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Healthcare Options for Immigrant Families

October 11, 2021 // Heavyn Jennings

The United States has a growing immigrant population. One in four children have an immigrant parent. 5% of children with US citizen parents in 2019 were uninsured. Uninsured rates increase to 9% for children with a noncitizen parent, 21% for children with green cards/Lawfully Permanent Residents (LPRs), and all the way up to 35% for undocumented children. Immigration status can be a barrier and has been shown to affect the ability to participate in health insurance options.

The barriers to accessing healthcare disproportionately affect Latino children. For Latino Children, 95% are citizens and about half have noncitizen parents. However, almost two-thirds of the uninsured Latino children in the US are in mixed status families, meaning some family members in the household are citizens and some are not. Despite insurance options being available for these children, fear and miscommunication may keep them from accessing available resources. In Tennessee, 5% of children were uninsured in 2019. This percentage skyrockets to 17.7%-the third highest of all states-among Latino children. This disparity should not exist since many of these children are eligible for coverage. TJC started the Insure Our Kids campaign in 2017 to help get all eligible children enrolled in TennCare and CoverKids. Learn more at insureourkids.org.

Healthcare Coverage Options for Mixed-Status Families in Tennessee

TennCare (Medicaid) and CoverKids (CHIP) is available to US citizens, US nationals, and qualified non-citizens, including US-citizen and qualified non-citizen children in mixed immigration status households. Social security numbers and other citizenship documentation is only needed for members of the household applying for coverage.

Qualified non-citizens is a complex term and many people who fall into this category have very specific requirements and limits on their eligibility for TennCare and CoverKids. This category includes LPRs, refugees, asylees, American Indians born in Canada, survivors of abuse and trafficking, and Afghan and Iraqi citizens granted Special Immigrant Status.

Notable restrictions for qualified non-citizens include LPRs/green card holders (unless they entered the US under one of the other qualified non-citizen categories) and survivors of abuse having to hold the status for 5 continuous years before they are eligible to apply for TennCare and CoverKids as well as Families First/TANF and SSI. This restriction is referred to as the five-year bar. Other groups such as certain refugees, asylees, and Afghan and Iraqi citizens granted Special Immigrant Status are only allowed to have TennCare/ CoverKids and SSI for 7 years. Once they reach the 7-year mark, they must be a US citizen, LPR, or associated honorably with the US Armed Forces for their coverage to continue. If they become an LPR, they are not subject to the five-year bar.

The qualified non-citizen category does not include undocumented non-citizens. It also does not cover Lawfully present non-citizens, which are those with temporary resident status, Temporary Protected Status, employment authorization, Deferred Action status (excluding Deferred Action Childhood Arrivals (DACAs)/Dreamers), or children with pending applications for Special Immigrant Juvenile status). Lawfully present non-citizens and qualified non-citizens subject to the 5-year-bar or seven-year limit can receive premium and cost-sharing assistance on health insurance through the Federal Marketplace at healthcare.gov. Click here for more detailed information.

Private insurance is available to all individuals without regard to citizenship status. Other notable coverage options are: CoverKids for pregnant women, Emergency Medical Services (EMS), and Children’s Special Services (CSS). CoverKids is available to all pregnant women in Tennessee who meet income requirements regardless of their citizenship. They get full CoverKids benefits for the duration of their pregnancy and 60 days postpartum.  EMS is available to individuals who would qualify for TennCare Medicaid but they do not meet the citizenship requirement. EMS covers life-saving procedures (excluding organ transplants) in which lack of treatment would lead to severe impairment or death.  CSS provides coverage for medical services and care coordination for those children who have qualifying diagnoses and meet the financial requirements. Children up to age 21 with special health care needs may qualify for CSS assistance. CSS has income limits, but there are no citizenship requirements.

How TN Can Increase Access and Enrollment for Non-Citizen and Mixed-Status families

We should implement policies like 12-month continuous eligibility, presumptive eligibility, and express lane eligibility to decrease child uninsured rates in Tennessee. Additionally, we should explore immigrant-specific policy changes and seek to raise awareness about existing coverage for mixed-status families.

