KFF designs, conducts and analyzes original public opinion and survey research on Americans’ attitudes, knowledge, and experiences with the health care system to help amplify the public’s voice in major national debates.
This case study of the evolution of Medicare managed care in Tampa-St. Petersburg, Florida, is one of four in a series being prepared by Mathematica Policy Research, Inc., for the Kaiser Family Foundation to examine the growth and impact of Medicare managed care. The Medicare risk (HMO) program has developed at different rates and with different degrees of success across the country. The four unique market areas selected for the project include two with high Medicare plan payment rates and two with moderate rates. The two with high adjusted average per capita cost rates (AAPCC) are Los Angeles and New York City. The two areas with more moderate AAPCC rates are Portland, Oregon and Tampa-St. Petersburg, Florida. Medicare managed care plans in Tampa-St. Petersburg have developed only recently, and they appear to be growing rapidly and prospering.
Que Es El Medicare Y Como Se Financia? Medicare es un programa de seguro medico nacional que atiende a 39 millones de ancianos y discapacitados. Antes de la existencia del Medicare, menos de la mitad de todos los norteamericanos de edad avanzada contaban con un seguro medico. Hoy en dia, practicamente todos los adultos de 65 anos de edad mayores se encuentran asegurados bajo Medicare. Medicare cubre a 34 millones de beneficiarios ancianos y a 5 millones de discapacitados. La cantidad de beneficiarios del Medicare se ha duplicado desde la concepcion del programa en 1965 y se estima que se volvera a duplicar en las siguientes tres decadas hasta alcanzar una cifra de 72 millones.
Americans Support Requiring Insurers To Cover Contraceptives, Even If Premiums Rise.
More Women and Men Say Contraceptives Should Be Covered Than Say Viagra
Embargoed for release until: 9:30 AM, ET, Friday, June 19, 1998
For further information contact: Tina Hoff or Matt James
Menlo Park, CA – Most Americans support requiring insurers to provide contraceptives as part of prescription coverage, even if premiums rise, according to a new national survey by the Kaiser Family Foundation. The public is also more likely to say contraceptives should be covered by insurers (75%) than Viagra, the new male impotence drug (49%).
Most Americans (62%) are not aware of proposals to require contraceptive coverage now before Congress. After learning that a “bill before Congress would require any health insurance plan with prescription coverage to pay for birth control methods just like any other prescription,” three quarters of Americans say they favor such a policy (45% “strongly favor” and 30% “somewhat favor” vs. 8% “strongly oppose” and 8% “somewhat oppose”). Both women and men (ages 18 and older) say contraceptives should be covered by insurers, though women (81%) are more likely to support such a policy than men (68%). Most (82%) who favor contraceptive coverage say all prescription methods currently on the market – oral contraceptives, IUDs or intra-uterine devices, Norplant implants, diaphragms, the injectable Depo-Provera, and cervical cap – should be paid for.
Support remains strong when people are told that contraceptive coverage could result in higher premiums. For example, when told that “the average cost individuals pay for health insurance could increase by $1-5 per month:” 43 percent “strongly favor” and 30 percent “somewhat favor,” vs. 12 percent “strongly oppose” and 8 percent “somewhat oppose.” Support drops somewhat, although a majority continues to favor contraceptive coverage, if premiums were to rise by larger amounts. For example, when asked their reaction if premiums were to rise by as much as $20 more per month: 30 percent “strongly favor” and 29 percent “somewhat favor,” vs. 19 percent “strongly oppose” and 13 percent “somewhat oppose.”
“Both men and women think comprehensive coverage for contraception makes sense; they think it should be part of prescription coverage, and they say they are willing to pay for it,” said Felicia H. Stewart, MD, Director of Reproductive Health Programs, Kaiser Family Foundation.
Americans More Mixed on Whether Viagra Should be Covered by Insurance
The new drug, Viagra, which sparked a recent debate over insurance coverage when it came on to the market earlier this Spring, draws more mixed views from Americans: 49 percent say the male impotence drug should be covered as part of prescription coverage; 40 percent say it should not be covered; and, 11 percent don’t know. Women (51%) are as likely to favor coverage of Viagra as men (47%).
