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Item O6BOARD OF COUNTY COMMISSIONERS AGENDA ITEM SUMMARY Meeting Date: _September 16, 2009 Bulk Item: Yes X No Division: BOCC Department: DIST 3 Staff Contact Person/Phone #: C. Schreck x 3430 AGENDA ITEM WORDING: Approval of a resolution of the Board of County Commissioners for Monroe County, Florida, urging immediate passage of comprehensive federal health reform legislation ITEM BACKGROUND: Congress is considering comprehensive federal health reform legislation. The National Association of Counties maintains county governments are integral to America's current health system and will be crucial partners in achieving successful reform. They have requested county governments consider passing resolutions urging the passing of comprehensive federal health reform legislation. PREVIOUS RELEVANT BOCC ACTION: CONTRACT/AGREEMENT CHANGES: STAFF RECOMMENDATIONS: TOTAL COST: 0 INDIRECT COST: 0 BUDGETED: Yes No COST TO COUNTY: 0 SOURCE OF FUNDS: na REVENUE PRODUCING: Yes No x AMOUNT PER MONTH Year APPROVED BY: County Atty x OMB/Purchasing Risk Management DOCUMENTATION: DISPOSITION: Revised 1/09 Included x Not Required AGENDA ITEM # RESOLUTION NO. -2009 A RESOLUTION OF THE BOARD OF COUNTY COMMISSIONERS FOR MONROE COUNTY, FLORIDA, URGING IMMEDIATE PASSAGE OF COMPREHENSIVE FEDERAL HEALTH REFORM LEGISLATION WHEREAS, experts from across the political spectrum agree that ,America's health system is deficient and financially unsustainable in its present configuration; and WHEREAS, families in Monroe County are experiencing this crisis right now, confronting the high cost of health care that threatens their financial stability, leaves them exposed to higher premiums and deductibles, and puts them at risk for a possible loss of health insurance; and WHEREAS, employer -sponsored health insurance premiums have nearly doubled in recent years making it increasingly difficult for employers, including county governments, to provide health insurance coverage for their employees and retirees; and WHEREAS, millions of Americans do not have health coverage, or have inadequate coverage and as our economic challenges multiply, the problem of health care access grows, further straining counties' capacity to provide care for the uninsured, underinsured and medically indigent; and WHEREAS, data collected from the 2007 Monroe County Health Risk Survey data indicates that 25% of those surveyed were diagnosed with hypertension, 37% with high cholesterol, 12% with diabetes and 9% reported suffering from heart attack, angina or stroke; and WHEREAS, the Florida Keys are experiencing a 6.2% unemployment rate (May 2009); and WHEREAS, an estimated 25% of the residents of the Florida Keys have no health insurance; and WHEREAS, county officials are elected to protect the health and welfare of their constituents: and WHEREAS, 60% of Monroe County's contribution to the Health Department can be allocated to direct patient care; and WHEREAS, the clinical/public health programs of Monroe County cost approximately $4,000,000; and WHEREAS, Monroe County also contributes the following to countywide non- profit health service agencies; Rural Health Network ($333,600), Womankind ($70,000), Good Health Clinic ($35,000), Florida Keys Area Health Education Center ($35,000 - children's medical services), AIDS Help ($25,500 - health care services for folks with HIV/AIDS), Florida Keys Healthy Start ($5,000 - health care screenings, preventive services, and education to pregnant women and toddlers), Easter Seals ($10,000 - special health care services for disabled), and Guidance Clinic/Care Center ($1,060,520 — mental health care); and WHEREAS, Monroe County's Prison Health Services costs approximately $2,600,000 per year; and WHEREAS, the Monroe County Health Department is currently covering revenue shortfalls through reserve funds, depleting those funds and expecting a $300,000 deficit for these programs this fiscal year; and WHERE AS, the Monroe County Health Department is requesting a budget increase from the county to avoid cutting back on services and to be prepared for a potential swine flu vaccination of county residents; and WHEREAS, the National Association of Counties (NACo) Health System Reform Working Group, appointed by President Don Stapley in July 2008 and chaired by President -Elect Valerie Brown, has held three regional hearings to explore the health crisis and to hear what county officials believe should be done about it and has summarized its findings in Restoring the Partnership for American Health: Counties in a 21" Century Health System which was approved and adopted by resolution of the NACo Health Steering Committee and Board of Directors on March 9, 2009. NOW THEREFORE BE IT RESOLVED by the Board of County Commissioners of Monroe County that: Section 1. The Board of County Commissioners of Monroe County hereby endorses NACo's health reform principles, as summarized in Restoring the Partnership for American Health: Counties in a 21" Century Health System; namely, that reform legislation should A. restore the partnership between county and federal governments; B. provide access to affordable, quality health care to all; C. invest in public health, including health promotion and disease and injury prevention; D. stabilize and strengthen the local health care safety net system, especially Medicaid and disproportional share hospital (DSH) payments; E. invest in the development of the health professional and paraprofessional workforce; F. ensure that county health agencies have the resources to meaningfully use health information technology; G. enable elderly and disabled persons to receive the services they need in the least restrictive environment; and H. reform the delivery and financing of health services in the jail system. Section 2. The Board strongly urges the 1111h Congress of the United States to enact comprehensive health reform legislation without delay before the end of its first session. Section 3. Upon adoption, the County Clerk is hereby directed to send a copy of this Resolution by United States mail to National Association of Counties c/o Ed Rosado, P.O. Box 549, Tallahassee, Florida 32302-0549; Congresswoman Reana Ros-Lehtinen, 2470 Rayburn H.O.B., Washington, DC 20515-0918; Senator Bill Nelson, United States Senate, 716 Senate Hart Office Building, Washington, DC 20510; and Senator Lemieux, United States Senate, 356 Russell Senate Office Building, Washington, DC 20510. Section 4. This Resolution shall be effective as of the date of its adoption. PASSED AND ADOPTED by the Board of County Commissioners of Monroe County, Florida, at a regular meeting of said Board held on the day of , 2009. Mayor George Neugent Mayor Pro Tern Sylvia Murphy Commissioner Heather Carruthers Commissioner Mario DiGennaro Commissioner Kim Wigington ATTEST: Danny L. Kohlage, Clerk Deputy Clerk BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA Mayor George Neugent r�WNRCiE COUNTY AT TOLE N EY APPROVED AS . O M. N r 0 All National Association of Counties The Voice of America's Counties Restoring the Partnership for American Health Counties in a 21 st Century Health System Full Partners: County governments are integral to America's current health system and will be crucial partners in achieving successful reform. At the most basic level, county officials are elected to protect the health and welfare of their constituents. County governments set the local ordinances and policies which govern the built environment, establishing the physical context for healthy, sustainable communities. County public health officials work to promote healthy lifestyles and to prevent injuries and diseases. Counties provide the local health care safety net infrastructure, financing and operating hospitals, clinics and health centers. County governments also often serve as the payer of last resort for the medically indigent. County jails must offer their inmates health care as required by the U.S. Supreme Court. Counties operate nursing homes and provide services for seniors. County behavioral health authorities help people with serious mental health, developmental disability and substance abuse problems who would have nowhere else to turn. And as employers, county governments provide health benefits to the nearly three million county workers and their retirees nationwide. Clearly, county tax payers contribute billions of dollars to the American health care system every year and their elected representatives must be at the table as full partners in order to achieve the goal of one hundred percent access and zero disparities. Local Delivery Systems — Access for All: NACo believes that reform must focus on access and delivery of quality health services. Coverage is not enough. County officials, particularly in remote rural or large urban areas know that even those with insurance may have difficulty gaining access to the services of a health care provider, which can be exacerbated by the severity of their illness. Local delivery systems should coordinate services to ensure efficient and cost-effective access to care, particularly primary and preventive care, for underserved populations. County governments are uniquely qualified to convene the appropriate public and private partners to build these local delivery systems in a way that will respect the unique needs of individuals and their communities. A restored federal commitment to such partnerships is necessary for equity's sake. Public Health and Wellness: NACo believes that a greater focus on disease and injury prevention and health promotion is a way to improve the health of our communities and to reduce health care costs. Disease and injury prevention and health promotion services can be delivered by a health care professional one patient at a time. Local health departments, in partnership with community based organizations and traditional health care providers, deliver community -based 25 Massachusetts Avenue, NW/Suite 500/Washington, DC20001 /202.393.6226/Fax 202.393.2639/www.naeo.orz