Why the Health Care Battle Matters for Immigrant Integration
The threat of repealing and replacing the Patient Protection and Affordable Care Act—often referred to as the “ACA” or “Obamacare”—has all but imploded in the nation’s capital. While there was a vocal base of support for repealing the law, it has become clear that the main challenge lies in the replacement part. The major reason for this is not surprising: people do not want to lose their health insurance.
Between 2010 (when Obamacare was signed into law) and 2015, rates of health insurance coverage for nonelderly adults increased from 79% to 87%, with the number insured rising by over 20 million. All of the proposals put forth thus far would result in a loss of coverage for some of them—particularly those that benefited from the expansion of Medicaid that took place in 32 states (including the District of Columbia).
When thinking of immigrant integration, healthcare is not always the first thing that comes to mind. However, given that immigrants and their children are less likely to have health insurance, and have seen disproportionate gains in coverage under Obamacare, it is certainly worth consideration. Indeed, analysis of the American Community Survey (ACS) from the Integrated Public Use Microdata Series shows that there have been important gains in health insurance coverage under Obamacare for immigrants and their children—and particularly among low-income families.
In 2015, there were about 5.9 million more nonelderly immigrant adults and 1.9 million more children of immigrants with health coverage than there were in 2010. While part of the increase is due to population growth, the gains are real and substantial. Given the multiple ways in which health insurance can enhance the economic and social well-being of immigrants and their families, the fight to preserve these gains in coverage matters for immigrant integration.
Health Insurance Coverage Gains under the ACA for Immigrants and their Children
In examining changes in coverage over time, I focus on nonelderly adults ages 18-64 and children (age 17 or under) and examine them separately. Children had far higher rates of coverage prior to the ACA, largely due to the Children’s Health Insurance Program (CHIP) enacted in 1997. Also, elderly adults age 65 or older were virtually all covered by Medicare prior to the ACA, and the law did not affect rates of coverage. Furthermore, because the Medicaid expansion covered families with incomes below 138% of the federal poverty level (at least for states that accepted it), I present data above and below this threshold.
Figure1 illustrates health insurance coverage rates for nonelderly adults between 2010 and 2015, the most recent year for which ACS data is available. In that period, health insurance coverage rates for all nonelderly adults combined rose by 8 percentage points—from 79% to 87%. However, there was a 13 percentage point increase for nonelderly immigrant adults (from 61% to 74%). The rise in coverage was steeper for those falling below 138% of the federal poverty level, particularly after 2013 when the Medicaid expansion kicked in. Between 2010 and 2015, coverage for nonelderly immigrant adults below 138% of the federal poverty level rose from 39% to 58%—a 19 percentage point increase.
Figure 1.
As noted above, children already had much higher levels of health insurance coverage in 2010, thanks in large part to CHIP. However, rates of coverage since the passage of Obamacare have still improved substantially. Similar to the experience for nonelderly adults, the gains in coverage have been steeper for children of immigrant parents (defined as having at least one immigrant parent living in same household), and for low-income children.
As shown in Figure 2, over 90% of all children falling into any of the classifications shown had health insurance coverage by 2015. While children of immigrants falling below 138% of poverty still had the lowest rate of coverage of 91%,this level reflects a dramatic increase of 9 percentage points since 2010, when only 82% were covered. Despite the high rates of coverage, there were still 3.5 million children without health insurance in 2015, and 1.3 million of them were children of immigrants.
Figure 2.
Why Does Health Insurance Matter for Immigrant Integration?
Obtaining health insurance leads to better access to medical care and reduced financial stress—both of which can improve personal health, and assist in reaching one’s full potential all areas of life such as economic success and civic participation. Previous research by USC CSII reviews the literature on how health insurance can improve health and well-being. While the evidence that having insurance actually makes people healthier is mixed, there is broad agreement that people are better off with it than without it. A Kaiser study focused on immigrants in particular found that Medicaid and CHIP are associated with broad quality of life improvements for immigrant families. Not having insurance causes financial stress, economic insecurity, and makes one more likely to go bankrupt in the case of a medical emergency. Given the tenuous economic situation often faced by immigrant families, the peace of mind alone that comes with having health insurance can go a long way toward fostering more successful integration overall.
