Implementing Federal Health Reform in the States: Who Is Included and Excluded and What Are Their Characteristics?

Assessing the impact of the Patient Protection and Affordable Care Act (ACA) on increasing health insurance coverage rates in the United States requires careful estimation of the population that is excluded from its coverage expansions as a result of immigration status. If the size of ineligible populations is estimated incorrectly, then estimates of the size and characteristics of the eligible population will be incorrect and evaluations of the impact of the ACA coverage expansions will be underestimated. This is particularly true in states that have large immigrant populations such as California and Texas. The ACA enacted far-reaching changes to the U.S. health care system and has expanded access to health insurance coverage for millions of Americans. The ACA access expansions included the optional expansion of Medicaid eligibility for most nonelderly adults with family incomes up to 138 percent of the federal poverty level (FPL), the establishment of federal and state health insurance exchanges, and an individual mandate that all U.S. citizens and legal immigrants, with a few exceptions, purchase health insurance coverage or face financial penalties. The ACA is expected to expand health insurance coverage by 25 million people by 2017 (Congressional Budget Office [CBO] 2014). Yet, in spite of the ACA coverage expansions, some 30 million people are still expected to be uninsured in 2017 (CBO 2014). Some will be uninsured because they choose not to obtain coverage and some because they are specifically excluded from key elements of the ACA. Notably, most legal permanent residents (LPRs) residing legally in the United States for 5 years or less and unauthorized immigrants are, with few exceptions, ineligible for full-benefit Medicaid coverage. The 5-year waiting period was established in 1996 with the passage of the Illegal Immigration and Immigrant Responsibility Act and the Personal Responsibility & Work Opportunity Reconciliation Act (Fortuny and Chaudry 2011). The 5-year ban deems most LPRs (individuals with “green cards”) ineligible for full participation in means-tested federally funded programs, including Medicaid, for the first 5 years that they are LPRs. Under the ACA, LPRs subject to the 5-year ban are allowed to purchase coverage in the federal and state health insurance exchanges, are eligible for income-related subsidies, including tax credits and cost-sharing reductions, and are subject to the individual mandate. In addition, in states that opt to create a Basic Health Program under the ACA, recently arrived LPRs will qualify for coverage up to 200 percent of the FPL. Unauthorized immigrants are not allowed to purchase coverage in the federal and state health insurance exchanges and are exempt from the individual mandate under the ACA. Limited services for low-income unauthorized immigrants and recent LPRs are covered under Emergency Medicaid, and several states also cover pregnant women and children who are otherwise ineligible for Medicaid (Pintor and Blewett 2011). However, most low-income unauthorized and recent LPRs are excluded from full-benefit Medicaid. Table ​Table11 provides an overview of citizenship/immigration status and eligibility under the ACA. Table 1 Citizenship/Immigration Status and Eligibility under the ACA Due to the sensitivity of asking individuals about their legal resident status, few federal surveys collect this information. Most surveys, such as the Census Bureau's American Community Survey (ACS) and Current Population Survey (CPS) and the National Center for Health Statistic's National Health Interview Survey (NHIS), include questions about citizenship status, year of entry into the United States, and place of birth but do not ask legal status of those who are not citizens. One exception to this is the Census Bureau's Survey of Income and Program Participation (SIPP), which includes a question on immigration status as part of a series of questions focusing on migration history. The chief limitation of the SIPP is that it does not have the sample size for state-specific analyses and is not designed to support this type of inquiry; therefore, it is not a useful tool for state-specific policy research. To overcome these data limitations, we impute immigration status reported in the SIPP into the ACS. The ACS is an important resource for states to use when monitoring the impact of health reform because it was designed to be state representative, its sample covers every county and county equivalent in the United States, and the state sample size varies from 5,000 to 350,000 per state per year (U.S. Census Bureau 2010). It is the only federal survey capable of producing statistically reliable single-year state health insurance estimates for the entire age distribution. The Pew Hispanic Center and the Department of Homeland Security Office of Immigration Statistics (DHS) provide annual estimates of the number of unauthorized immigrants but have limited information on the characteristics of the unauthorized (Passel and Cohn 2009, 2011; Hoefer, Rytina, and Baker 2010). Although the PEW Hispanic Center provides estimates of unauthorized immigrants for all states, DHS only includes the top 10 immigration states in its annual public reports. In addition, these and other demographic analyses of immigration do not provide estimates of coverage expansion eligibility under the ACA (Wasem 2010; Warren and Warren 2013). The prevailing approach in these analyses is to use a residual estimation method to arrive at an estimate of unauthorized immigrants by state using data from either the CPS or ACS to estimate the size of the legal resident foreign-born population and then subtract that from the total foreign-born population (Passel and Cohn 2009). A more detailed description of the residual approach and our multiple imputation approach can be found in the technical appendix. Although there is published research that excludes those ineligible for ACA health reforms from eligibility and coverage estimates (Buettgens and Hall 2011; Buettgens, Holahan, and Carroll 2011; Clemans-Cope et al. 2012; Holahan et al. 2012; Kenney et al. 2012), or focuses on the national characteristics of unauthorized immigrants (Zuckerman, Waidmann, and Lawton 2011), ours is the only study that explicitly estimates the characteristics of those eligible and ineligible and shows the distribution of these populations at the state level. Characteristics including income and family size are used to estimate those eligible and ineligible for the ACA coverage expansions by state. Finally, we use the multiple imputation approach pioneered by Rubin (1996) to incorporate the error from the prediction model. The use of multiple imputation to combine information from distinct samples has been applied in other situations, such as imputing clinical information in the NHIS from the National Health and Nutrition Examination Survey (Schenker, Raghunathan, and Bondarenko 2010). In the remainder of the paper, we first discuss the SIPP, focusing on the immigration status variable that will be used for the imputation model and then the ACS which has asked questions on health insurance status since 2008. We describe the imputation model based on the SIPP and then apply the model to the ACS, comparing the size and composition of the populations predicted to be LPRs within the 5-year ban or unauthorized immigrants at the state and national level. We focus on the population targeted by the Medicaid expansion—nonelderly adults with family income at or below 138 percent of the FPL—and those targeted for subsidies in the health insurance exchanges—nonelderly adults with family income from 139 to 400 percent of the FPL.