Health Coverage and Care for Immigrants

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1 Health Coverage and Care for Immigrants Samantha Artiga, Anthony Damico, Katherine Young, Elizabeth Cornachione, and Rachel Garfield Immigrants, particularly those who are not citizens, historically have faced disproportionate barriers to accessing health coverage and care. The ACA offers new options to increase coverage for naturalized citizens and lawfully present immigrants, but undocumented immigrants remain ineligible for assistance. This brief provides an overview of the noncitizen immigrant population and their health coverage and access to care. It shows: As of 2014, there were 42.2 million immigrants residing in the United States, accounting for 13% of the total population. This group includes an estimated 19.7 million naturalized citizens, 9.9 million lawfully present immigrants, and 12.5 million undocumented immigrants. Noncitizen immigrants are significantly more likely than citizens to be uninsured. Among the nonelderly population, nearly a quarter (23%) of lawfully present immigrants and four in ten (40%) undocumented immigrants are uninsured compared to one in ten (10%) U.S. born and naturalized citizens. Two-thirds (66%) of uninsured lawfully present immigrants are eligible for assistance under the ACA, but undocumented immigrants are excluded from coverage options. Although lawfully present immigrants may qualify for the ACA Medicaid expansion, they remain subject to certain Medicaid eligibility restrictions. Undocumented immigrants remain ineligible for Medicaid and are prohibited from purchasing Marketplace coverage. Noncitizens fare worse than citizens on measures of access to care and generally report lower utilization of services relative to citizens. These patterns persist among noncitizens with coverage, suggesting they face additional barriers to accessing and utilizing care beyond their higher uninsured rates. Overall, these findings show that noncitizens continue to face barriers to accessing health coverage and care. The ACA increased coverage options for lawfully present immigrants, but targeted outreach and enrollment efforts will be important for enrolling eligible immigrants in coverage. However, coverage alone will not overcome the barriers to care faced by many noncitizens. Additional efforts will be needed to address their gaps in care. In the absence of coverage options, undocumented immigrants will likely continue to have a high uninsured rate and face significant barriers to care. As such, safety-net providers and resources continue to be important for meeting the needs of this population. Some states also are exploring options to expand coverage for immigrants who remain ineligible for the ACA coverage options due to their immigration status.

2 Immigrants, particularly those who are not citizens, historically have faced disproportionate barriers to accessing health coverage and care. This issue brief provides a portrait of the noncitizen immigrant population today, an overview of their health coverage and care, and discusses how they have been affected by the Affordable Care Act (ACA) Medicaid and Marketplace coverage expansions. It draws on two sources of data. Estimates of demographics, coverage, and eligibility for ACA coverage are from Kaiser Family Foundation analysis of the 2015 Current Population Survey. Estimates of access to care and utilization are from the 2014 Kaiser Survey of Low-Income Americans and the ACA. More information about the methods underlying analysis of the Current Population Survey and the Kaiser Survey of Low-Income Americans and the ACA are available through the linked resources. As of 2014, there were 42.2 million immigrants residing in the United States, accounting for 13% of the total population (Figure 1). They include an estimated 19.7 naturalized citizens, 9.9 million lawfully present immigrants and 12.5 million undocumented immigrants (Text Box 1). Although immigrants reside throughout the United States the majority reside in a small number of states. (See Appendix Table A.) Among this total population, there are an estimated 8.5 million nonelderly lawfully present immigrants and 12.4 million nonelderly undocumented immigrants. The remaining sections of the brief focus on noncitizen immigrants since they historically have faced disproportionate barriers to health coverage and care relative to citizens. Moreover, the analysis is limited to the nonelderly population since this group was targeted by the ACA coverage expansions. Figure 1 Immigrants as a Share of the Total U.S. Population by Immigration Status, 2014 U.S. Born Citizens 87% 316 Million Total U.S. Population 6% 3% 4% Naturalized Citizens (19.7 million) Lawfully Present Immigrants (9.9 million) Undocumented Immigrants (12.5 million) All Immigrants 13% (42.2 million) Text Box 1: Lawfully Present and Undocumented Immigrants Lawfully present immigrants are foreign-born individuals who have not become U.S. citizens but are lawfully residing in the United States. This group includes legal permanent residents (LPRs, i.e., green card holders), refugees, asylees, other humanitarian immigrants, and other lawfully present temporary immigrants. 1 Undocumented immigrants are foreign-born individuals residing in the United States who are not legal residents, including individuals who entered the country without authorization; individuals who were legally admitted and stayed after their visa expired; and quasi-legal individuals, such as people with temporary protective status or those who have applied for asylum but whose claims have not yet been resolved. Health Coverage and Care for Immigrants 2

