Welfare Reform and Elderly Legal Immigrants
conomic status, especially in old age, is often dependent on a lifetime of choices and opportunities. Retirement income is directly dependent on previous labor force experiences, savings, and thehealth and insurance coverage of family members. Good health and high educational attainment tend toresult in better employment opportunities, a greater likelihood of a pension, and increased prospects forsaving. Poor health, the death of a spouse, lack of education, or poor employment opportunities canmitigate the opportunity for a secure retirement income.
Table 3 provides a profile of the educational attainment of elderly citizens and legal immigrants. Over 30 percent of elderly legal immigrants had not gone past the sixth grade, compared to 7 percentof elderly citizens. Interestingly, more than 8 percent of elderly legal immigrants had earned a law,medical, dental, or doctorate degree. In contrast, less than 2 percent of elderly citizens had earnedprofessional or academic doctorate degrees.
Educational Attainment of Elderly Citizens and Legal Immigrants
(Percentage Distribution) Educational Attainment Legal Immigrants Citizens 6th grade or less 30.6 7.2 Grades 7-11 11.6 29.9 High school graduate 40.8 35.7 Some college through a Masters degree 9.2 25.5 Professional degree (MD, DDS, JD) or Ph.D. level. 8.4 1.8
Source: National Academy on Aging tabulations of the 1993 Survey of Income and Program Participation.
Consistent with educational attainment, elderly legal immigrants were more likely than elderlycitizens to be poor. Figure 4 shows that the average family income among elderly legal immigrants isabout half that of elderly citizens ($16,934/year for legal immigrants and $12,408 for citizens). Evenamong working elderly, average monthly earnings for legal immigrants were about 66 percent less thanelderly citizens (about $950 a month compared to $1,438, in 1993).20 As a consequence, legalimmigrants are nearly twice as likely to be poor as are elderly citizens (24 percent verses 14 percent). This is true even though elderly legal immigrants were more than three times as likely to be living withothers, including an adult child who may be working.21
Missing from this portrait are the employment histories of elderly legal immigrants. About 10percent of elderly legal immigrants in 1993 were working. Three-quarters (76 percent) of the elderlylegal immigrants had worked long enough under Social Security-covered employment to becomeentitled to Social Security benefits.22 This requires paying a minimum amount of FICA taxes in fortydifferent quarters (i.e., working at least for ten years). However, it should be noted that Social Securitybenefits alone do not necessarily provide income that is above the poverty threshold. A lifetime of low-paying jobs will result in Social Security benefits that are below poverty. In 1995, almost two-thirds(63 percent) of all elderly Supplemental Security Income (SSI) beneficiaries were also receiving SocialSecurity benefits.
The PRA did not change legal immigrant’s entitlement to earned benefits such as Social Securityand Medicare. By working enough years, like citizens, legal immigrants can collect SocialSecurity retirement benefits at age 62 and, hence, Medicare benefits at age 65. As already indicated,three-quarters of elderly legal immigrants had worked long enough in covered employment to beentitled to Medicare. Through the exemption, these elderly legal immigrants should be able to retainMedicaid or obtain Medicaid (as well as SSI and other benefits) in the same way as do citizens. However, for the 24 percent of the elderly legal immigrants who have not worked long enough to beentitled to Medicare, they may lose their access to Medicaid, depending on how states decide to treatlegal immigrants under their Medicaid program.
Figure 5 shows the distribution of Medicare and Medicaid coverage among elderly legalimmigrants and citizens. In 1993, virtually all (98 percent) elderly citizens were Medicare beneficiaries;by comparison, 76 percent of elderly legal immigrants were also beneficiaries. It should be noted thatMedicare beneficiaries also have private supplemental health insurance policies (Medigap) whichprimarily covers Medicare copayments and deductibles. About 22 percent of elderly legal immigrantsand 77 percent of elderly citizens had some form of private health insurance.23
Overall, Medicaid covered 64% of all elderly legal immigrants. By comparison, Medicaidcovered 12 percent of all elderly citizens. However, 16 percent of elderly legal immigrants relied onMedicaid alone compared to less than 1 percent of all elderly citizens. Moreover, 8 percent of elderlylegal immigrants and 2 percent of elderly citizens had neither Medicare nor Medicaid. It is these lattertwo groups, the 16 percent of elderly legal immigrants with Medicaid, but no Medicare and the 8percent with neither Medicare nor Medicaid who will no longer be eligible for cash assistance, foodstamps and other means-tested benefits.