Women of “Reproductive Age” and Privately Insured Supportive of Contraceptive Coverage
Women between the ages of 18-44, so-called “reproductive age,” are most supportive of legislation to require coverage of prescription contraceptives: almost nine out of ten favor such a policy (67% “strongly support” and 21% “somewhat support” vs. 4% “strongly oppose” and 5% “somewhat oppose”). There is no drop in support if the additional cost for providing this coverage falls in the low range ($1-5 per month) for an individual premium (87% support vs. 11% oppose); even at the higher range ($15-20 per month): 74 percent support (22% oppose). Women in this age range also are the most likely to say all methods should be covered (83%).
Three quarters of these women, who are most likely to use prescription contraceptives, say whether or not a certain method is covered by their insurance is something they would factor into their decision about what to use: 40 percent say coverage is “very” important, and 34 percent say “somewhat” in choosing birth control.
Family planning services, including contraceptives, are a required benefit under Medicaid, the public program that provides health coverage for low-income Americans. The contraceptive coverage proposal now before Congress applies to the privately insured population. Among this group, which would most directly benefit from the expanded coverage as well as potentially bear some of the additional costs if their insurer does not currently provide a full-range of contraceptive options, most support the policy. Eight out of ten privately-insured Americans, excluding those eligible for Medicare (65 and older), support contraceptive coverage (47% “strongly support” and 33% “somewhat support ” vs. 7% “strongly oppose” and 8% “somewhat oppose”). Even if their premiums were to go up, this group says they would still favor it ($1-5 per month: 78% support vs. 18% oppose; $15-20 per month: 64% support vs. 31% oppose). Women of reproductive age and the privately insured are no more likely than the average American to know that legislation has been proposed.
Methodology
The Kaiser Family Foundation 1998 National Survey on Insurance Coverage of Contraceptives is a random-sample telephone survey of 1,015 adults 18 and older living in the United States. It was designed by staff at the Foundation and Princeton Survey Research Associates (PSRA) and conducted by PSRA between May 22-26, 1998. The margin of sampling error is plus or minus 3 percent for the national sample; it may be higher for smaller sub-groups.
The Kaiser Family Foundation, based in Menlo Park, California, is an independent national health care philanthropy and is not associated with Kaiser Permanente or Kaiser Industries.
The questionnaire and top line from the survey are available by calling the Kaiser Family Foundation’s publication request line at 1-800-656-4533 (Ask for documents #1404). This release is also available on the Kaiser Family Foundation website at www.kff.org
Three reports examining how health issues are handled by the Latino-oriented media today and how Latinos use the media as an information source on health issues. The three new studies were released at the National Association of Hispanic Journalists (NAHJ) conference. The studies are also available separately: A National and Three Region Survey of Latinos on the Media and Health, conducted by Princeton Survey Research Associates (#1410), A Study of Health Coverage in Latino Newspapers, Television and Radio News, 1997-1998 (#1411), A Study of Sexual Health Coverage in Latino Magazines, 1997-1998 (#1412), Summary of the three reports (#1413).
This report assesses the potential impact of selected recommendations of the Managed Health Care Improvement Task Force in the areas of access to care and specialists, information disclosure, and dispute resolution. The Managed Health Care Improvement Task Force was established in 1998 to inform state leaders about the health industry in California; the impact of managed care on quality, access, and cost of care; issues of special concern to consumers; and the appropriate role of government in relation to managed care.
The Employee Retirement Income Security Act (ERISA) currently preempts state law related to the wrongful denial or delay of health benefits to the extent that such laws relate to a health benefit plan sponsored by a private employer. This report examines the frequency, nature and costs associated with the appeals and litigation that state and local governmental employers have experienced. Information was gathered through multiple telephone interviews with individuals with extensive involvement in administrative appeals and litigation experience of health benefit issues for these government-sponsored health benefit programs.