prevention services targeted at an entire population. Population -based prevention services can save money by keeping people healthy and reducing the costs of treating unchecked chronic disease. These critical services include assessment of the health status of communities to identify the unique and most pressing health problems of each community and health education to provide individuals with the knowledge and skills to maintain and improve their own health. The public health response to emergencies should be fully integrated into each county's emergency management plan. Local public health considerations likewise should be systematically integrated into land use planning and community design processes to help prevent injuries and chronic disease. Policies are also needed to address health inequity, the systemic, avoidable, unfair and unjust differences in health status and mortality rates, as well as the distribution of disease and illness across population groups. Investing in wellness and prevention across all communities will result in better health outcomes, increased productivity and reduce costs associated with chronic diseases. Expanding Coverage: NACo supports universal health insurance coverage. Existing public health insurance systems should be strengthened and expanded, including Medicare, Medicaid and the State Children's Health Insurance Program (SCHIP). As states and counties attempt to shoulder their legislatively mandated responsibilities to provide care for the indigent and uninsured, federal regulatory barriers should be removed to allow flexibility and innovation at the local level. Furthermore, in the effort to expand coverage, reformers should not forget that the coverage must be meaningful, without imposing additional mandates on county governments. The benefit package must be defined so as to provide the full range of services people need, including prevention services, full parity for behavioral health, substance abuse and developmental disability services. Barriers to cost-effective treatments, like living organ donation, should be removed. Maintaining a Safety Net: NACo believes that the intergovernmental partnership envisioned in the Medicaid statute should be restored and strengthened. Local safety nets constructed under Medicaid should not be dismantled to "pay for" universal coverage. We must not allow the safety net infrastructure to be undermined. County hospitals and health systems, in particular, will continue to need extra support to carry out their missions to reduce disparities and serve underserved populations. Health Workforce: NACo believes that the health professional and paraprofessional workforce must be supported and enhanced. Every effort should be made to recruit, train, license and retain health professionals, and allied professionals and paraprofessionals, on an expedited basis. A large body of evidence supports the contribution of direct care staff, nurses and nursing assistants, to quality outcomes. Funding for existing education and training programs — in secondary, post -secondary and vocational educational settings — should be increased and targeted towards initiatives to expand and diversify the health workforce. Partnerships between local economic developers and workforce development professionals should be encouraged to meet growing health care sector demand. Targeted incentives including scholarships, loan forgiveness and low -interest loan repayment programs should be developed to encourage more providers to enter and remain in primary care and public health careers. Primary care providers should be empowered to — and compensated for — case management services. Health IT: The federal government should support the integration of health information technologies into the local health care delivery system. NACo supports the President's goal of implementing a nation-wide system of electronic health records in five years. NACo supports efforts to promote the use of a range of information technologies to facilitate appropriate access to health records and improve the standard of care available to patients, while protecting privacy. This includes deployment of broadband technologies to the widest possible geographic footprint. Other tools facilitate evidence -based decision making and e- prescribing. Using broadband technologies, telemedicine applications enable real-time clinical care for geographically distant patients and providers. Remote monitoring can also facilitate post -operative care and chronic disease management without hospitalization or institutionalization. Long Term Care: Federal policies should encourage the elderly and disabled to receive the services they need in the least restrictive environment. Since counties provide and otherwise support long term care and other community based services for the elderly and disabled, state and federal regulations and funding programs should give them the flexibility to support the full continuum of home, community -based or institutional care for persons needing assistance with activities of daily living. Nursing home regulatory oversight should be reformed in order to foster more person -centered care environments. Jail Health: Reforming America's health care system must include reforms to its jail system. Counties are responsible for providing health care for incarcerated individuals as required by the U.S. Supreme Court in Estelle v. Gamble, 429 U.S. 97 (1976). This unfunded mandate constitutes a major portion of local jail operating costs and a huge burden on local property tax payers. The federal government should lift the unfunded mandate by restoring its obligation for health care coverage for eligible inmates, pre -conviction. Furthermore, a true national partnership is needed to divert the non-violent mentally ill from jail and into appropriate evidence -based treatment in community settings, if possible. Finally, resources should be made available to counties to implement timely, comprehensive reentry programs so that former inmates have access to all the health and social services, including behavioral health and substance abuse treatment, to avoid recidivism and become fully integrated into the community. CLINICAL RESEARCH STUDY Medical Bankruptcy in the United States, 2007: Results of a National Study David U. Himmelstein, MD,' Deborah Thorne, PhD,b Elizabeth Warren, JD,` Steffie Woolhandler, MD, MPHa "Department of Medicine, Cambridge HospitalJHarvard Medical School, Cambridge, Mass; Department of Sociology, Ohio University, Athens; and `Harvard Law School, Cambridge, Mass. BACKGROUND: Our 2001 study in 5 states found that medical problems contributed to at least 46.2% of all bankruptcies. Since then, health costs and the numbers of un- and underinsured have increased, and bankruptcy laws have tightened. METHODS: We surveyed a random national sample of 2314 bankruptcy filers in 2007, abstracted their court records, and interviewed 1032 of them. We designated bankruptcies as "medical" based on debtors' stated CONCLUSIONS: Illness and medical bills contribute to a large and increasing share of US bankruptcies. © 2009 Elsevier Inc. All rights reserved. • The American Journal of Medicine (2009) 122, 741-746 As recently as 1981, only 8% of families filing for bank- ruptcy did so in the aftermath of a serious medical problem.' By contrast, our 2001 study in 5 states found that illness or medical bills contributed to about half of bankruptcies. Since then, the number of un- and underinsured Ameri- cans has grown;3 health costs have increased; and Congress tightened the bankruptcy laws.¢ Here we report the first -ever national random -sample survey of bankruptcy filers. Authorship: All authors had access to the data and a role in writing the manuscript. Requests for reprints should be addressed to David U. Himmelstein, MD, Department of Medicine, Cambridge Hospital/Harvard Medical School, 1493 Cambridge Street, Cambridge, MA 02139. E-mail address: dimmelstein@challiance.org 0002-9343/$ -see front matter © 2009 Elsevier Inc. All rights reserved. doi: 10. 1016/j.amjmed.2009.04.012 METHODS We used 3 data sources: questionnaires mailed to debtors immediately after bankruptcy filing; court records; and tele- phone interviews with a sub -sample of debtors. Sample Design Between January 25 and April 11, 2007, we obtained from Automated Access to Court Electronic Records, a list of all 118,308 bankruptcy petitions filed in the US. We excluded filings in Guam and Puerto Rico, nonpersonal bankruptcies, and cases missing a name or address. Within 2 weeks of their filings, we mailed introductory letters to 5251 ran- domly selected debtors; 275 were returned as undeliverable. We then mailed self-administered questionnaires to the 4976 debtors with valid addresses; 2314 (46.5%) were com- pleted and returned; 124 were returned incomplete (2.5%); and 83 (1.7%) declined to participate; 2455 (49.3% of those with valid addresses) did not respond. We compared court records (described below) of respon- dents with a random sample of 99 nonrespondents. Nonre- 742 The American Journal of Medicine, Vol 122, No 8, August 2009 spondents resembled respondents in income, assets, debts, net worth, market value of homes, and history of prior bankruptcy. Questionnaire Introductory letters described the study and offered debtors the op- tion of obtaining a Spanish -lan- guage version of the question- naire. The questionnaire and $2 were mailed a few days later. Non - respondents received replacement questionnaires, another $2, and were invited to respond via telephone or on-line. Subsequently, we offered nonrespondents $50 to complete the questionnaire. The questionnaire asked about demographics, health insurance, and gaps in coverage, occupa- tion, employment, housing, and efforts to cope financially before filing. It also asked about specific reasons for filing for bankruptcy; the range of out-of-pocket medical expense (none, $1-$999, $1000- $5000, or >$5000); loss of work -related income; and borrowing to pay medical