Boosting coverage now can pay large dividends in the future, too. In 2015, there were over 43 million immigrants in the U.S. making up 13% of the population. Better coverage for immigrant parents can facilitate well-being for themselves and their children. Children of immigrants will play an important role in the future workforce: they account for about one in four (24%) of all children under 18 years old. For those concerned about the future prosperity of our country, it is important to keep the next generation of workers (and their parents) healthy so they are better able to reach their full potential, and strengthen the U.S. economy over the coming decades.
None of this seems very likely in the current political environment. Tightened immigration enforcement has meant a ramping up of arrests of individuals whose only crime is being in the country without documentation. This is likely to drive immigrants—particularly the undocumented, but also legal residents who may be in mixed status families—to be fearful of enrolling in or using medical services, and is bad for public health and bad for the integration immigrants and their children into U.S. society.
So, part of expanding health coverage to immigrants and their families will require bringing health care reform and comprehensive immigration reform into the same conversation. Barriers to health insurance coverage for undocumented immigrants are a key reason why coverage for all immigrants and their families is lower than for the native-born population. Moreover, the increased economic prosperity that would come with legal status would likely increase rates of coverage as well. Much research has made clear the economic benefits of immigration reform with a path to citizenship over the current reality of an enforcement-only approach, and there is also a logical economic case to be made for expanding healthcare coverage to undocumented immigrants.
For example, given the large savings in medical expenditures obtained by increasing preventative care, insuring more of the undocumented (and likely increasing their use of preventative services) could reduce costs over the long term, even if publicly subsidized. Immigrants also tend to be younger and healthier than the general population, and incurlower health care costs, making them seemingly desirable candidates for any insurance pool if the goal is to lower per-person costs. Places like California—where putting the words “healthcare” and “immigrant” in the same sentence does not put an end to a political career—seem to have recognized the benefits of expanding insurance coverage to all Californians and have taken steps to do so.
The California Example: Implications for Healthcare Policy and Immigrant Integration
In 2015, SB 75 was passed extending coverage under Medi-Cal (California’s Medicaid program) to undocumented children, and the next year SB 10 required Covered California (the state’s insurance market) to apply to the U.S. Department of Health and Human Services for a waiver to allow undocumented immigrants to purchase health plans (although the waiver was not approved). This year, Senators Ricardo Lara and Toni Atkins proposed a single-payer healthcare system for the state, which would cover everyone, including the undocumented. While the proposal faced many barriers (namely, how to pay for it), and was put to rest by the Assembly Speaker in June, California will likely continue to be testing grounds for policies on healthcare (and immigration).
If the Congress is serious about passing a health care bill, it seems it will have to come to grips with the reality that Obamacare has improved the lives of tens of millions of U.S. residents—and low-income families in particular. Any rolling back of that coverage is not likely to go over well with constituents (even among many of those who supported President Trump). A successful proposal will need to maintain current progress on expanded coverage. Focusing on the potential savings that could result from increased use of preventative care could help bring along those in Congress whose primary motivation is shrinking the federal budget.
Whatever happens, the fact that the ACA has improved health coverage rates for immigrant families, bringing them far closer to the national average, is a good thing for immigrant integration. Further gains in coverage for immigrant families will require addressing barriers for the undocumented, but this seems highly unlikely under the current Congress (to put it mildly). Indeed, what seems more likely are proposals that add to the barriers for immigrant—and particularly undocumented—residents. In the meantime, those concerned with the plight of low-income families generally and immigrant integration in particular can look to California as an example of forging a brighter future.
About the author
Justin Scoggins is the data manager at the USC Program for Environmental and Regional Equity (PERE) and the Center for the Study of Immigrant Integration (CSII), specializing in empirical analysis of social equity issues in the areas of environmental justice, regional equity, and immigrant integration. He is responsible for organizing the broad array of datasets used in and conducting the quantitative analyses called for by various projects, including work done under PERE’s partnership with PolicyLink, which is responsible for the National Equity Atlas.