Declining Immigrant Applications for Medi-Cal and Welfare Benefits in Los Angeles County

The 1996 federal welfare reform law (the Personal Responsibility and Work Opportunity Reconciliation Act, PRWORA) barred many legal immigrants from receiving food stamps and gave states a number of options to restrict immigrant eligibility for other benefit programs. In California, however, immigrant eligibility has not changed for AFDC/TANF (now CalWORKs), Medicaid (Medi-Cal in California) or the county-funded cash assistance program, General Relief.²

Nonetheless, the complex reforms introduced by the welfare law as well as related policy changes and practices may be having a chilling effect on immigrants' use of benefits for which they remain eligible. Legal immigrants may mistakenly believe they and their families are no longer eligible for AFDC/TANF and Medi-Cal.³ Immigrants may be concerned about new requirements that state agencies verify citizenship and immigration status and report undocumented immigrants to the Immigration and Naturalization Service. Immigrants may also fear that their own or their children's use of benefits will render them a "public charge" under immigration laws which, they may believe, would affect their ability to gain legal permanent residence, to naturalize or even lead to deportation. Recently immigrants have mistakenly been made to repay Medi-Cal benefits in order to gain legal permanent resident status or re-enter the country after a trip abroad. News of these events also may limit immigrants' willingness to apply for benefits.

The following analysis is based on administrative data from the Los Angeles County Department of Public Social Services. The data provide information on monthly approvals of applications for AFDC/TANF, Medi-Cal and General Relief for January 1996 to January 1998. The data show that the number of non-citizen monthly approvals for these benefits has dropped significantly since January 1996 while the number of citizen approvals has either remained the same or declined more moderately. Since immigrant eligibility for these benefits has not changed in California since January 1996, this decline appears to reflect fewer immigrants applying for assistance for which they remain eligible.⁴

1. Non-citizen approved applications fell dramatically following welfare reform. Approved applications by non-citizen families for AFDC/TANF and Medi-Cal declined sharply in the months following August 1996 when federal welfare reform became law. Since then, the number of monthly approvals of non-citizen-headed cases has remained lower than it had been through most of 1996. In the initial months of 1996, about 3,000 non-citizen headed cases were approved for AFDC/TANF and Medi-Cal each month, compared to about 1,500 for most of 1997.⁵ At the same time, the number of monthly approvals of citizen-headed cases remained the same at about 4,000 per month. Monthly approvals of non-citizen-headed cases therefore dropped by 52 percent between January 1996 and January 1998 while the number of citizen cases approved each month did not change (Table 1). The decline in total monthly approvals during those two years (-23 percent) is, therefore, entirely attributable to the decline in approvals of non-citizen-headed cases.

2. The number of legal immigrant-headed cases has dropped faster than undocumented cases. The drop in approved applications was greater for cases headed by a legal immigrant than for cases headed by an undocumented immigrant (-71 vs. -34 percent) where an ineligible undocumented parent typically applies only for her citizen child (Table 1). One possible explanation for the sharper decline among legal than undocumented immigrants is that during 1996 and 1997 large numbers of legal immigrants naturalized those people would, of course, apply as citizens rather than non-citizens.⁶ It is also possible that many legal immigrants did not understand that although their eligibility for food stamps had changed, their eligibility for TANF/AFDC and Medi-Cal had not. Additionally, there may have been widespread (mistaken) concern among legal immigrants that using public benefits would hurt their chances for naturalization.

3. The number of citizen children applying for AFDC/TANF and Medi-Cal declined. Because so many non-citizen adults have U.S.-born citizen children, the drop in approvals of non-citizen- headed cases has led to fewer citizen children receiving assistance.⁷ The number of newly approved citizen children of non-citizen parents for AFDC/TANF and Medi-Cal dropped by 48 percent between January of 1996 and 1998, compared to almost no change (6 percent increase) for citizen children of citizen parents (Table 2). Since the vast majority of those receiving AFDC/TANF and Medi-Cal in Los Angeles receive food stamps as well, these drops also reflect a decrease in applications for food stamps by citizen children who remain eligible for them. The cumulative impact of this decline in approved applications may be significant: nearly 25,000 more children would have applied and been approved for AFDC/TANF and Medi-Cal between December 1996 and January 1998 if the number of citizen children of immigrant parents had remained at about the same level as it had been in January to November 1996.