3 Nonelderly noncitizens include individuals of different races/ethnicities, but the majority of both lawfully present and undocumented immigrants are Hispanic. Among the nonelderly, over half (51%) of lawfully present immigrants and more than six in ten (64%) undocumented immigrants are Hispanic, with the remainder of these groups including individuals who identify as non-hispanic White, non-hispanic Black, or another race, including individuals of mixed race (Figure 2). In contrast, nearly two-thirds of nonelderly citizens are non-hispanic White, with the remainder non-hispanic Black (13%), Hispanic (16%), or another race (8%). Figure 2 Nonelderly Population by Race/Ethnicity and Immigration Status, % 13% 16% 23% 8% 19% 6% 63% 51% 64% Other Black Hispanic White 17% 11% Citizens Lawfully Present Immigrants Undocumented Immigrants Million 8.5 Million 12.4 Million Indicates statistically significant difference from citizens at p<0.05 level. Note: Totals may not sum to 100% due to rounding. Among the nonelderly, noncitizens are more likely than citizens to be adults. About nine in ten of both nonelderly lawfully present immigrants (91%) and undocumented immigrants (90%) are adults, and a larger share of lawfully present (29%) and undocumented immigrants (41%) are young adults between ages 19 and 34 compared to citizens (25%) (Figure 3). Nonelderly lawfully present immigrants and undocumented immigrants also are more likely to be parents compared to citizens (Figure 4). Figure 3 Nonelderly Population by Age and Immigration Status, 2014 Figure 4 Share of the Nonelderly Population that is a Parent by Immigration Status, % 25% 31% 62% 29% 48% 41% 9% 10% Citizens Lawfully Present Immigrants Undocumented Immigrants Million 8.5 Million 12.4 Million Indicates statistically significant difference from citizens at p<0.05 level. Note: Totals may not sum to 100% due to rounding % 42% 45% Citizens Lawfully Present Immigrants Undocumented Immigrants Million 8.5 Million 12.4 Million Indicates statistically significant difference from citizens at p<0.05 level. Health Coverage and Care for Immigrants 3

4 Nonelderly noncitizens are as likely as citizens to have a full-time worker in the family, but they are more likely to be lowincome. Over eight in ten nonelderly citizens and noncitizens live in a family with at least one full-time worker (Figure 5). However, noncitizens are more likely than citizens to be low-income, with 46% of lawfully present immigrants and 56% of undocumented immigrants living in a family with income below 200% of the federal poverty level compared to 32% of citizens. This finding reflects the fact that noncitizens are more likely to work in lowwage, blue-collar jobs and industries compared to citizens. 2 Figure 5 Employment and Income Among the Nonelderly Population by Immigration Status, 2014 Citizens Lawfully Present Immigrants Undocumented Immigrants 82% 82% 81% At Least One Full-Time Worker in the Family 32% 46% 56% Low-Income (<200% FPL) Indicates statistically significant difference from citizens at p<0.05 level. Nonelderly noncitizens are significantly more likely than citizens to be uninsured. Among the total nonelderly population, nearly a quarter (23%) of lawfully present immigrants and four in ten (40%) undocumented immigrants are uninsured compared to one in ten (10%) citizens (Figure 6). Coverage patterns are very similar among nonelderly adults, with 23% of lawfully present immigrants and 42% of undocumented immigrants lacking coverage compared to 12% of citizens. Uninsured rates for children are lower than adults across groups. However, among children, lawfully present and undocumented immigrants remain more likely to lack coverage compared to citizens. Nearly one in five lawfully present children (17%) and nearly one in four undocumented immigrant children (23%) are uninsured compared to 6% of citizen children. Figure 6 Uninsured Rates Among Nonelderly Adults and Children by Immigration Status, % Citizens Lawfully Present Immigrants Undocumented Immigrants 40% 23% 23% 12% 42% 6% 23% 17% All Nonelderly Nonelderly Adults Children Indicates statistically significant difference from citizens at p<0.05 level. Noncitizens can obtain private coverage on the individual market, through an employer, or as a dependent, but have lower rates of private coverage relative to citizens. Although non-citizens are as likely as citizens to work, many are in jobs, firms, and industries that do not offer health coverage to workers. Non-citizens are disproportionately likely to work in low-wage jobs as service workers, laborers, clerical workers, and technicians; or in small firms; which are less likely to offer health coverage benefits. 3 As such, low-income non-citizens have limited access to employer-based coverage, and private coverage on the individual market is often unaffordable given their limited incomes. Lawfully present non-citizens can enroll in Medicaid and CHIP but are subject to eligibility restrictions. Since 1996, most lawfully present immigrants must wait five years after receiving a qualified 4 immigration status before they may enroll in Medicaid and CHIP, and some groups of immigrants with Health Coverage and Care for Immigrants 4