bills. Finally, it asked respon- dents if, for $50, they would be willing to complete a follow-up interview. Court Records We obtained the public bankruptcy court records of respon- dents and the sample of nonrespondents from the federal court's electronic filing system. Research assistants (mainly law students) abstracted each record. The court records included the chapter of filing, income, assets, and debts outstanding at the time of filing. These records indicate the creditor to whom money is owed, but not why the debt was incurred. Telephone Interviews There were 2314 debtors who completed questionnaires, 2007 of whom were willing to be interviewed. By February 2008, research assistants had completed telephone inter- views (in English or Spanish) with 1032 of them; 69 debtors no longer wished to be interviewed. We were unable to reach 906. Interviewers collected additional detail about employ- ment, finances, housing, borrowing to pay medical bills, and whether medical bills or income loss due to illness had contributed to their bankruptcy (questions we used to verify written questionnaire responses from the entire sample of 2314 debtors). The 1032 telephone interviews identified 639 patients (debtors or dependents) whose health problems contributed to bankruptcy; details about medical expenses, health insur- ance, and diagnoses were obtained. Two physicians grouped diagnoses into 14 categories. Telephone survey participants resembled other respon- dents on most financial and demographic characteristics. They were slightly older and better educated. Data Analysis We used data from the question- naires and court records to analyze demographics, health insurance coverage at the time of filing, and gaps in coverage. The questionnaires were the basis for our 2001-2007 time trend analysis. For this analysis, we rep- licated the most conservative de- finition employed in the 2001 study, which designated as "med- ically bankrupt" debtors citing ill- ness or medical bills as a specific reason for bankruptcy; OR report- ing uncovered medical bills >$1000 in the past 2 years; OR who lost at least 2 weeks of work -related income due to illness/injury; OR who mortgaged a home to pay medical bills. Debtors who gave no answers regarding reasons for their bankruptcy were excluded from analyses. For all other analyses (ie, those not reporting time trends) we adopted a definition of medical bankruptcy that utilizes the more detailed 2007 data. We altered the 2001 criteria to include debtors who had been forced to quit work due to illness or injury. We also reconsidered the question of how large out-of-pocket medical expenses should be before those debts should be considered contributors to the fa- mily's bankruptcy. Although we needed to use the threshold of $1000 in out-of-pocket medical bills for consistency in the time trend analyses, we adopted a more conservative threshold—$5000 or 10% of household income —for all other analyses. Adopting these more conservative criteria reduced the estimate of the proportion of bankruptcies due to illness or medical bills by 7 percentage points. To arrive at nationally representative estimates, we weighted the data to adjust for the slight underrepresenta- tion of respondents who filed under Chapter 13 (bankrupt- cies with repayment plans). In calculating mean out-of- pocket medical expenses from our telephone interviews, we trimmed outliers at $100,000. Chi -squared and 2-tailed t tests were used for univariate analyses. We used forward stepwise logistic regression analysis on the 2007 cohort to assess predictors of medical bankruptcy and predictors of home loss or foreclosure among homeowners. Finally, we performed logistic regres- sion using the combined 2001 and 2007 cohorts to examine whether the odds of a bankruptcy being medical were higher in 2007 than in 2001, after controlling for demographics, income, and insurance status. SAS Version 9.1 (SAS Insti- tute Inc., Cary, NC) was used for all analyses. Himmelstein et al Medical Bankruptcy 743 P Value Medical Nonmedical Medical vs All Bankruptcies Bankruptcies Bankruptcies Nonmedical Bankruptcies Mean age 44.4 years 44.9 years 43.3 years .01 Debtor or spouse/partner male 44.5% 44.9% 44.3% NS Married 43.9% 46.3% 40.1% .02 Mean family size -debtors + dependents 2.71 2.79 2.63 .02 Attended college 61.9% 60.3% 65.8% .02 Homeowner or lost home within 5 years 66.7% 66.4% 67.8% NS Current homeowner 52.3% 52.0% 53.2% NS Occupational prestige score >20 87.3% 86.1% 89.8% .01 Mean (median) monthly household income $2676 ($2299) $2586 ($2225) $2851 ($2478) .002 at time of bankruptcy filing Debtor or spouse/partner currently employed 79.2% 75.5% 85.0% .001 Debtor or spouse/partner active duty 19.4% 20.1% 18.4% NS military or veteran Market value of home (mean) $147,776 $141,861 $159,145 .03 Mean net worth (assets-debts) -$41,474 -$44,622 -$37,650 NS Human subject committees at Harvard Law School and The Cambridge Health Alliance approved the project. RESULTS The demographic characteristics of our sample are shown in Table 1. Compared with other debtors, medical debtors had slightly lower incomes, educational attainment, and occu- pational prestige scores; more were married and fewer were employed (reflecting more disability). Medical debtors were older and had larger families. Although similar proportions were homeowners, medical debtors' homes had 11% lower market value. The average net worth was similar (and neg- ative) for medical and nonmedical debtors (-$44,622 vs -$37,650, P >.05). Data from the detailed telephone survey yielded confir- matory results. When asked about problems that contributed very much or somewhat to their bankruptcy, 41.8% of interviewees specifically identified a health problem, 54.9% cited medical or drug costs, and 37.8% blamed income loss due to illness. Overall, 68.8% cited at least one of these medical causes. An additional 6.8% had recently borrowed money to pay medical bills. Insurance Status of Debtors and Dependents an additional 7% had uninsured family members (Table 3). Medically bankrupted families, however, had more often experienced a lapse in coverage during the 2 years before filing (40.0% vs 34.1%, P = .005). Percent of All Bankruptcies Debtor said medical bills were reason for 29.0% bankruptcy Medical bills >$5000 or >10% of annual 34.7% family income Mortgaged home to pay medical bills 5.7% Medical bill problems (any of above 3) 57.1% Debtor or spouse lost >2 weeks of income due 38.2% to illness or became completely disabled Debtor or spouse lost ?2 weeks of income to 6.8% care for ill family member Income loss due to illness (either of above 2) 40.3% Debtor said medical problem of self or spouse 32.1% was reason for bankruptcy Debtor said medical problem of other family 10.8% member was reason for bankruptcy Any of above 62.1% 744 The American Journal of Medicine, Vol 122, No 8, August 2009 Medical Bankruptcy Nonmedical Bankruptcy P Value Debtor or a dependent 30.8% 30.7% .93 uninsured at time of bankruptcy filing Debtor or a dependent had 40.0% 34.1% .005 a [apse in coverage during 2 years before bankruptcy filing In multivariate analysis, being uninsured at filing did not predict a medical cause of bankruptcy, while a gap in coverage did (odds ratio [OR] = 1.35, P = .002). Other predictors included: older age (OR = 1.016/year, P = .0001), married (OR = 1.59, P = .0001), female (OR = 1.34, P = .002), larger household (OR = 1.97/household member, P = .01), and lower income quartile (OR = 1.30, P = .0001). Medical debtors' court records identified more debt owed directly to doctors and hospitals than did nonmedical debtors', a mean of $4988 vs $256, respectively (P <.0001). Medical debtors with coverage gaps owed providers a mean of $8338, vs $2740 (P <.0001) for medical debtors with con- tinuous coverage. Nonmedical debtors had few medical debts, averaging under $300 regardless of insurance status. (Medical debts financed through credit cards or other bor- rowing, or owed to collection agencies are not included because they cannot be identified through court records.) Patients Whose Illness Contributed to Bankruptcy Telephone interviews identified 639 patients whose illness contributed to bankruptcy: the debtor or spouse in 77.9% of cases; a child in 14.6%; and a parent, sibling or other adult in 7.5%. At illness onset, 77.9% were insured: 60.3% had private insurance as their primary coverage; 10.2% had Medicare; 5.4% had Medicaid; and 2% had Veterans Af- fairs/military coverage. Few of the uninsured lacked cover- age because of a preexisting condition (2.8%) or belief that coverage was unnecessary (0.3%); nearly all cited economic reasons. By the time of bankruptcy, the proportion of patients with private coverage had fallen to 54.1%, while the per- centage with Medicare and Medicaid had increased to 16.4% and 9.9%, respectively. The proportion whose em- ployers contributed to coverage decreased from 43.2% to 36.6%. Out-of-pocket medical costs averaged $17,943 for all medically bankrupt families: $26,971 for uninsured pa- tients, $17,749 for those with private insurance at the outset, $14,633 for those with Medicaid, $12,021 for those with Medicare, and $6545 for those with Veterans Affairs/mili- tary coverage. For patients who initially had private cover- age but lost it, the family's out-of-pocket expenses averaged $22,568. Among common diagnoses, nonstroke neurologic ill- nesses such as multiple sclerosis were associated with the highest out-of-pocket expenditures (mean $34,167), fol- lowed by diabetes ($26,971), injuries ($25,096), stroke ($23,380), mental illnesses ($23,178), and heart disease ($21,955). Hospital bills were the largest single out-of-pocket ex- pense for 48.0% of patients, prescription drugs for 18.6%, doctors' bills for 15.1%, and premiums for 4.1%. The re- mainder cited expenses such as medical equipment and nursing homes. While hospital costs loomed largest for all diagnostic groups, for about one third of patients with pul- monary, cardiac, or psychiatric illnesses, prescription drugs