Our analysis shows that most elderly legal immigrants did not come to the U.S. to gain accessto Medicaid benefits. As shown previously, more than three-quarters of elderly legal immigrantsarrived in this country before they were elderly. More importantly, legal immigrants who came to theUnited States after the age of 65 were not more likely than those who entered the United Statesbetween the ages of 40 and 64 to be receiving Medicaid benefits when they were elderly. Elderly legalimmigrants arriving between age 41 and 64 were 3.5 times more likely than those arriving before age40 and 2 times more likely than those arriving after age 65 to be Medicaid beneficiaries. Elderly legalimmigrants who arrived here when they were under 40 years old, however, were less likely than thosewho arrived after age 40 to be Medicaid beneficiaries (when elderly).
Preliminary analysis also suggests that, overall, elderly immigrants are more likely than elderlycitizens to need long-term care. Immigrants were twice as likely as citizens to need assistance withpersonal care.24 These findings are consistent with the educational attainment and income distribution ofelderly legal immigrants. Regardless of citizenship, people with less schooling generally have lessincome and poorer health.25 If an elderly legal immigrant with health care needs is not providedbenefits, their access to care will be seriously impeded. Although there are a few safety-net providerswho will provide acute care to the uninsured, without insurance or public coverage it is impossible toobtain a regular source of care. Having a regular source of care is necessary for chronic healthconditions. Without substantial resources or access to Medicaid, it is impossible to obtain long-termcare.
Unlike other types of health care, there is no last resort for long-term care generally and nursinghome care, in particular the nursing home is the last resort. Nursing homes routinely use ability to payto decide who to accept. They also can dismiss people who outlive their resources. Nursing homeresidents include some of the most frail and cognitively impaired people. The typical nursing homeresident is over age 85 and widowed. Nursing home residents are less likely to have any adult children,and if they do, their adult children are also likely to be elderly and have their own medical conditions.
Nursing home costs can easily exceed $3,000 a month, beyond the reach of most very oldpeople, and especially most legal immigrants. An estimated 80,000 to 90,000 nursing home residents in1995 were elderly legal immigrants.26 While this is less than 10 percent of all elderly nursing homeresidents, it does represent nearly $2.5 billion in revenues to nursing homes.
Elderly legal immigrants who have not worked long enough to become entitled to Medicare arelikely to lose cash assistance and food stamps and will be dependent on State action to ensure theiraccess to Medicaid. It is this population that is under discussion in the budget negotiations currentlyunderway in the U.S. Congress. In the non-binding budget agreement between the Congress and thePresident, it was agreed that PRA would be amended to restore SSI and Medicaid to legal immigrantswith disabilities. The agreement covered legal immigrants who were receiving SSI on August 22, 1996and who were legal immigrants on August 22, 1996, but not receiving SSI on that date but whosubsequently become disabled. In the bill that is now moving through Congress, the PRA would beamended to include just the first category-legal immigrants receiving SSI on August 22, 1996. Elderlypeople receiving SSI are also eligible for Medicaid. Even if both provisions under discussion weremade, legal immigrants arriving after August 22, 1996, regardless of their ensuing health care needs,could, depending on the State s actions, be denied access to Medicaid unless they had worked 40quarters or become naturalized prior to needing medical assistance.
This paper provides a portrait of the lives of elderly legal immigrants. Reflecting on their livesoffers a glimpse at the life ahead for younger immigrants arriving today. The findings in thispaper strongly suggest that the elderly legal immigrant did not come to the United Statesbecause of its welfare program. Most of them arrived here more than two decades earlierand before the age of 65. Some elderly legal immigrants served in the military,27 most worked, and, asa consequence, they paid taxes. Most raised children and because so many elderly legal immigrants areliving in households with children, they are probably helping to raise their grandchildren.