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.
Table 3Educational 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.
Footnotes
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.
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.
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).
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.
References
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.
Prepared for: The Henry J. Kaiser Family Foundation
The Henry J. Kaiser Family Foundation, based in Menlo Park, California, is an independentnational health philanthropy and is not associated with Kaiser Permanente or Kaiser Industries. Established in 1948 by industrialist Henry J. Kaiser and his wife Bess, the Foundation focusesits work on four main areas: health reform/health policy, reproductive health, HIV, and health anddevelopment in South Africa. The Foundation also maintains a special interest in health care inits home state of California.table of contents
Welfare reform, technically the Personal Responsibility and Work OpportunityReconciliation Act of 1996 (PRA), was signed into law on August 22, 1996. UnderPRA most legal immigrants arriving after August 22, 1996 will no longer be eligible forcash assistance and food stamps and are effectively barred from other services, including Medicaid, forat least a decade.1 Legal immigrants residing in the United States on August 22, 1996 will also losetheir entitlements unless they meet certain exemptions. A critical exemption enables legal immigrantswho have worked for forty quarters (10 years) in Social Security covered employment to retainbenefits. The various provisions concerning legal immigrants are complicated and the ensuing confusionhas already resulted in the denial of assistance to some qualified immigrants.
Relative to the federal budget, the reductions in welfare expenditures are modest. To theindividuals who depend on them they are of enormous importance. Most of the cuts come in the formof reduced benefits and time limits. The cuts for legal immigrants are especially severe: theCongressional Budget Office estimates that over the first six years the Personal Responsibility andWork Opportunity Reconciliation Act of 1996 will reduce federal spending by nearly $54.2 billion fromwhat would have been spent.2 About 44 percent of the total reductions ($23.8 billion) over the first sixyears, will be borne entirely by legal immigrants.
In 1995, there were an estimated 1.1 million legal immigrants age 65 or older. Elderly legalimmigrants are concentrated in a small number of states. In fact, more than one-half of the elderly legalimmigrant population lives in three states and 80 percent live in seven states. This suggests that thebroader economic consequences of these cuts will fall disproportionately on the citizens of communitieswith immigrant populations.
The portrait that emerges from the analysis suggests that the typical elderly legal immigrant didnot come to the United States because of its welfare programs. More than half of elderly legalimmigrants arrived in the United States over twenty years ago, and over three-quarters arrived prior totheir 65th birthday. Some elderly legal immigrants have served in the military, most have worked andpaid taxes, and more than three-quarters paid sufficient FICA taxes to earn Social Security andMedicare benefits. As a result, most elderly legal immigrants will not lose public assistance but the mostvulnerable those without Social Security and Medicare might lose some or all of their publicassistance. They are likely to lose SSI, food stamps, and other means-tested benefits. They could alsolose access to Medicaid, the principal source of nursing home care, depending on legislative andadministrative decisions made by each state.
Elderly legal imigrants are substantially more likely than elderly citizens to rely upon Medicaidbecause of their lower income levels. They are also more likely than elderly citizens to be uninsured. As a group, elderly legal immigrants were nearly twice as likely to live in households with incomesbelow the poverty level, and are more likely to be receiving some form of public assistance than elderlycitizens. The average family income among elderly legal immigrants is about half that of elderly citizens. Even among the working elderly, average monthly earnings for legal immigrants were about 66 percentless than elderly citizens. As a consequence, legal immigrants are nearly twice as likely to be poor aselderly citizens (24% versus 14%).
Elderly legal immigrants were found to be more likely than elderly citizens to have long-termcare needs. An estimated 80,000 to 90,000 nursing home residents in 1995 were elderly legalimmigrants; relying principally upon Medicaid to finance their care. The welfare reform law enacted lastyear permits states to discontinue Medicaid eligibility and coverage for legal immigrants, including thosein nursing homes. Those in nursing homes who lose Medicaid coverage have limited options. It isunlikely that the typical nursing home resident will have the physical and/or cognitive ability to become anaturalized citizen, in order to assure Medicaid coverage.Public assistance is critical for many elderly legal immigrants. Given the concentration of elderlylegal immigrants within families and specific communities, the implications of these changes go beyondthe elderly legal immigrant and their families, but will also affect the citizens in communities in which theylive.