were the largest expense. Our telephone interviews indicated the severity of job problems caused by illness. In 37.9% of patients' families, someone had lost or quit a job because of the medical event; 24.4% had been fired, and 37.1% subsequently regained employment. In 19.9% of families suffering a job loss, the job loser was a caregiver. Changes in Medical Bankruptcy, 2001 to 2007 In our 2007 study, 69.1 % of the debtors met the legacy definition of medical bankruptcy employed in our 2001 study, a 22.9 percentage point absolute increase (49.6% relative increase) from 2001, when 46.2% met this defini- tion (P <.0001). Inflation, which might edge families over our $1000 medical debt threshold, did not account for this change. An analysis that used all criteria except the size of medical debts found a 48.7% relative increase. An analysis limited to the 5 states in our 2001 study yielded virtually identical findings. In multivariate analysis, a medical cause of bankruptcy was more likely in 2007 than in 2001 (OR = 2.38, P <.0001) (Table 4). DISCUSSION In 2007, before the current economic downturn, an Amer- ican family filed for bankruptcy in the aftermath of illness every 90 seconds; three quarters of them were insured. Since 2001, the proportion of all bankruptcies attribut- able to medical problems has increased by 50%. Nearly two thirds of all bankruptcies are now linked to illness. How did medical problems propel so many middle-class, insured Americans toward bankruptcy? For 92% of the medically bankrupt, high medical bills directly contributed to their bankruptcy. Many families with continuous cover- age found themselves under -insured, responsible for thou- sands of dollars in out-of-pocket costs. Others had private coverage but lost it when they became too sick to work. Nationally, a quarter of firms cancel coverage immediately when an employee suffers a disabling illness; another quar- Himmelstein et al Medical Bankruptcy 745 Odds 95% Confidence Ratio Interval P Value Age 1.02 1.01-1.02 .0001 Married 1.32 1.13-1.55 .0006 Own home now or in past 5 1.10 0.93-1.30 NS years All family members insured at 1.23 1.03-1.46 .02 time of filing Gap in health insurance 1.64 1.38-1.94 .0001 coverage for any family member within past 2 years Income quartile .99 .82-1.07 NS Attended college 1.02 .87-1.18 NS Year of bankruptcy filing, 2.38 2.05-2.77 .0001 2007 vs 2001 ter do so within a year. Income loss due to illness also was common, but nearly always coupled with high medical bills. The present study and our 2001 analysis provide the only data on large cohorts of bankruptcy filers derived from in-depth surveys. As with any survey, we depend on respon- dents' candor. However, we also had independent checks - from court records filed under penalty of perjury -on many responses. Because questionnaires and court records were available for our entire sample, we used them for most calculations. The lowest plausible estimate of the medical bankruptcy rate from these sources is 44.4%-the propor- tion who directly said that either illness or medical bills were a reason for bankruptcy. But many others gave reasons such as "aggressive collection efforts" or "lost income due to illness" and had large medical debts. Indeed, detailed telephone interview data available for 1032 debtors revealed an even higher rate of medical bankruptcy than our 62.1% estimate -at least 68.8% of all filers. Our current methods address concerns expressed about our previous survey. We assembled a random, national sample and asked far more detailed questions. In addition, we adopted more stringent criteria for medical bankruptcy. Adopting an even more stringent threshold for medical debts (eg, eliminating those with medical debts below 10% of family income) would reduce our estimate by <1%. Teasing causation from cross -sectional data is chal- lenging. Multiple factors push families into bankruptcy. Yet, our data clearly establish that illness and medical bills play an important role in a large and growing pro- portion of bankruptcies. Changes in the Law Between our 2001 and 2007 surveys, Congress enacted the Bankruptcy Abuse Prevention and Consumer Protection Act (BAPCPA), which instituted an income screen and proce- dural barriers that made filing more difficult and expensive. The number of filings spiked in mid-2005 in anticipation of the new law, then plummeted. Since then, filings have increased each quarter. They are likely to exceed one mil- lion households in 2008, representing about 2.7 million people. BAPCPA's effects appear nonselective. Current filers differ from past ones mainly in having struggled longer with their debts.' New restrictions fall equally on medical and nonmedical bankruptcies, with no preferences for medical debts or sick debtors. It is implausible to ascribe the grow- ing predominance of medical causes of bankruptcy to BAPCPA. Conversely, there is ample evidence that the financial burden of illness is increasing. The number of under -insured increased from 15.6 million in 2003 to 25.2 million in 2007.3 Of low- and middle -income households with credit card balances, 29% use credit card borrowing to pay off medical expenses over time." Collection agencies contacted 37.2 million Americans about medical bills in 2003.9 Be- tween 2005 and 2007, the proportion of nonelderly adults reporting medical debts or problems paying medical bills rose from 34% to 41%.'0 Adding to Other Studies We have reviewed elsewhere the older studies on medical bankruptcy.2,11 Most rely exclusively on court records where many medical debts are invisible, disguised as credit card debt or mortgages. In our cohort, most medical debtors had charged unaffordable medical care to credit cards. Similarly, debts turned over to collection agencies by doc- tors or hospitals may be unrecognizable on court records. Moreover, income loss due to illness cannot be identified. In short, even though such studies find substantial rates of medical bankruptcy,12,13 estimates based solely on court records understate medical bankruptcies.9 Population -based studies also are problematic because many debtors are unwilling to admit to filing. Thus, a study based on the Panel Survey of Income Dynamics could identify only 74 bankruptcies (0.4% of respondents), half the actual filing rate among the national population from which the sample was drawn.13 A few studies employed novel methods to analyze med- ical bankruptcy. One found a high bankruptcy filing rate in a cohort of patients with serious neurologic injuries.14 A survey of cancer patients documented a 3 % bankruptcy rate; 7% had taken a second mortgage to pay for treatments.15 A questionnaire -based study found medical contributors to 61% of Utah bankruptcies; 58% of families seeking help at bankruptcy clinics in upstate New York reported outstand- ing medical debts.16 Medical impoverishment, although common in poor na- tions,l',1" is almost unheard of in wealthy countries other than the US.19 Most provide a stronger safety net of dis- ability income support. All have some form of national health insurance. The US health care financing system is broken, and not only for the poor and uninsured. Middle-class families fre- 746 The American Journal of Medicine, Vol 122, No 8, August 2009 quently collapse under the strain of a health care system that treats physical wounds, but often inflicts fiscal ones. ACKNOWLEDGMENTS Additional support came from Harvard Law School and the American Association of Retired Persons. Professors Mel- issa Jacoby, Robert Lawless, Angela Littwin, Katherine Porter, John Pottow, and Teresa Sullivan played key roles in the Consumer Bankruptcy Project. References 1. Sullivan TA, Warren E, Westbrook JL. The Fragile Middle Class: Americans in Debt. New Haven, CT: Yale University Press; 2000. 2. Himmelstein DU, Warren E, Thorne D, Woolhandler S. Illness and injury as contributors to bankruptcy. Health Aff (Millwood). February 2, 2005 [Web exclusive]. Available at: http://content.healthaffairs.org/ cgi/reprint/hlthaff.w5.63vl. Accessed August 6, 2008. 3. Schoen C, Collins SR, Kriss JL, Doty MM. How many are underin- sured? Trends among U.S. adults, 2003 and 2007. Health A j' (Mill- wood). June 10, 2008 [Web exclusive: w298-w309]. Available at: http://content.healthaffairs.org/cgi/reprint/hlthaff.27.4.w298vl?ijkey= rhRn2Tr4HAKZ.&keytype=ref&siteid=healthaff. Accessed August 6, 2008. 4. Bankruptcy Abuse Prevention and Consumer Protection Act of 2005, Public Law No. 109-8, 119 Stat. 23 (2005). 5. NORC (National Opinion Research Center). Occupational Prestige/Sum- mary. Available at: http://cloud9.norc.uchicago.edu/faqs/prestige.htm. Accessed July 23, 2008. 6. Pereira J. Left behind casualties of a changing job market; parting shot: to save on health-care costs, firms fire disabled workers. Wall Street Journal. July 14, 2003:A1. 7. Lawless RM, Littwin AK, Porter KM, et al. Did bankruptcy reform fail? An empirical study of consumer debtors. Am Bankruptcy Law J. 2008;82:349-405. 8. Zeldin C, Rukavina M. Borrowing to stay healthy: how credit card debt is related to medical expenses. The Access Project and Demos, 2007. Available at: http://www.accessproject.org/adobe/borrowing_ to_stay_healthy.pdf. Accessed July 18, 2008. 9. Doty MM, Edwards IN, Holgren AL. Seeing red: Americans driven into debt by medical bills. Commonwealth Fund. August 10, 2005. Available at: http://www.commonwealthfund.org/usr_doc/837_Doty_ seeing_red_medical_debt.pdf?section=4039. Accessed July 17, 2008. 10. The Commonwealth Fund Commission on a High Performance Health System. Why not the best? Results from the National Scorecard on U.S. Health System Performance, 2008. The Commonwealth Fund. 2008. Available at: http://www.commonwealthfund.org/usr_doc/ Why_Not_the_Best_ national_ scorecard_2008.pdf?section=4039. Ac- cessed July 17, 2008. 11. Himmelstein DU, Warren E, Thorne D, Woolhandler S. Discounting the debtors will not make medical bankruptcy disappear. Health Aff (Millwood). 2006;25:W84-W88. 