Elderly legal immigrants as of the day the PRA was enacted will retain access to publicassistance if they meet specific exemptions; those arriving after August 22, 1996 will face newprovisions that will effectively bar them from assistance for at least a decade if they are able to find andaccumulate forty quarters of Social Security covered employment during that time or until they becomenaturalized. Some immigrants will no longer be considered legal and are in the process of losing theirbenefits. These immigrants are receiving benefits due to special provisions under PRUCOL.
Legal immigrants receiving benefits are now having their cases reviewed and will be deniedcoverage unless they meet specific exemptions.28 One of those exemptions is having paid FICA taxesfor forty quarters. Because of this exemption, more than three-quarters of the elderly legal immigrantsare likely to remain entitled to their benefits. However, because of confusion about the law, some legalimmigrants entitled to benefits may think they are not entitled or may find that they are denied servicefrom providers concerned about being reimbursed.
About a quarter of current elderly beneficiaries, however, did not work long enough and theywill not only lose access to SSI and food stamps but they could, depending on what happens in thestate they live, lose access to Medicaid. Elderly legal immigrants seeking public assistance after August22, 1996 are barred from applying for Medicaid for 5 years, after which they must include theirsponsor’s resources in their application. They will also be ineligible for food stamps and cashassistance until they are naturalized or unless they are able to find Social Security covered employmentfor 40 quarters.
Despite having worked, elderly legal immigrants were more likely than elderly citizens to bepoor. Elderly legal immigrants have lower incomes because they have, on avergae, fewer years ofeducation and language and cultural differences may have hindered employment opportunities. Thissuggests that if legal immigrants found work, it was more likely to be low-paying and without benefits. Limited employment opportunities make it that much more difficult to maintain an adequate level ofretirement income once one has left the labor force.
In the future, the proportion of poor elderly immigrants not eligible for public assistancedepends on how legal immigrants respond to the law and on their ability to find and maintainemployment. Future legal immigrants will be barred from Medicaid for five years and will require theinclusion of their sponsor s resources when they apply thereafter. Deeming of their sponsor sresources is likely to keep many elderly legal immigrants ineligible for assistance. Alternatively they willhave to become a citizen before applying for public assistance. Citizenship requires five years of legalresidency, being able to read and write simple English, and being able to answer basic questions aboutU.S. history and the government.29 Clearly, some of the same factors that hinder employmentopportunities, such as reading and writing English, may be barriers to obtaining citizenship.
Barring access to benefits for the first five years, and then until naturalization or until they haveaccumulated forty quarters of work, leaves substantial periods in which people are vulnerable. Accidents and illness can occur at any time. People at any age can find themselves in need of acute orlong-term care. Without public or private coverage, this care is beyond the financial means of virtuallyeveryone.
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 fundamentallychanged the nature of public assistance. Although the cuts in federal spending on public assistancewere relatively small, a substantial portion of the cuts fall on legal immigrants and their extended families. As shown in this profile, this public assistance is absolutely critical for many elderly legal immigrants. Given the concentration of elderly legal immigrants within families and specific communities, theimplications of these changes go beyond the elderly legal immigrant and their families, but will also affectthe citizens in communities in which they live.
1. Technically, the bar from Medicaid is five years, but applicants must include the resources of their sponsor after the five-year bar, for as long as they remain legal immigrants, or until they have worked and paid FICA taxes for at least forty quarters, which takes at least ten years. Legal immigrants are barred from Food Stamps and SSI until they become citizens (which takes a minimum of five years) or until they have paid FICA taxes for at least forty quarters.
2. Federal Budgetary Implications of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Congressional Budget Office, December 1996. Summary Tables 1 and 2.
3. Federal Budgetary Implications of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, Congressional Budget Office, December 1996. Summary Tables 1 and 2.
4. Ibid., Table 4.
5. The category of “unqualified aliens” includes nonimmigrants, applicants for asylum, registry, cancellation or removal, or adjustment of status, aliens granted deferred action, family unity, temporary protected status or an order supervision, and aliens “permanently residing under the color of law (PRUCOL).” See Charles Wheeler and Josh Bernstein, New Laws Fundamentally Revise Immigrant Access to Government Programs, National Immigration Law Center, November 8, 1996, p. 7.