5 permission to be in the U.S. are ineligible for coverage regardless of their length of time in the country. The Children s Health Program Reauthorization Act of 2009 (CHIPRA) provided states an option to eliminate the five-year waiting period for lawfully residing children and pregnant women who are otherwise eligible for Medicaid or CHIP. 5 Over half of states have elected the CHIPRA option for lawfully residing immigrant children and nearly half have elected the option for lawfully residing pregnant women. 6 Undocumented immigrants are ineligible for Medicaid and CHIP. However, Medicaid payments for emergency services may be made on behalf of individuals who are otherwise eligible for Medicaid but for their immigration status. These payments cover costs for emergency care (including labor and delivery) for lawfully present immigrants who remain ineligible for Medicaid as well as undocumented immigrants. Since 2002, states have had the option to provide prenatal care to women regardless of immigration status by extending CHIP coverage to the unborn child. In addition, some states have state-funded health programs that provide coverage to some groups of immigrants regardless of immigration status. There are also some locally-funded programs that provide coverage or assistance without regard to immigration status. The ACA increased coverage options through an expansion of Medicaid and the establishment of new Health Insurance Marketplaces with tax credit subsidies. The ACA fills historical gaps in Medicaid eligibility by extending Medicaid to nearly all nonelderly adults with incomes at or below 138% of the federal poverty level (FPL) ($27,724 for a family of three in 2015). With the June 2012 Supreme Court ruling, the Medicaid expansion effectively became optional for states. As of January 2016, 30 states and DC have implemented the ACA Medicaid expansion. The ACA also established Health Insurance Marketplaces where individuals can purchase insurance and allows for federal tax credits for such coverage for people with incomes from 100% to 400% FPL ($19,790 to $79,160 for a family of three in 2015). 7 Tax credits are generally only available to people who are not eligible for other coverage. Because the ACA envisioned low-income people receiving coverage through Medicaid, people with incomes below poverty are not eligible for Marketplace subsidies. Thus, in the 20 states not implementing the Medicaid expansion, some adults fall into a coverage gap of earning too much to qualify for Medicaid but not enough to qualify for premium tax credits. Lawfully present immigrants can receive coverage through these expansions, although they continue to face eligibility restrictions for Medicaid. Lawfully present immigrants may qualify for Medicaid, but remain subject to the five-year waiting period before they may enroll. Although states have the option to eliminate this five-year waiting period for children and pregnant women, this option does not extend to other adults. As such, lawfully present immigrants may qualify for the ACA Medicaid expansion, but they remain subject to the five-year waiting period before they can enroll. Lawfully present immigrants can purchase coverage through a Marketplace during the period of time they are excluded from enrolling in Medicaid and can receive tax credits for this coverage (Table 1, next page). Undocumented immigrants are ineligible for ACA coverage options. Undocumented immigrants were ineligible for Medicaid prior to the ACA and remain ineligible. They also are prohibited from purchasing coverage through a Marketplace or receiving tax credits. Health Coverage and Care for Immigrants 5