12. Zhu N. Household consumption and personal bankruptcy. Social Sci- ence Research Network. February 2007. Available at: http://papers. ssrn.com/sol3/papers.cfm?abstract_id=971134. Accessed July 16, 2008. 13. Mathur A. Medical bills and bankruptcy filings. American Enterprise Institute. July 2006. Available at: http://www.aei.org/docLib/ 20060719_Medica1BillsAndBankruptcy.pdf. Accessed July 16, 2008. 14. Hollingworth W, Relyea-Chew A, Comstock BA, et al. The risk of bankruptcy before and after brain or spinal cord injury: a glimpse at the iceberg's tip. Med Care. 2007;45:702-711. 15. USA Today, Kaiser Family Foundation, and Harvard School of Public Health National Survey of Households Affected by Cancer (November 2006). Available at http://kff.org/upload/7590.pdf. 16. de Jung T. A Review of Medical Debt in Upstate New York. Albany, NY: Empire Justice Center; 2006. 17. Xu K, Evans D, Carrin G, et al. Protecting households from cata- strophic health spending. Health Aff (Millwood). 2007;26:972-983. 18. Raccanello K, Anand J, Dolores EGB. Pawning for financing health expenditures: do health shocks increase the probability of losing the pledge? In: Wood D, ed. The Economics of Health and Wellness: Anthropologic Perspectives. Oxford, UK: Elsevier; 2008. 19. Reid TR. Interviews with leading health policy experts in several nations. Available at: http://www.pbs.org/wgbh/pages/frontline/ sickaroundtheworld/interviews/. Accessed July 18, 2008. Mirror. Mirror on the Wall: An International Llpdate on the Connparati littp:.•'./www.comnzonwealthftnid.or,,'Content'Publ icat ions/Fund-Report... 0 R Pnvate FcvrOakin Working Tovard a High Performance Health System Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care May 15, 2007 1 Volume 59 Author(s): Karen Davis, Ph.D., Cathy Schoen, M.S., Stephen C. Schoenbaum, M.D., M.P.H., Michelle M. Doty, Ph.D., M.P.H., Alyssa L. Halmgren, M.P.A., Jennifer L. Kriss, and Katherine K. Shea Editor(s): Deborah Lorber L Downloads i and Repori (652K PDF ) is har tp sck [317K PDF ] ;I .(1780K PPT ) Executive Sumtnary Oven iew Despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries. This report —an update to two earlier editions —includes data from surveys of patients, as well as information from primary care physicians about their medical practices and views of their countries' health systems. Compared with five other nations Australia, Canada, Germany, New Zealand, the United Kingdom --the U.S. health care system ranks last or next -to -last on five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives. The U.S. is the only country in the study without universal health insurance coverage, partly accounting for its poor performance on access. equity. and health outcomes. The inclusion of physician survey data also shows the U.S. lagging In adoption of information technology and use of nurses to improve care coordination for the chronically ill. The U.S. health system is the most expensive in the world, but comparative analyses consistently show the United States underperforms relative to other countries on most dimensions of performance. This report, which includes information from primary care physicians about their medical practices and views of their countries' health systems, confirms the patient survey findings discussed in previews editions of Mirror, Mirror. It also includes information on health care outcomes that were featured in the U.S. health system scorecard issued by the Commonwealth Fund Commission on a High Performance Health System. Among the six nations studied —Australia, Canada, Germany, New Zealand, the United Kingdom. and the United States —the U.S. ranks last, as it did in the 2006 and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U S. is last on dimensions of access, patient safety, efficiency, and equity. The 2007 edition includes data from the six countries and incorporates patients' and physicians' survey results on care experiences and ratings on various dimensions of care. The most notable way the U.S. differs from other countries is the absence of universal health insurance coverage. Other nations ensure the accessibility of care through universal health insurance systems and through better ties between patients and the physician practices that serve as their long-term "medical home." It is not surprising, therefore, that the U.S. substantially underperforms other countries on measures of access to care and equity in health care between populations with above -average and below average incomes. With the inclusion of physician survey data in the analysis, it is also apparent that the U.S. is lagging in adoption of information technology and national policies that promote quality improvement The U.S. can learn from what physicians and patients have to say about practices that can lead to better management of chronic conditions and better coordination of I ofa 9/8;20094:05 PM Mirror, Mirror on the Wall: An International Update on lie Coniparati-.- http:/www-commclnweaIthfund.oryContenl.il'ubIications/f=und-Report... care. Information systems in countries like Germany. New Zealand, and the U-K- enhance the ability of physicians to monitor chronic conditions and medication use- These countries also routinely employ non -physician clinicians such as nurses to assist with managing patients with chronic diseases. The area where the U.S- health care system performs best is preventive care. an area that has been monitored closely for over a decade by managed care plans. Nonetheless, the U.S- scores particularly poorly on its ability to promote healthy lives, and on the provision of care that is safe and coordinated, as well as accessible, efficient, and equitable. For all countries, responses indicate room for improvement. Yet, the other five countries spend considerably less on health care per person and as a percent of gross domestic product than does the United States. These findings indicate that, from the perspectives of both physicians and patients, the U.S. health care system could do much better in achieving better value for the nation's substantial investment in health. Figure ES-1. Overall Ranking Ca -y It.M.-ja 1 t.aa-z.6c 2-67 J-33 j ' tlew Ul.1.d UIn6-d ■kmral-e cmk4 to G.IIMIIy ).alai xl N.-U Io SI.-1.4 GVVAM RM*ru jMrl 11A R. bra_ srs s 7 - Favcrd-:_ { AC40ss j 3 t 2 1 ETMC1e-1CY { ] 2 t Ewty i 3 1 M.aMhy M.akff E.8-4s v.a pe- Caprla 20LLr 52.676' l $1.165 UM5' r $2-061 1<I.S46 S6.102 -; -- . .,,.r«rcr n,..,.,rrr.. r... rlr.r.r.s fa•...r ...Ir,........no e...l :..y .-r.rrin..�i .r,,,n. o.•n.i •. .. in, .,.,...... i....71•r....1 :[N,•.i-ne•rid�r,s.Mam4or[r'.w-., �r :.-k.::wi r�-,a. - ....nr,nrr..r�r.�nr.w..,r-l.:,...r :e r•r:r..r. •.r. �..,,.. y,;7 r'M � vrm,onn.M� r ��f ' :� vrr::,; �� :r . Mi P..ivrri,x•: • .I.an� 1. r V.^ I,Yrc•rs ': -v'. [ a' Key Findings Quality: The indicators of quality were grouped into four categories: right (or effective) care, safe care, coordinated care, and patient -centered care. Compared with the other five countries. the U.S- fares best on provision and receipt of preventive care, a dimension of "right care-" However, its low scores on chronic care management and safe. coordinated, and patient - centered care pull its overall quality score down. Other countries are further along than the U.S. in using information technology and a team approach to manage chronic conditions and coordinate care. Information systems in countries like Germany, New Zealand, and the U.K. enhance the ability of physicians to identify and monitor patients with chronic conditions- Such systems also make it easy for physicians to print out medication lists, including those prescribed by other physicians. Nurses help patients manage their chronic diseases, with those services financed by governmental programs. Access: Not surprising ---given the absence of universal coverage ---people in the U-5. go without needed health care because of cost more often than people do In the other countries. Americans were the most likely to say they had access problems related to cost, but If Insured, patients in the U.S. have rapid access to specialized health care services- In other countries, like the U-K and Canada, patients have little to no financial burden, but e)perience long wait times for such specialized services. The U S. and Canada rank lowest on the prompt accessibility of appointments with physicians, with 21 ol'4 9/8i2009 4:0 I'M Mirror, Mirror nn the Wall: An international Update on die Comparati... hup-.//www.cornmonxveaIthfiuzd.or,,,'C'ontenuPublications/Fund-Report... patients more likely to report waiting six or more days for an appointment when needing care. Germany scores well on patients' perceptions of access to care on nights and weekends and on the ability of primary care practices to make arrangements for patients to receive care when the office is closed. overall, Germany ranks first on access. Efficiency: On indicators of efficiency, the U.S. ranks last among the six countries, with the U.K. and New Zealand ranking first and second, respectively. The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of the use of information technology and multidisciplinary teams. Also, of sicker respondents who visited the emergency room, those in Germany and New Zealand are less likely to have done so for a condition that could have been treated by a regular doctor, had one been available. Equity: The U.S. ranks a clear last on all measures of equity. Americans with below -average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick, not getting a recommended test, treatment or follow-up care, not filling a prescription, or not seeing a dentist when needed because of costs. On each of these indicators, more than two -fifths of lower -income adults in the U.S. said they went without needed care because of costs in the past year. Healthy lives: The U.S. ranks last overall with poor scores on all three indicators of healthy lives. The U.S. and U.K. had much higher death rates in 1998 from conditions amenable to medical care?with rates 25 to 50 percent higher than Canada and Australia. Overall, Australia