6. “Qualified aliens” are lawful permanent residents, refugees, persons granted asylum, withholding of deportation, or conditional entrant status; persons paroled into the United States for at least a year, and certain battered spouses and children [PRA Sec. 431(b)].
7. The categories of immigrants who are exempt from this provision during their first five years in the country include refugees, people seeking asylum, and persons granted “withholding of deportation.” Also exempt are those legal immigrants who are active duty members of the U.S. Armed Forces or honorably discharged U.S. veterans and their spouses and unmarried dependent children. The bill also exempts immigrants who have worked forty quarters (ten years) in the United States [PRA Sec. 402(a)(2)]. Also exempt are Cuban and Haitian entrants, as defined in Section 501(e)(2) of the Refugee Education Assistance Act of 1980, who are paroled into the United States for at least one year [PRA Sec. 403(b)(1) and Sec. 403(b)(2)].
8. It should be noted that while refugees and those seeking political asylum are exempt from the bar on benefits for five years, it takes at least seven for them to become naturalized citizens. As of June 10, 1997 the Budget Reconciliation bill now moving through Congress, includes a provision to change the five year exemption for refugees, asylees, and persons granted withholding of deportation, to seven years.
9. See note 6 above.
10. Rachel L. Swarns, “Confused by Law, Nursing Homes Bar Legal Immigrants,” New York Times, April 20, 1997, A1.
11. Letter from Department of Health and Human Services Health Care Financing Administration to state Medicaid directors, October 4, 1996.
12. See footnote 6, above.
13. “Title XX of the Social Security Act provides block grants to the states that they use for a wide variety of purposes, including child care, in-home care for disabled persons, programs to combat domestic violence, programs for abused and neglected children, [etc.]” (Social Security Act, Title XX, 42 USC Sec. 303, et seq.).
14. Temporary Assistance for Needy Families or TANF replaced AFDC which provided cash assistance to low-income families with children. Most elderly, however, were not eligible for AFDC.
15. “The term ‘federal means-tested benefit’ is not defined in the final version of the legislation. The term was deleted from the bill because of a procedural rule that effectively prevents a budget bill from legislating on programs that do not involve direct spending. The term will likely be interpreted to include Medicaid and TANF services; other means-tested programs, such as food stamps and SSI, are barred to legal immigrants under separate provisions.” (Wheeler and Bernstein, Op. Cite., p. 15.)
16. Programs from which states are not allowed to deem a sponsor s income to the applicant’s income include emergency medical assistance; short-term, non-cash, in-kind emergency disaster relief; immunizations with respect to immunizable diseases and testing and treatment of symptoms of communicable diseases, whether or not such symptoms are caused by communicable disease; certain community-based programs, services, or assistance designated by the attorney general; school lunch and breakfast programs; and child nutrition programs [PRA Sec. 422(b)].
17. The same categories exempt from the five-year bar, except for veterans and their families, are also exempt from sponsor-to-alien deeming. Veterans are the only class of immigrants who are subject to deeming, but not to the five-year bar [PRA Sec. 421(a), Sec. 403(b)].
18. Projections for 1995 are based on data from the 1990 Census of Population and the 1993 Survey of Income and Program Participation (SIPP), and 1995 population estimates from the Current Population Survey.
19. In addition to the 7 states listed in Table 1, the following 9 states have elderly legal immigrants comprising more than 3 percent of their elderly population: Alaska, Arizona, Connecticut, District of Columbia, Hawaii, Maryland, Nevada, Rhode Island, and Washington.
20. In 1993, nearly 12 percent of elderly citizens and slightly less than 10 percent of elderly legal immigrants were in the paid labor force. National Academy on Aging tabulations of SIPP, 1993.
21. About 46 percent of legal immigrants and 14 percent of elderly citizens live in a household of three or more people. Elderly legal immigrants were more than twelve times as likely as elderly citizens to live in a household of five or more people. Over 25 percent of elderly legal immigrants lived in a household with a child, compared to less than 2 percent of elderly citizens. (National Academy on Aging tabulations of SIPP 1993.)
22. National Academy on Aging tabulations of SIPP, 1993.
23. National Academy on Aging tabulations of SIPP, 1993.
24. In 1990, 17 percent of elderly citizens and 36 percent of elderly legal immigrants indicated that they needed assistance with personal care. National Academy on Aging Tabulations of the 1990 Census Public Use Micro Data Sample.