Remove 5-year bar. Currently, LPRs/green card holders must have the status for five years before they are eligible for TennCare, CoverKids, Families First, SSI, and SNAP (unless under 18 or receive disability assistance). States are allowed to waive this requirement for children and pregnant women on Medicaid/CHIP. 35 states have waived the requirement for pregnant women and/or children. Tennessee has not waived this for children or pregnant women on Medicaid. However, as stated above, Pregnant women can get CHIP in Tennessee (and 16 other states) regardless of citizenship status. The Lifting Immigrant Families Through Benefits Access Restoration (LIFT the BAR) Act, sponsored by Congresswoman Pramila Jayapal (D-Washington-7), is the most recent piece of legislation pushing for the removal of the 5-year bar. It also restores public benefit eligibility for DACA recipients and those with Special Immigrant Juvenile Status. Lastly, it removes state authority to implement additional restrictions and adds flexibility for states to use their own funds to provide benefits.

Cover All Kids. To increase child enrollment, states can provide public health insurance options for all children regardless of immigration status. Seven states (California, Illinois, Massachusetts, New York, Oregon, Washington and the District of Columbia) already do this using state funds. Five other states (Connecticut, New Jersey, Utah, Virginia, Vermont) have submitted legislation to pursue this. Covering all children regardless of immigration status would help counter the chilling effect of anti-immigration legislation and ensure all children in this country are set up for success.

Combat the chilling effect. The first major anti-immigration legislation was the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) passed in 1996. This Act established the five-year bar for Medicaid, CHIP, TANF, SNAP, and SSI and other restrictions on public benefit programs. After it was enacted, immigrant families were hesitant to use public benefits. This created a chilling effect. The chilling effect can be described as the decreased use or hesitancy to use public benefits by immigrants and their families out of fear of negative consequences.

When DHS is deciding whether to give LPR status to some people or admit a noncitizen into the US, they can deny someone if they are deemed to be a “public charge”. This is an individual the government believes will rely heavily on government assistance. In determining the likelihood of someone becoming a public charge, they consider the person’s socioeconomic status and general demographics including age and disabilities. Many immigrants, particularly humanitarian immigrants such as refugees, asylees, and survivors of abuse, do not have to pass a public charge test.

The 2019 Department of Homeland Security (DHS) public charge rule introduced during the Trump Administration took anti-immigration to another level. It proposed that in addition to receipt of cash assistance usage of noncash assistance (Head Start, CHIP, Medicaid, ACA marketplace subsidies, SNAP, WIC, and even housing and utility assistance) should be considered to make public charge determinations. This meant children and elderly individuals, those with limited English and education, and individuals with certain medical conditions were at a disadvantage. It exacerbated the chilling effect. There was a widespread decrease in public benefit usage by mixed-status families. In 2020, one in five adults in immigrant families (including LPRs) with children reported that they or a family member avoided noncash government benefits or other assistance because of immigration concerns. This increased to 42.3% for adults in families with at least one nonpermanent resident. People avoided enrolling or even voluntary disenrolled their eligible children in public benefit programs like SNAP, Medicaid, CHIP out of fear it would lead to deportation or denials for green cards. The families in need of the most help were the most hesitant to get it. To make matters worse, the 2019 Public Charge rule was confusing. It was hard for families to locate accurate information. While the rule was only in effect for a short period, enrollment in public benefits started dropping very soon after it was introduced.

In March 2021, DHS issued a final rule saying that the 2019 public charge rule would be vacated and 1999 field guidance would be reimplemented. This means usage of SNAP, WIC, P-EBT, TennCare (unless for long-term care), CHIP, stimulus payments, child tax credit, unemployment benefits and housing assistance programs are not a factor for public charge determinations. Only usage of cash assistance for income maintenance and long-term care paid by Medicaid are considered in the DHS public charge determination. Lately, DHS has been hosting listening sessions to gather public feedback on what a public charge should look like. This is a step in the right direction, but it does not address the current chilling effect and fear left after the 2019 Public Charge rule. Best practices for combatting the chilling effect are trainings on public charge, resource documentation, partnerships and outreach, and relentless empathy for those who were affected by the 2019 Public Charge Rule.