6 Individuals may enroll if they meet income and other eligibility criteria. Many individuals remain subject to a five-year wait before they may enroll or are excluded from eligibility. States may choose to eliminate the fiveyear wait for otherwise eligible children and pregnant women but not for other adults. Remain ineligible for Medicaid. Individuals who are not eligible for Medicaid can buy coverage through Marketplaces. Tax credits are available to individuals with incomes between 100%-400% of poverty who do not have access to affordable employer or other coverage. Individuals may purchase Marketplace coverage and receive tax credits on the same basis as citizens. Individuals with incomes below 100% of poverty who are ineligible for Medicaid based on immigration status also may purchase Marketplace coverage and receive tax credits. Prohibited from purchasing Marketplace coverage and receiving tax credits. As of 2015, nearly two-thirds of uninsured lawfully present immigrants are eligible for assistance under the ACA, while all uninsured undocumented immigrants remain excluded from assistance. Among nonelderly uninsured lawfully present immigrants, 29% are eligible for Medicaid and 36% are eligible for tax credit subsidies to purchase Marketplace coverage (Figure 7). Despite having lower incomes than citizens, they are less likely to qualify for Medicaid and more likely to qualify for Marketplace tax credits than citizens. This likely reflects the fact that poor lawfully present immigrants are eligible for Marketplace tax credits but excluded from Medicaid during the five-year waiting period. A little over one-third of uninsured nonelderly lawfully present immigrants remain ineligible for assistance, including 8% who fall into the coverage gap that exists in states that have not implemented the Medicaid expansion and 27% who have an offer of employer sponsored insurance or have income above the tax credit limit. All uninsured nonelderly undocumented immigrants remain ineligible for assistance based on their immigration status. Figure 7 Eligibility for ACA Coverage Among Nonelderly Uninsured by Immigration Status as of % 27% 8% 12% 36% 26% 100% Ineligible for Financial Assistance Ineligible Due to Immigration Status In the Coverage Gap Tax Credit Eligible Eligible for Medicaid 32% 29% Citizens Lawfully Present Immigrants Undocumented Immigrants Notes: Totals may not sum to 100% due to rounding. Ineligible for Financial Assistance Share includes those ineligible due to offer of ESI or income. Tax Credit Eligible share includes adults in MN and NY who are eligible for coverage through the Basic Health Plan. Source: Kaiser Family Foundation analysis based on 2015 Medicaid eligibility levels and 2015 Current Population Survey. Health Coverage and Care for Immigrants 6

7 Longstanding research demonstrates that health insurance is associated with significant improvements in health access and utilization. 8 However, noncitizens may face additional barriers to accessing and utilizing care. Using data from the 2014 Kaiser Survey of Low-Income Americans and the ACA, this section examines health access and utilization for noncitizen immigrant adults by coverage status. It finds that among insured adults, noncitizens face a range of disparities in access and utilization compared to citizens. Among insured adults, noncitizens are less likely to have a usual source of care compared to citizens. About half of uninsured adults report having a usual source of care among citizens, lawfully present immigrants, and undocumented immigrants. The share of insured citizens reporting a usual source of care is significantly higher at 81% (Figure 8). However, the differences between insured and uninsured adults are smaller for lawfully present and undocumented immigrants. As such, among insured adults, lawfully present and undocumented immigrants are significantly less likely to report a usual source of care than citizens. Regardless of coverage status, noncitizens are significantly more likely than citizens to rely on a clinic as their usual source of care. Among uninsured adults, the majorities of lawfully present and undocumented immigrant adults cite a clinic as their usual source of care, compared to less than four in ten citizens (Figure 9). Lawfully present immigrants with insurance coverage are about half as likely as their uninsured counterparts to use a clinic as their usual source of care, but they remain significantly more likely than insured citizens to utilize a clinic. Nearly two-thirds (63%) of undocumented immigrant adults rely on a clinic even when covered. Figure 8 Share of Adults with a Usual Source of Care by Coverage Type and Immigration Status, % Citizen Lawfully Present Immigrant Undocument Immigrant 51% Uninsured 48% 81% Indicates statistically significant difference from U.S. citizen group at p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. Figure 9 38% 64% Uninsured 81% 19% 66% Insured 32% Insured 52% Share of Adults who Report a Clinic as their Usual Source of Care by Coverage Type and Immigration Status, 2014 Among those with a Usual Source of Care: Citizen Lawfully Present Immigrant Undocumented Immigrant Indicates statistically significant difference from U.S. citizen group at p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. 63% Health Coverage and Care for Immigrants 7