25. See for example, Victor R. Fuchs, How We Live, (Cambridge, MA: Harvard University Press, 1983), or Michael Grossman, The Correlation Between Health and Schooling, in Household Production and Consumption, ed. Nestor E. Terleckyj, (New York: Columbia University Press, 1976), or Linda K. George, Social Factors and Illness, in Handbook of Aging and the Social Sciences, ed. Robert H. Binstock and Linda K. George, (New York: Academic Press, 1996).
26. National nursing home surveys in the past have not asked about the citizenship status of residents and most population-based surveys exclude the nursing home population. The 1990 census does note where people live. People living in a nursing home are designated as living in an institution. Unfortunately, the data does not distinguish a nursing home from any other type of institution (prison, hospital, assisted-living facility, or life care community, for example). Applying the proportion of the elderly legal immigrants living in institutions from the 1990 census data to the elderly nursing home population suggests that as many as 114,000 elderly nursing home residents during 1995 were legal immigrants. Adjusting for the likelihood that not all institutionalized people were only in nursing homes, however, suggests that the number of elderly legal immigrants in nursing homes was probably closer to 80,000.
27. In 1993, about 20,000 elderly legal immigrants were receiving veterans benefits from having served in the Military. (Academy tabulations of SIPP).
28. See note 6 for a summary of exemptions.
29. Throughout this paper the term “legal immigrant” has been used to describe people here in the United States legally, but under different visas. Technically, the holding of some visas do not count toward the five years of residency and hence some people must change their visa status and hold that status for five years. There are exemptions to the five-year residency requirement, however. For example, the time period is three years if married to an American citizen, or none in either the case of having served three years in the U.S. military, or having been discharged honorably after less than three years during specifically defined war actions. There are also some people exempt from the English language test, but not the exam of the basic understanding of U.S. history and government. The English language test is waived for persons over age 50 who have been a legal permanent resident alien for twenty years, or for persons age 55 or older if they have been a legal permanent resident alien for fifteen years, or for persons age 55 or older who cannot understand English because of a disability, such as deafness.
American Association for Homes and Services for the Aging. Issue Brief: Welfare Reform Act. 1996.
Committee on Ways and Means, U.S. House of Representatives. 1996 Green Book. Washington, DC: Government Printing Office, 1996.
Congressional Budget Office. Federal Budgetary Implications of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. Washington, DC: Congressional Budget Office, 1996.
Cox, Carole. Block Grants: Where We’ve Been and Where We’re Going. Washington, D.C.: National Academy on Aging, July 1995.
Fuchs, Victor R. How We Live. Cambridge, MA: Harvard University Press, 1983.
George, Linda K. “Social Factors and Illness,” in Handbook of Aging and the Social Sciences, Robert H. Binstock and Linda K. George, eds. New York: Academic Press, 1996.
Grossman, Michael. “The Correlation Between Health and Schooling,” in Household Production and Consumption, Nestor E. Terleckyj, ed. New York: Columbia University Press, 1976.
Moon, Marilyn, Crystal Kuntz, and Laurie Pounder. Protecting Low-Income Medicare Beneficiaries. The Commonwealth Fund, November 1996.
Social Security Act, Title XX, 42 USC, Sec. 303, et seq.
Swarns, Rachel L. “Confused by Law, Nursing Homes Bar Legal Immigrants.” New York Times. April 20, 1997, A1.
U.S. House of Representatives. Personal Responsibility and Work Opportunity Reconciliation Act of 1996. Washington, DC: Government Printing Office, 1996.
Peterson, George. “A Block Grant Approach to Welfare Reform.” In Welfare Reform: An Analysis of the Issues. The Urban Institute, 1995.
Super, David A., Sharon Parrott, Susan Steinmetz, and Cindy Mann. The New Welfare Law. Center on Budget and Policy Priorities, August 14, 1996.
Wheeler, Charles, and Josh Bernstein. New Laws Fundamentally Revise Immigrant Access to Government Programs. Washington, D.C.: National Immigration Law Center, November 8, 1996.
Welfare Reform and Elderly Legal Immigrants:
Part One Part Two