Public assistance is critical for many elderly legal immigrants. Given the concentration of elderly legal immigrants within families and specific communities, the implications of these changes go beyond the elderly legal immigrant and their families, but will also affect the citizens in communities in which they live.
Introduction
Welfare reform, or technically the Personal Responsibility and Work OpportunityReconciliation Act of 1996 (PRA), was signed into law on August 22, 1996. This lawfundamentally changed the nature of federal public assistance by eliminating some federalentitlement programs and delegating to the states authority over who would be eligible to receive publicassistance. In addition, federal money provided to states and to beneficiaries for public assistance wasreduced. The Congressional Budget Office estimates that over the first six years the PersonalResponsibility and Work Opportunity Reconciliation Act of 1996 will reduce federal spending bynearly $54.2 billion.3 About 44 percent of the total reductions ($23.8 billion) over the first six years willbe borne entirely by legal immigrants. Eliminating legal immigrants from benefits reduces the federaldeficit annually by $5.1 billion when fully phased-in in 2002.4
Relative to the federal budget, these expenditure cuts are modest. However, to the individualswho depend on them they are of enormous importance. Elderly immigrants are particularly vulnerable,based on their service and their income needs. Analysis indicates that the majority of elderly legalimmigrants come to the U.S. long before they are elderly or in need of health or long-term care. Eliminating public support for these services especially for people already residing here impactsimmigrants, their extended families, and their communities, for circumstances beyond their control.
Elderly Immigrants and the Personal Responsibility and Work Opportunity Reconciliation Act
The Personal Responsibility and Work Opportunity Reconciliation Act (PRA) of 1996 eliminated theopen-ended federal entitlement program of Aid to Families with Dependent Children (AFDC) andreplaced it with Temporary Assistance to Needy Families (TANF), a block grant with a fixed amountof funding given to states to provide time-limited cash assistance to low-income families. The new lawalso fundamentally alters access to federal assistance for legal immigrants.
The PRA distinguishes between two classes of immigrants unqualified and qualified. Unqualified immigrants are effectively illegal immigrants and qualified are legal immigrants.5 Prior toPRA, illegal immigrants were not eligible for most federal means-tested benefits except for emergencymedical care, federally subsidized housing, and services related to the protection of life and safety. Illegal immigrants could, however, receive some forms of assistance by being categorized as”permanently residing under color of law” (PRUCOL). The new law eliminates this category, makingthem ineligible for benefits.
Under prior law, legal immigrants or those considered qualified in the PRA, could apply forpublic assistance.6 This too was changed under PRA. To understand these changes, one mustdifferentiate between legal immigrants who were receiving public assistance on August 22, 1996 andthose who were not. An overview of the changes in law are provided in Figure 1.
Figure 1Restrictions on Public Assistance to Immigrants Under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 Benefit Aliens permanently residing under color of law (PRUCOL)1 Legal Immigrants receiving benefits before August 22, 1996 Legal Immigrant that arrived before August 22, 1996, but not receiving benefits Legal immigrant arriving after August 22, 1996 Refugee Supplemental Security Income Immediate cut-off Cut off over the next year, unless in exempt category2 Ineligible until naturalization, unless in exempt category2 Ineligible until naturalization, unless in exempt category2 Eligible for first five years after entry, then denied until naturalization Food Stamps Immediate cut-off Cut off over the next year, unless in exempt category2 Ineligible until naturalization, unless in exempt category2 Ineligible until naturalization, unless in exempt category2 Eligible for first five years after entry, then denied until naturalization Medicaid Immediate cut-off State option to continue, unless in exempt category5 States have the option to bar coverage until naturalization5 Ineligible for first five years5 after entry, then subject to deeming.4 States have the option to bar coverage until naturalization.5 Eligible for first five years after entry, the state option to continue State and Local government assistance Immediate cut-off State option to continue, barring exemptions listed below State option to continue. State may require deeming State option to continue. State may require deeming4 Eligible for first five years after entry, then state option to continue1. Under prior law, certain illegal immigrants could be eligible for specific public benefits if they were considered to be “permanently residing under color of law” (PRUCOL). Under the new law, this category of immigrants has been eliminated, making this group like other illegal immigrants ineligible for benefits.