ranks highest on healthy lives, scaring first or second on all of the indicators. Summary and Implications Findings in this report confirm many of the findings from the earlier two editions of Mirror, Mirror. The U.S ranks last of six nations overall. As in the earlier editions, the U.S. ranks last on indicators of patient safety, efficiency, and equity. New Zealand, Australia, and the U.K. continue to demonstrate superior performance, with Germany joining their ranks of top performers. The U.S. is first on preventive care, and second only to Germany on waiting times for specialist care and non -emergency surgical care, but weak on access to needed services and ability to obtain prompt attention from physicians. Any attempt to assess the relative performance of countries has inherent limitations. These rankings summarize evidence on measures of high performance based on national mortality data and the perceptions and experiences of patients and physicians. They do not capture important dimensions of effectiveness or efficiency that might be obtained from medical records or administrative data. Patients' and physicians' assessments might be affected by their experiences and expectations, which could differ by country and culture. The findings indicate room for improvement across all of the countries, especially in the U.S. If the health care system is to perform according to patients' expectations, the nation will need to remove financial barriers to care and improve the delivery of care. Disparities in terms of access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home. The U.S. must also accelerate its efforts to adopt health information technology and ensure an integrated medical record and information system that is accessible to providers and patients. While many U.S. hospitals and health systems are dedicated to improving the process of care to achieve better safety and quality, the U.S. can also learn from innovations in other countries?including public reporting of quality data, payment systems that reward high -quality care, and a team approach to management of chronic conditions. Based on these patient and physician reports, the U.S. could improve the delivery, coordination, and equity of the health care system by drawing from best practices both within the U.S. and around the world. Citation K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J. L. Kriss, and K. K. Shea, Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care, The Commonwealth Fund, May 2007 3 o1'4 9..&'2009 41 05 PNI Obama's Hurdle: Selling The Satisfied On Health Care: NPR http://www.npr.org/tempIates/story/story.php?storyid=112627732 Obama's Hurdle: Selling The Satisfied On Health Care by JULIE ROVNER September 8, 2009 teM size A A A How do you sell something to someone who doesn't know they need it? That, in a nutshell, is the biggest hurdle President Obama and Congressional leaders face in trying to push a health care overhaul to the roughly 180 million Americans who have private health insurance coverage. The president previewed some of the themes he's likely to use in his address to a joint session of Congress Wednesday at a Labor Day picnic in Cincinnati. "I see reform where we bring stability and security to folks who have insurance today," he said, "where you never again have to worry about going without coverage if you lose your job or you change your job or you get sick." But the sagging poll numbers, both for Obama and his top domestic priority, show that so far, the public isn't buy what he's selling. Robert Blendon, a public opinion expert at the Harvard School of Public Health, says he's not that surprised. "This recession... has not left Main Street people's lives," he said. "And for them to really sign onto these bills they have to feel that their insurance premiums will be lower in the future and their out-of-pocket costs. And they just don't see that." Karen Pollitz, an insurance expert at Georgetown University, says the problem is actually even bigger: Most people who have insurance don't realize that they might not have as much protection as they think. The reason most people say they're satisfied with their health insurance? They don't use it very much. "The majority of Americans who are healthy account for only about 3 percent of total medical spending," Pollitz said. "It's kind of like hearing that most people are satisfied with their new car before they drive it off the dealer's lot." On the other hand, those who do run up big bills often experience problems. One survey, Pollitz said, "found... that more than one in five cancer patients who had health insurance the whole time they were in treatment nonetheless, ended up using up all or most of their savings on medical bills." Pollitz says that because most people are healthy, insurance companies have tried to attract their business by holding down premiums. But what many people don't realize is that those lower premiums often mean less coverage when you really need it. For example, she says, "you might be paying a lower premium because the drug benefit in your policy only covers generic drugs." That's no problem if you have a common ailment like high blood pressure or only require the occasional antibiotic. But if you're diagnosed with a serious illness for which there are no generic medications, like multiple sclerosis, "you need very very expensive name brand drugs that cost thousands of dollars every month," Pollitz said. Harvard's Robert Blendon says the Obama administration, like the Clinton administration 16 years ago, may have misstepped in trying mount a campaign for changes to the health care system that's too similar to the one it mounted to get its candidate elected president. "People's investing in a president is different from having their health care changed," Blendon said. In getting people to vote for a candidate, he says, "they don't have a lot to lose. They like the candidate; they want something called change. And so you may get audiences excited for Obama or Clinton when they're running for office, that don't get excited at all about their health care getting changed." Instead, Blendon says, what backers of health care overhaul should be doing is running a campaign like people do for local school bond referenda, where voters must raise their own taxes for the greater good. In those cases and this one, he says, "You really have to convince people that if their taxes go up their schools will be better; it won't be a waste of money." That convincing starts with the president's speech Wednesday night. comments Please note that all comments must adhere to the NPR.org discussion rules and terms of use. See also the Community FAQ. 1 of 3 9/8/2009 3:42 PM Congressional Research Service in Treatment of Noncitizens H.R. 3200 Alison Siskin Specialist in Immigration Policy Erika K Lunder Legislative Attorney August 25, 2009 Congressional Research Service 7-5700 wwwwrs.gov R40773 CRS Report for Congress Preparc,d fi)r Alk.unbers alld Cr wnitte(-:7,s of'Conc),ress d,b Treatment o f Noncitizens in H.R. 3200 Summary This report outlines the treatment of noncitizens (aliens) under H.R. 3200, America's Affordable Health Choices Act of 2009. In. particular, the report analyzes specific provisions in. H.R. 3200, and whether there are eligibility requirements for noncitizens in the provisions. within the bill, nonciti:;-r,ens are treated differently in several provisions. In 2008, there were approximately 37.3 million foreign -born persons in the United States. The foreign -born population was comprised of approximately 15.1 million naturalized U.S. citizens and 22.2 million noncitizens. H.R. 3200 includes an individual mandate to have health insurance, with tax penalties for noncompliance. Individuals who do not maintain acceptable health insurance coverage for themselves and their children would be required to pay an additional tax. Some individuals, including nonresident aliens, would be exempt from the individual mandate. "Nonresident alien" is a term under tax but not imm-igration law. For federal tax purposes, alien individuals are classified as resident or nonresident aliens. In general, an individual is a nonresident alien unless he or she meets the qualifications under a residency test. Thus, legal permanent residents, and nonciti:;-P,ens and unauthorized aliens who qualify as resident aliens (i.e., meet the substantial presence test), would be required under H.R. 3200 to have health insurance. In addition, under H.R. 3200, a "Health Insurance Exchange" would begin operation in 2013 and would offer private plans alongside a public option. The Exchange would provide eligible individuals and small businesses with access to insurers' plans, including the public option, in a comparable way. Individuals would only be eligible to enroll in an Exchange plan if they were not enrolled in other acceptable coverage (for example, from an employer, Medicare and generally Medicaid). H.R. 3200 does not contain any restrictions on noncitzens participating in the Exchange whether the noncitizens are legally or illegally present, or in the United States temporarily or permanently. Nonetheless, only aliens who could be classified as resident aliens would be required under the bill to have health insurance. In 2013 under H.R. 3200, some individuals would be eligible for premium credits (i.e., subsidies based on income) toward their required purchase of health insurance. To be eligible for the premium credits under H.R. 3200, individuals must be lawfully present in a state in the United States, excluding most nonimmigrants (i.e., those in the United States for a specific purpose and a specific period of time). The exceptions for nonim igrants who could obtain premium credits under H.R. 3200 would be tracking victims, crime victims, fiancees of U.S. citizens, and those who have had applications for legal. permanent residence (LPR) status pending for three years. It is expected that almost all aliens in these excepted nonimmigrant categories will. become LPRs (i.e., immigrants) and remain in the United States permanently. Furthermore, unauthorized aliens would be barred from receiving the premium credit. H.R. 3200 as reported from. the House Energy and Commerce Committee (E&C) would extend Medicaid eligibility up to 133 .113% of poverty for populations that previously were not covered (e.g., childless adults and many parents). This extension of benefits could mean an increase in the number of noncitizens who already meet the itnrnigration status requirements for Medicaid eligibility who would be eligible for Medicaid. Also, H.R. 3200 as reported by E & C would make eligible for full. Medicaid noncitizens who lawfully reside in the United States in accordance with the Compacts of. Free Association between the Government of the United States and the Governments of the Federated States of Micronesia, the Republic of. the Marshall. Islands, and the Republic of Palau, and are otherwise eligible for such. assistance. This report will. be updated. Congressional Research Service Treatment o ffoncitizens in H.R. 3200 Contents Introduction................................................................................................................................ l Overview of. the Noncitizen Population in the United States........................................................ l Noncitizens and Provisions in H.R. 3200.....................................................................................2 Individual Mandate...................................................................... 2 Exchange.............................................................................................................................. 4 Credits.................................................................................................................................. 4 Medicaid/CHIP..................................................................................................................... 6 Noncitizen Eligibility for Medicaid/CHIP ............... Emergency Medicaid ..................................................... ................ 7 ................................. Extension of Medicaid Coverage to Citizens of the Freely Associated States ................... 8 Contacts Author Contact Information ........................................................................................................ 8 Acknowledgments...................................................................................................................... 8 Key Policy Staff................................................................................................... ....... 8 ................ Congressional Research Service Treatment o f Noncitizens in H.R. 3200 Introduction This report outlines the treatment of noncitizens' under H.R. 3200, America's Affordable Health Choices Act of 2009. The report analyzes specific provisions in H.R. 3200, and whether there are eligibility requirements for noncitizens in. the selected provisions. H.R. 3200 was ordered. reported by the House Committees on Education and Labor, ways and. Means, and Energy and Commerce. Y Noncitizens are treated differently in several provisions of the bill. For example, H.R. 3200 would mandate that as of 2013, resident aliens (as defined in the Internal Revenue Code and discussed below) have health insurance. However, not all. resident aliens would qualify for the credits (i.e., subsidii�s based on income) that would be created under the bill toward their required purchase of health insurance, because eligibility for the credits is based on immigration status (as defined under the Immigration and Nationality Act) not on status as a resident alien, as defined under the tax code. Overview of the Noncitizen Population in the United States Using the March 2008 Current Population Survey (CPS), the Congressional Research Service estimated that in the beginning of 2008 there were approximately 37.3 million foreign -born persons. in the United States.3 The foreign -born population was comprised of approximately 15.1 in.iIlion naturalized U.S. citizens4 and 22.2 million noncitizens." Researchers at the Pew Hispanic Center used the same data, but adjusted the survey weights to account for noncitizen undercounts in the survey. They also assigned a specific immigration status (e.g, Legal permanent resident, unauthorized alien) to each foreign -born survey respondent, and used a methodology to estimate the illegally present population. The Pew Hispan.]ic Center estimated that in the beginning of 2008 there were approximately 40 million foreign -born persons in the United States, and of the foreign -born population, approximately 14.2 'A noncitizen is anyone who is not a citizen or national of the United States and is synonymous with the terms alien and forei m national. Noncitizens include those in the United States permanently (e.g., legal permanent residents, refugees), those in the country temporarily (e.g., students, temporary workers), and those who are in the country illegally (i.e., unauthorized aliens). For more information on the different categories of noncitizens, see CRS Report RS2091 b, Imrnigration and Naturalization Fundcrmentcils, by Ruth Ellen Wasem. 2 The bill was reported by the House Ways and Means Committee and the House Education and Labor Committee on July 17, 2009. The House Energy and Commerce Committee reported the bill on July 31, 2009. 3 A foreign -born resident is anyone in the United States who was born in another country, and did not automatically acquire U.S. citizenship at birth. 4 Under U.S. immigration law, all legal permanent residents are potential citizens and may become so through a process known as, nciliawl ration. s Since the CPS does not ask citizenship status, CRS does not use the CPS to estimate the different noncitizen populations (e.g., legal permanent residents, temporary workers, unauthorized aliens). h Jeffrey S. Passel and D'vera Colin, A .Portrait of Unauthorized .In7inigrants in the United States, Pew Hispanic Center, Washington, D.C., April 14, 2009, p. 48. http://pew,hispanic.org%f les/reports/107.pdf. CongresSionai Research Serzrice Treatment of Noncitizens in H.R. 3200 million (36%) were naturalized U.S. citizens, 12.3 million (31 %) were legal permanent residents (LPRs), 1.4 million (4%) were temporarily in the United States (i.e., nonimmigrants),' and 11.9 million (30%) were estimated to be unauthorized (illegal) residents.' The Center for Immigration Studies, using the monthly public use files of the CPS, estimated that in the first quarter of 2009 (January/February/March), the unauthorized alien population declined to approximately 10.8 million. "' Noncitizens and Provisions in H.R. 3200 Individual Mandate Section. 401 of H.R. 3200 includes an individual mandate to have health insurance unless expressly exempted, with penalties for noncompliance effective in 2013. Individuals would be required to maintain acceptable coverage, defined as coverage under a qualified health benefits plan (QQHBP), an employment -based plan, a grandfathered nongroup plan, Part A of Medicare, Medicaid, military coverage (including Tricare), Veteran's health care program, and coverage as deterrriined by the Secretary of Health and Human Services (HHS) in coordination with the Health Choices Commissioner (Commissioner)." Notably, there is nothing in H.R. 3200 that would alter current law relevant to restrictions on certain categories of aliens (i.e., legal permanent residents within the first five years after entry, nonirnmigrants, unauthorized aliens) receiving Medicaid. (These restrictions are discussed below.) This provision in the legislation would be put into effect through a change in the tax law (i.e., as an amendment to the Internal Revenue Code (I.R.C.)). Individuals who do not maintain acceptable health insurance coverage for themselves and their children would be required to pay an additional tax. Some individuals, including nonresident aliens, would not be required to obtain health insurance under H.R. 3200 (i.e., would be exempt from the individual mandate).13 For federal tax purposes, The two) basic types of legal aliens are immigrants and nonimmigrants. Immigrants are persons admitted as legal permanent residents (LPRs) of the United States. Non immigrants —such as tourists, foreign students, diplomats, temporary agricultural workers, exchange visitors, or intracompany business personnel —are admitted for a specific purpose and a temporary period of time. Nonimmigrants are required to leave the country when their visas expire, though. certain classes of nonimmigrants may adjust to LPR status if they otherwise qualify. For more information on the different categories of noncitizens, see CRS Report RS2091 6, Immigration and 'naturalization Fundamentals, by Ruth Ellen Wasem. s Jeffrey S. Passel and D'Vera Cohn, A Portrait of'Unauthorized Immigrants in the United States, Pew Hispanic Center, Washington, D.C., April 14, 2009, p. 3, http://pewliispan.ic.org/f les reports/l 07.pdf. `' Steven A. Cainarota and Karen Jensenius, A Shifting Tide: Recent Trends in the Illegal Inimigrant Population, Center for Immigration Studies, Washington, D.C., July 1009, http://cis.org/Illegallmmigration-ShiftingTide. 10 For a discussion of the difTerences in the methodologies of the estimates, see CRS Report RL33874, Unauthorized Aliens Residing in the United States: Estimates Since 1986, by Ruth Ellen Wasem. 11 The duties of the Health Choices Commissioner are defined in, §142 of H.R. 3200. 1' The ta.x would be prorated for the time the individual (or family) does not have coverage, and would be equal to the lesser of (1) 2.5 % of the taxpayer's modified adjusted gross income (MAGI) over the amount of income required to file a tax return, or (2) the national average premium for applicable single or family coverage. See CRS Report R40724, Private Ifealth Insurance Provisions of H.R. 3200, by Hinda Chaikind et al. "Other exemptions would include individuals residing outside of the United States, individuals residing in possessions (continued...) Congressional Research Service Treatment o f Noncitizens in H.R. 3200 foreign nationals are classified as resident or nonresident aliens. 