8 Noncitizens with health coverage are less likely to have a regular doctor than their citizen counterparts. Among uninsured adults, less than a third of all groups report having a regular doctor, and undocumented immigrants are less likely than citizens to have a regular provider (17% vs. 28%). The share of adults with a regular provider is significantly higher among insured adults compared to those without coverage. However, among insured adults, lawfully present and undocumented immigrants are significantly less likely to have a regular provider compared to citizens (Figure 10). Figure 10 Share of Adults that Has a Regular Doctor at Usual Source of Care by Coverage Type and Immigration Status, 2014 Citizen Lawfully Present Immigrant Undocumented Immigrant 28% 28% Uninsured 17% 71% Indicates statistically significant difference from U.S. citizen group at p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. 58% Insured 35% Among insured adults, noncitizens are less likely to report using medical services compared to citizens. Among uninsured adults, roughly half of citizens, lawfully present immigrants, and undocumented immigrants report using any medical services. Among citizens, insured adults are significantly more likely to report using medical care compared to those who are uninsured. However, the differences between insured and uninsured adults are smaller for lawfully present and undocumented immigrants. As such, among insured adults, lawfullypresent and undocumented immigrants are less likely to report using medical services compared to citizens (Figure 11). Figure 11 Share of Adults that Used any Medical Services by Coverage Type and Immigration Status, % Citizen Lawfully Present Immigrant Undocumented Immigrant 54% Uninsured 53% 81% Indicates statistically significant difference from U.S. citizen group at p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. 70% Insured 59% Insured noncitizens also are less likely to report receiving preventive care compared to insured citizens. Among uninsured adults, about a quarter of both citizens (24%) and lawfully present immigrants (25%) report receiving a preventive visit or check-up, while over a third (35%) of undocumented immigrants report receiving preventive care. In contrast, among insured adults, over two thirds (67%) of citizens report a preventive visit, a significantly higher share than the 55% of lawfully present immigrants and 46% of undocumented immigrants who report receiving this care (Figure 12). Figure 12 Share of Adults that had Check up or Preventive Visit by Coverage Type and Immigration Status, % Citizen Lawfully Present Immigrant Undocumented Immigrant 25% Uninsured 35% 67% Indicates statistically significant difference from U.S. citizen group at p<0.05 level. SOURCE: 2014 Kaiser Survey of Low-Income Americans and the ACA. 55% Insured 46% Health Coverage and Care for Immigrants 8

9 In sum, these findings show that noncitizens continue to face disparities in health coverage. The ACA coverage expansions increased coverage options for lawfully present immigrants but targeted outreach and enrollment efforts will be important for enrolling eligible lawfully present immigrants in coverage. Immigrant families face numerous barriers to enrolling in coverage, including confusion regarding their eligibility, fear of immigration enforcement, concerns about harming their status or the status of their family members, concerns about their sponsors, difficulty completing the application process, and language and literacy challenges. Conducting outreach and providing one-on-one assistance through trusted organizations and individuals with strong ties to the immigrant community will be important for overcoming these barriers. 9 Undocumented immigrants remain excluded from coverage options. In the absence of coverage options, undocumented immigrants will likely continue to have a high uninsured rate and face significant barriers to care. As such, safety-net providers and resources continue to be important for meeting the needs of the population. Some states also are exploring options to expand coverage for immigrants who remain ineligible for the ACA coverage options due to their immigration status. Data show that noncitizen adults with insurance fare better than those who are uninsured on measures of access and utilization. However, noncitizen adults continue to face disparities in access and utilization compared to citizens when covered. Together these data suggest that gains in coverage among lawfully present immigrants under the coverage expansions will likely lead to some improvements in access to care but that they will continue to face additional barriers to care relative to citizens. As such, it will be important to address other challenges to accessing needed care, such as language and literacy barriers, lack of transportation, and fears and confusion related to navigating the health care system. In the absence of coverage, undocumented immigrants will likely continue to face significant barriers to care. Regardless of coverage, safety-net providers, particularly community health centers, remain a major source of care for immigrants. Safety-net providers are viewed as a trusted source for care and often offer culturally and linguistically appropriate services that meet the needs of diverse populations. These providers will likely remain a primary source of care for immigrants moving forward. Samantha Artiga, Katherine Young, Elizabeth Cornachione, and Rachel Garfield are with the Kaiser Family Foundation. Anthony Damico is an independent consultant to the Kaiser Family Foundation. Health Coverage and Care for Immigrants 9