4. Fewer non-English speakers have applied and been approved for benefits. Data on monthly approvals by primary language of the applicant tell a similar story. Between January 1996 and January 1998, the number of cases approved in which the applicant's primary language is Spanish fell by 46 percent while it fell by only 9 percent for English speakers. For the much smaller group who speak an Asian language the number fell by 59 percent (Table 3).

5. The number of non-citizens applying for "Medi-Cal-only" benefits decreased. The number of persons applying for only Medi-Cal because they are ineligible for cash or food assistance has also dropped faster for non-citizens than citizens. Between 1996 and 1998 non-citizens approved each month for "Medi-Cal-only" dropped by 24 percent while citizen approvals stayed virtually flat, falling by only 7 percent (Table 4). The drop in applications among immigrant families is even higher, however, when the citizen children of immigrant adults (who are included in the citizen column) are considered.⁸ The full decline in non-citizen enrollment in Medi-Cal encompasses both the drop in Medi-Cal-only applications the decline in non- citizens plus their citizen children (Table 4) and the drop in applications for AFDC/TANF and Medi-Cal (Tables 1 and 2). Further, the decline in enrollment of undocumented immigrants in Medi-Cal-only (who make up about twenty percent of all approvals) means that welfare reform and related policies appear to be having an impact not only on legal immigrants' use of regular Medi-Cal but also on undocumented immigrants' use of emergency medical services and prenatal care.

6. Non-citizen applications for General Relief also decline. Similarly, the number of non- citizens approved on a monthly basis for General Relief, Los Angeles's safety net assistance program, declined more than twice as fast as the number of citizens. While the number of citizens newly approved for General Relief fell 22 percent between January 1996 and January 1998, the number of non-citizens dropped 47 percent during the same time period (Table 5).

These findings raise questions about a number of broader policy issues, including rising uninsurance rates and federal, state and local efforts to increase health insurance coverage among children. The federal government recently created the Child Health Insurance Program (CHIP), called Healthy Families in California, which provides funding to states to expand health insurance for low-income children. L.A. County recently adopted a plan to enroll 100,000 more children in Medi-Cal by September 1999 (the Los Angeles County Child Medi-Cal Enrollment Project) a goal that may be difficult to reach if Medi-Cal enrollment of children in immigrant families remains low. A recent GAO report found that most uninsured children in California are children of immigrants: in 1996, 73 percent of uninsured Medicaid-eligible children in California were either foreign-born or had a foreign-born parent.⁹ To include the children of immigrants in efforts such as these, policy reforms and outreach efforts will need to take issues specific to immigrant families such as a misunderstanding of immigrant eligibility rules and concerns over public charge laws into account.

These data also may have implications for the current debate over declining welfare caseloads. Although an initial examination of Los Angeles's AFDC/TANF caseload data for January 1995 to April 1997 does not suggest that the number of non-citizens receiving welfare has fallen faster than the number of citizens, it may be too soon to tell if the drop in immigrant applications is contributing to declines in overall caseloads.

