (any race) close a bit, but the gaps between those categories and White alone increase. Only 2.2 percent of people who reported being White alone said they were uninsured. For Black alone 5 percent were uninsured and for Hispanic (any race) 6.5 percent were uninsured.

At this income New Yorkers are no longer eligible for any type of public coverage or premium assistance. Native-born New Yorkers and some immigrants can use the New York State of Health to shop for insurance and pay the full premium themselves.

“Of all the forms of inequality, injustice in health is the most shocking and inhuman”, Martin Luther King Jr. famously said in 1966.

Dr. King’s statement is sadly as true today in 2019 as it was in 1966. As a new HCFANY publication outlines (download it here), the quality of health care we receive in New York State is still shockingly unequal based on one’s race and ethnicity. For example, African-American New Yorkers have unequal outcomes as compared to Whites for a large range of health measures, including low birthweight babies, asthma hospitalizations and coronary heart disease mortality.  And 6.8% of Blacks and 11.8% of Hispanics in New York State lacked health coverage as of 2016, as compared to 4.5% of Whites.  Perhaps most dramatically, undocumented New Yorkers are excluded from most forms of health insurance due to punitive federal legislation. This is a major reason why so many lack primary care or have regular contact with health providers, resulting in serious health problems later on in life.

HCFANY’s new publication, released today, sets out a broad health justice agenda that will begin to address some of the inequities people of color face in the health care justice system in our state. Our proposals seek to expand and protect health coverage, and address the inferior care New Yorkers of color receive.  Among our proposals are to:

  • Expand New York’s popular low cost Essential Plan to all New Yorkers, irrespective of immigration status;
  • Reach additional people of color communities to enroll them in health coverage;
  • Expand consumer assistance funding to enable more New Yorkers, particularly people of color and low income New Yorkers, to better use their health coverage;
  • Create a fairer distribution of “indigent care funding” so that the hospitals that most serve the uninsured and Medicaid patients receive additional funding; and
  • Give impacted neighborhoods more say when community hospitals close, downsize or are absorbed into large health systems.

HCFANY, along with coalition partners throughout New York State, will be working hard for the remainder of 2019 to ensure that the health care needs of people of color are heard by New York decision-makers.  The health care agenda we have developed is an important contribution to a discussion we need to have as to how we can make health care access and delivery more equitable in our state.