2. The following categories of immigrants are exempt from restrictions to SSI and Food Stamp programs during their first five years in the country: refugees, people seeking asylum, 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 law also exempts immigrants who have worked forty quarters (ten years) in the U.S.
3. Aliens exempt from the five-year bar include the same categories that were exempt from restrictions on SSI and Food Stamps. However, there is an additional exempt category of Cuban and Haitian entrants who are paroled into the U.S. for at least one year.
4. 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.
5. States must continue to provide Medicaid to legal immigrants who are veterans or on active military duty, refugees, and persons who have been granted asylum within the last five years, and those who have worked for at least ten years within the United States.
Current Legal Immigrants
The PRA would not change the eligibility for public assistance forlegal immigrants who meet specific exemptions. One of these exemptions is having worked for morethan forty quarters in Social Security covered employment. Since most elderly legal immigrants worked, they are more likely to be exempt. Legal immigrants whowere unable to work long-enough or who did not meet one of the other exemptions could lose benefitsor become ineligible to apply for benefits. If they were receiving benefits on August 22, 1996, benefitswill be terminated subsequent to a case-by-case review now underway to determine whether there isany basis for continued eligibility (for example, legal immigrants who served in the military or who havebeen in Social Security-covered employment for forty quarters).7 If they do not fall into one of thoseexempt categories and are not naturalized by the time their cases are reviewed, they will lose theirbenefits.8 Legal immigrants receiving Medicaid on August 22, 1996 continued to receive benefitsthrough January 1, 1997. After this date the State may decide whether to continue medical assistancethrough Medicaid for this group of immigrants (most states are expected to continue Medicaid for thisgroup). Elderly immigrants who arrived prior to the law s enactment (August 22, 1996), and who atthat time were not receiving assistance, immediately become ineligible for applying for food stamps andSSI, unless they, too meet one of the exemptions.9
Confusion over these provisions, however, has already resulted in nursing homes denyingaccess to legal immigrants with Medicaid coverage even when the state has made it clear that they willcontinue their Medicaid coverage.10 For current beneficiaries whose Medicaid was based on theirreceipt of SSI, however, the state will need to find another eligibility criterion (of which there areseveral) if they are no longer qualified for SSI.11 However, this process too could cause some elderlylegal immigrants to lose their access to Medicaid.
Future Legal Immigrants
Elderly legal immigrants arriving on or after August 22, 1996,are prohibited from receiving SSI or food stamps until they become naturalized citizens or fit one of theexemptions, such as working forty qualifying quarters (which takes a minimum of ten years).12 They arealso restricted from applying for Medicaid, Title XX-funded social services,13 Temporary Assistancefor Needy Families,14 and other federal means-tested benefits15 (other than SSI and food stamps), for aperiod of five years on entry into the U.S. as a legal immigrant (States have the option to extend thisrestriction until naturalization). After the five-year bar expires, legal immigrants must include thefinancial resources of their sponsor in their application for assistance.
This provision is called “deeming.”16 Given the low income and asset limits for means-tested programs such as Medicaid, “deeming,” is likely to keep most very poor legal immigrants from becoming eligible for assistance until they become citizens or fulfill some other criterion like working forty quarters in covered employment.17 Prior to PRA, legal immigrants were not barred from applying for assistance and although their sponsor s income was deemed, it was done for just the first three orfive years (depending on the public assistance sought).