Tables

Table 1. Cases Newly Approved for AFDC/TANF with Medi-Cal in Los Angeles County by Immigration Status of Household Head*: January 1996-January 1998

Table 2. Children Newly Approved for AFDC/TANF with Medi-Cal in Los Angeles County by Immigration Status of Household Head*: January 1996-January 1998

Table 3. Cases Newly Approved for AFDC/TANF with Medi-Cal in Los Angeles County by Primary Language*: January 1996- January 1998

Table 4. Persons Newly Approved for Medi-Cal-Only* in Los Angeles County by Immigration Status: January 1996- January 1998

Table 5. Persons* Newly Approved for General Relief in Los Angeles County by Citizenship Status: January 1996- January 1998

Notes

1. This analysis was funded by the Office of the Assistant Secretary for Planning and Evaluation, the Administration for Children and Families and The Health Care Financing Administration(now known as Centers for Medicare and Medicaid Services(CMS)), U.S. Department of Health and Human Services, The Food, Nutrition and Consumer Services and the Economic Research Service, U.S. Department of Agriculture, and the Immigration and Naturalization Service.

2. PRWORA gave states the option of providing TANF and Medicaid to immigrants who had entered the United States by August 22, 1996. It barred immigrants who enter the country after that date from receiving any federally-funded TANF and Medicaid for their first five years in the country. California has opted to provide TANF and Medi-Cal to immigrants in the United States regardless of date of entry and is using state funds to pay for benefits to newly entering immigrants during the five year bar. California has not implemented new Medi-Cal eligibility restrictions on certain immigrants who were formerly considered permanently residing under color of law, or PRUCOL. Undocumented immigrants were, and continue to be, ineligible for TANF and General Relief and are eligible for only emergency services under Medicaid. California continues to provide state-funded pre-natal care under Medicaid to undocumented women. Governor Wilson's efforts to end this pre-natal care have been blocked by litigation.

3. Although most of its provisions have been held up by litigation, California's Proposition 187, which attempted to restrict undocumented immigrants' access to a wide array of public services, may also have contributed to confusion and misunderstanding of eligibility rules.

4. During the time period examined (January 1996 to January 1998) the overall number of applications for AFDC/TANF and Medi-Cal declined while the overall denial rate did not change. These trends are consistent with the observation that falling numbers of approved applications for immigrants and their families are a product of declining numbers of applications. Data are not available, however, on application denial rates by immigration status. In addition, no general eligibility or program changes to AFDC/TANF were implemented during the period examined. Los Angeles County began implementing its new welfare-to-work program, CalWORKs, in April 1998.

5. In Los Angeles County, a family can apply for AFDC/TANF, Medi-Cal and food stamps using only one application. Everyone who is eligible for AFDC/TANF is also eligible for Medi-Cal and most also receive food stamps, excluding non-citizens who were made ineligible for them under the federal welfare reform law. Data on case approvals for AFDC/TANF and Medi-Cal combine all members of a household (usually the parent (s) and children). A non-citizen-headed case is one where the "first adult" in the household is a non-citizen; a citizen-headed case is one where the first adult is a citizen. Data on children approved for AFDC/TANF and Medi-Cal (Table 2), on General Relief (Table 5) and on "Medi- Cal-only" (Table 4) are for individuals and reflect each person's immigration status.

6. It cannot be determined, however, how much of the decline in approved applications is accounted for by rising naturalization, though it is unlikely to account for the steep drop in the number of legal-immigrant headed cases.

7. In the Los Angeles metropolitan area, sixty-three percent of children in families with incomes below 200 percent of the federal poverty level had at least one non-citizen parent and one citizen child. March 1997 Current Population Survey, Urban Institute tabulations.

8. We cannot tell how many of the citizens in column 1 of Table 4 are the children of immigrants since the Medi-Cal-only data are not available by alien status of household head. The change in applications for Medi-Cal-only, therefore, cannot be compared to that for AFDC/TANF with Medi-Cal (in Table 1) since the Medi-Cal-only data are presented for individuals while the AFDC/TANF with Medi-Cal data are presented for families (cases), by immigration status of the household head.

9. The proportion of uninsured children who had a non-citizen parent (as opposed to foreign- born), which was not included in the report, would be somewhat lower. The report used data from the Current Population Survey (CPS) for its analysis. U.S. General Accounting Office, "Medicaid: Demographics of Nonenrolled Children Suggest State Outreach Strategies," GAO/HEHS-98-93, March 1998.