10 Alabama 4,768,000 4,605,000 52,000 46,000 64,000 Alaska 696, ,000 32,000 14, Arizona 6,657,000 5,582, , , ,000 Arkansas 2,896,000 2,728,000 56,000 48,000 64,000 California 38,701,000 28,622,000 5,118,000 1,856,000 3,105,000 Colorado 5,377,000 4,767, , , ,000 Connecticut 3,578,000 3,092, , , ,000 Delaware 929, ,000 39,000 23,000 29,000 DC 657, ,000 38,000 25,000 41,000 Florida 19,731,000 15,831,000 2,141, , ,000 Georgia 9,965,000 8,968, , , ,000 Hawaii 1,365,000 1,136, ,000 57,000 48,000 Idaho 1,610,000 1,501,000 38,000 32,000 40,000 Illinois 12,798,000 11,069, , , ,000 Indiana 6,478,000 6,097, , , ,000 Iowa 3,081,000 2,928,000 52,000 42,000 59,000 Kansas 2,853,000 2,606,000 92,000 72,000 82,000 Kentucky 4,316,000 4,128,000 43,000 69,000 75,000 Louisiana 4,557,000 4,339,000 90,000 46,000 82,000 Maine 1,300,000 1,256,000 21, Maryland 5,939,000 5,023, , , ,000 Massachusetts 6,658,000 5,551, , , ,000 Michigan 9,906,000 9,189, , , ,000 Minnesota 5,419,000 4,931, , , ,000 Mississippi 2,965,000 2,875, Missouri 5,961,000 5,789,000 96,000 41, Montana 1,009, ,000 6, Nebraska 1,881,000 1,743,000 36,000 47,000 55,000 Nevada 2,823,000 2,309, , , ,000 New Hampshire 1,320,000 1,244,000 43,000 17,000 16,000 New Jersey 8,939,000 6,963,000 1,065, , ,000 New Mexico 2,035,000 1,833,000 69,000 67,000 66,000 New York 19,679,000 15,268,000 2,391,000 1,299, ,000 North Carolina 9,836,000 9,023, , , ,000 North Dakota 733, ,000 9, ,000 Ohio 11,536,000 11,029, , , ,000 Oklahoma 3,742,000 3,513,000 59,000 72,000 97,000 Oregon 3,962,000 3,557, , , ,000 Pennsylvania 12,627,000 11,818, , , ,000 Rhode Island 1,048, ,000 79,000 33,000 36,000 South Carolina 4,764,000 4,568,000 80,000 47,000 70,000 South Dakota 847, , Tennessee 6,502,000 6,149, ,000 76, ,000 Texas 26,687,000 22,301,000 1,449,000 1,022,000 1,916,000 Utah 2,929,000 2,701,000 86,000 63,000 80,000 Vermont 617, ,000 18, Virginia 8,259,000 7,293, , , ,000 Washington 7,085,000 6,174, , , ,000 West Virginia 1,826,000 1,803, Wisconsin 5,747,000 5,489, ,000 55,000 73,000 Wyoming 572, ,000 8,000 5, Note: -- = Sample size is not sufficient for a reliable estimate. Source: Kaiser Family Foundation analysis of March 2015 Current Population Survey, Annual Social and Economic Supplement Health Coverage and Care for Immigrants 10

11 1 Coverage for lawfully present immigrants, HealthCare.gov, accessed January 12, 2016, https://www.healthcare.gov/immigrants/lawfully-present-immigrants/ 2 Kaiser Commission on Medicaid and the Uninsured, Key Facts on Health Coverage for Low-Income Immigrants Today and Under the Affordable Care Act (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, March 2013), 3 Ibid. 4 The term qualified non-citizen includes: Lawful Permanent Residents (LPRs/green card holders); asylees, refugees; Cuban/Haitian entrants; individuals paroled in the U.S. for at least one year; conditional entrants granted before 1980; battered noncitizens, spouses, children or parents; victims of trafficking and his or her spouse, child, sibling or parent or individuals with a pending application for a victim of trafficking visa; individuals granted withholding of deportation; member of a federally recognized Indian tribe or American Indian born in Canada. See Coverage for lawfully present immigrants, HealthCare.gov, accessed November 2, 2015, https://www.healthcare.gov/immigrants/lawfully-present-immigrants/. 5 CHIPRA also expanded the groups of immigrants considered lawfully present who could qualify for coverage. 6 Tricia Brooks, et al., Medicaid and CHIP Eligibility, Enrollment, Renewal and Cost-Sharing Policies as of January 2016: Findings from a 50-State Survey (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, January 2016). 7 Tax credit eligibility in 2015 is based on 2014 poverty guidelines. In addition to the premium tax credits, the federal government also makes available cost-sharing subsidies to reduce what people with incomes between 100% and 250% of poverty have to pay out-ofpocket to access health services. The cost-sharing subsidies are also available on a sliding scale based on income. 8 Melissa Majerol, Vann Newkirk, and Rachel Garfield, The Uninsured: A Primer Key Facts about Health Insurance and the Uninsured in the Era of Health Reform (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, November 2015), 9 Oscar Gomez, Liberty Day, and Samantha Artiga, Connecting Eligible Immigrant Families to Health Coverage and Care: Key Lessons from Outreach and Enrollment Workers (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, October 2011), Health Coverage and Care for Immigrants 11

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