The meaning of the PRA and the procedures needed to implement it are still subject to politicaldebate and judicial interpretation. The President and the Congress are revisiting some provisions inparticular, the elimination of benefits for current legal immigrants and the access to benefits for legalimmigrants here but not receiving benefits on August 22, 1996. The outcome is likely to impact currentelderly legal immigrants, but unlikely to change provisions for future elderly legal immigrants. To betterunderstand the consequences of this legislation, the following describes where and who elderly legalimmigrants are and their need for assistance.
A Profile of Elderly Legal Immigrants
The Size and Distribution of the Population
Nationally there are relatively few elderly legal immigrants. Census data suggest that in 1995 therewere about 1.1 million elderly legal immigrants.18 In 1995, elderly legal immigrants representedabout 3.2 percent of the country’s elderly population. Although elderly legal immigrants live in everystate, some states have a particularly high concentration. More than one-half of elderly legal immigrants(60.4 percent) lived in three states California, Florida, and New York. Adding Texas, New Jersey,Illinois and Massachusetts accounted for nearly 80 percent of elderly legal immigrants (see Table 1).
In most states, the elderly legal immigrant population constitutes less than 1 percent of theelderly population. However, in these seven states (see Table 1) and in nine others, whose numbers ofimmigrants are small, elderly legal immigrants are more than 3 percent of the state s elderlypopulation.19 For example, Hawaii has fewer than 14,000 elderly legal immigrants, but they constituteover 9 percent of the state s elderly population. Since the concentration of elderly legal immigrants isconsistent with that of legal and probably, illegal immigrants of all ages, the impact of the PRA on thecommunity is substantially larger than what just happens with elderly legal immigrants. Communitieswith a large proportion of people who need public assistance are less likely to have public and privateresources to assist those in need.
Table 1Distribution of Elderly Legal Immigrants Ranked by State, 1995. State Elderly Legal Immigrants Proportion of Elderly California 358,720 10.4% Florida 159,007 6.0% New York 157,778 6.5% Texas 74,466 3.9% New Jersey 49,416 4.5% Illinois 46,770 3.2% Massachusetts 34,145 4.0% All other States 237,254 1.2% Total 1,117,556 3.2%Source: National Academy on Aging estimates.
Demographic Characteristics
Table 2 provides a basic overview of the elderly legal immigrant population. Elderly legalimmigrants are primarily white, female, and between the ages of 65 and 74. About 61 percent ofelderly legal immigrants in 1993 were women and 68 percent were white. Compared to elderlycitizens, elderly legal immigrants are substantially more likely to be Asian or a Pacific Islander. Legalimmigrants are less likely to be married and living with their spouse, and are more likely than elderlycitizens to be widowed, divorced, separated, or never married.
Table 2Basic Demographics of Elderly Citizens and Legal Immigrants(Percentage Distribution) Race Legal Immigrants Citizens White 68.0 90.0 Black 2.5 8.5 Asian/Pacific Islander 29.4 1.3 Gender Legal Immigrants Citizens Male 39.0 42.0 Female 61.0 58.0 Age Legal Immigrants Citizens 65-74 60.0* 58.4* 75 and older 40.0* 41.6* Marital Status Legal Immigrants Citizens Married, spouse present 45.0 55.0 Widowed 37.0 33.0 Divorced, separated, or never married 14.8 11.1*The differences in age distributions were not statistically significant.Source: National Academy on Aging tabulations of the 1993 Survey of Income and Program Participation.
Figure 2 provides information on the country of origin of elderly legal immigrants. The largestnumber of elderly legal immigrants originated from Asia or a Pacific Island (29 percent), followed byEurope (19 percent), and then Mexico (18 percent). Another 11 percent were from Cuba, and lessthan 5 percent were from Central or South America.
When Did the Elderly Legal Immigrant Arrive in America?
People have expressed concern that elderly legal immigrants enter the United States after havingretired from the work force of their own country. While this assumption could be true for some, itdoes not hold for the majority of elderly legal immigrants. More than half of elderly legal immigrantsarrived in the United States over twenty years ago, and over three-quarters arrived prior to their 65thbirthday (see Figure 3). About 22 percent did arrive after they were age 65.