14 These terins are in the I.R.C. but do :not exist in the Immigration and Nationality Act (INA)' � (i.e., immigration law). As a result, ithe specific immigration statuses under the INA do not align directly with the terms resident and nonresident alien. Based on time in the United States and treaty obligations, for example, some foreign agricultural workers (H-2A visa holders)16 would be considered resident aliens while others would be considered nonresident aliens for tax purposes. In general, an individual is a nonresident alien unless he or she meets the qualifications under one of the following residency tests Green card test: the individual. is a lawful permanent resident of the United States at any time during the current year, or Substantial presence test: the individual is present in the United States for at least 31. days during the current year and at least 183 days during the current year and previous two years. For computing the 183 days, a formula is used that counts all the qualifying days in the current year, one-third of the qualifying days in the immediate preceding year, and one -sixth of the qualifying days in the second preceding year. " There are several situations in which an individual may be classified as a nonresident alien even though he or she meets the substantial presence test. For example, an individual will generally be treated as a nonresident alien if he or she has a closer connection to a foreign country than to the United States, maintains a tax home in the foreign country, and is in the United States for fewer than 183 days during the year. R Another example is that an individual in the United States under an F-, J-, M-, or Q-visa' g may be treated as a nonresident alien if he or she has substantially complied with visa requirements.- Other individuals who may be treated as nonresident aliens even if they would otherwise meet the substantial presence test include employees of foreign governments and international organizations, regular commuters from Canada or Mexico, aliens who are unable to the leave the United States because of a medical condition, foreign vessel crew (...continued) of the United States, those with qualified religious exemptions, those allowed to be a dependent for tax -filing purposes, and others granted an exemption by the Secretary of Health and Human Services. 14 It is possible for an individual to be a resident alien and a nonresident alien during the same year. For an explanation of the rules on determining residency starting and ending dates and dual -status filing, see .[RS Publication 519: US. Tax Guide for Aliens, which is available at http://www.irs.gov. '' 8 U.S.C. § 1101 et seq. 16 The visa letter is derived from the subparagraph of section 101(a)(15) of the Immigration and Nationality Act that describe, the type of visa. For further information, see CRS Report RL31381, U.S. Immigration Policy on Temporal-v Admissions, by Chad C. Haddal and Ruth Ellen wasem. 17 I.R.C. §§7701(b)(1)(A) and (b)(3). A nonresident alien may elect, under certain circumstances, to be treated as a resident alien if the substantial presence test is met in the year following the election. I.R.C. §7701(b)(4). A dual -status or nonresident alien married to a U.S. citizen or resident may qualify to be treated as a resident alien for the entire year. I.R.C. §§6013(g) and (h). " I.R.C. §7701(b)(3)(B). 19 These :individuals are temporarily admitted into the United States as students, teachers, trainees, and cultural exchange visitors. 20 I.R.C. § 7701(b)(5). There are limits on how long an individual may be exempt from the substantial presence test. See id. Congressional Research Seruice Treatment of .Noncitizens in H.R. 3200 members, and athletes participating in charitable sporting events.2' Additionally, depending on where -the individual is from, there may exist an income tax treaty between that country and the United States with provisions for determining residency status." Under H.R. 3200, all legal permanent residents (LPRs),'' nonimmigrants, and unauthorized aliens who meet the substantial presence test (defined above) would be required to obtain health insurance.?4 Noncitizens meeting the definition of nonresident aliens (e.g., temporary visitors, temporary workers in the United States for less than 183 days in the year) would not be required to obtain health insurance. Notably, the IRC does not contain special rules for individuals who are in the United States without authorization (i.e., illegal or unauthorized aliens). Instead, the IRC treats these individuals in the same manner as other foreign nationals an unauthorized individual who has been in the 'United States long enough to qualify under the substantial presence test is classified as a resident alien; otherwise, the individual is classified as a nonresident alien.'' Thus, it would appear that unauthorized aliens who meet the substantial presence test would be required under H.R. 3200 to have health insurance. Exchange Under .'R.R. 3200, a "Health Insurance Exchange'' would begin operation in 2013 and would offer private plans alongside a public option. The Exchange would not be an insurer; it would provide eligible individuals and small businesses with access to insurers' plans, including the public option, in a comparable way. Individuals would only be eligible to enroll in an. Exchange plan if they were not enrolled in other acceptable coverage (for example, from an employer, Medicare and generally Medicaid) . 6 H.R. 3200 does not contain any restrictions on. noncitzens whether legally or illegally present, or in the United States temporarily or permanently participating in the Exchange. However, as discussed above, H.R. 3200 would only mandate that resident aliens would The required to have health insurance. Credits In 201-3, under §241 of H.R. 3200, certain individuals would be eligible for premium credits (i.e., subsidies based on income) toward their required purchase of health insurance. Even when individuals have health insurance, they may be unable to afford the cost sharing (deductible and copayments) required to obtain health care. Under H.R. 3200, those eligible for premium credits would also be eligible for cost -sharing credits (i.e., subsidies). To be eligible for credits, `' I.R.C. §§7701(b)(3)(D), (b)(5), and (b)(7). See, for example, Treas. Reg. §301.7701(b),-7. 23 Legal permanent residents are also referred to as immigrants in the INA. 24 In other words, all aliens who meet the definition of resident alien under the I.R.C. 25 For more on taxation of aliens, see CRS Report RS21732, Federal Taxation ofAliens working in the United States and Selected Legislation, by Erika K. Ludder. 26 For more on the Exchange, see CRS Report R40724, Private Health Insurance Provisions of'H.R. 3200, by Hinda Chaikind et al. 27 H.R. 3:?00 would not change any of the alien eligibility restrictions on the receipt of Medicaid. Thus, there could be aliens who would meet the categorical and income eligibility requirements for Medicaid but are ineligible due to their alien status (e.g., legal permanent residents within five years after entry to the United Stites), who under H.R. 3200 would be required to have health insurance. Congressional Research Service Treatment of Noncitizens in H.R. 3200 individuals must have family income of less than 400% of the federal poverty level (FPL), among other requirements.28 To be eligible for the credits under §242 of H.R. 3200, individuals must be lawfully present in a state in the United States, but generally not in the United States temporarily (i.e., nonimmigrants) .29Nonimmigrants that is, foreign nationals who are admitted to the United States for a specified period of time and a specific purpose are "lawfully present," but most, with exceptions noted below, would be ineligible for the credits under H.R. 3200. The exceptions for nonimmigrants who could obtain credits under H.R. 3200 would be trafficking victims, crime victims, fiancees of U.S. citizens, and those who have had applications for legal permanent residence (LPR) status pending for three years; these individuals are likely to become LPRs (i.e., immigrants) and remain in the United States permanently. Furthermore, §246 would bar unauthorized aliens from. receiving any premium or cast -sharing credit.3° Notably, many categories of nonimmigrants in the United States who have work authorization (i.e., temporary workers) would meet the definition of a resident alien, and as a result would be required under. H.R. 3200 to have health. insurance. Nonetheless, many of these aliens would be ineligible for the credits under the bill. For example, professional specialty workers (H-1 B) are admitted to the United States for up to three years, and can stay for a maximum of six years. Thus, in general., these aliens would be considered resident aliens under the I.R.C. and would be required under H.R. 3200 to have health insurance, but would be ineligible for the credits under the bill. because they are nonirnmi.grants.'' In addition, the credits are based on an individual's eligibility, but many tax returns are filed jointly or with dependents. There could be instances where some family members would meet the definition of an eligible individual for purposes of the credit, while other family members would. not. For example, in. a family consisting of a U.S. citizen married. to a.n. unauthorized alien and a U.S. citizen child, the U.S. citizen spouse and child could meet the criteria for being a credit - eligible: individual., while the unauthorized alien spouse would not meet the criteria. H.R. 3200 does not expressly address how such a situation would be treated. Therefore, it appears that the Health Choices Commissioner would be responsible for determining how the credits would be administered in the case of mixed -status families. 32 Some have expressed concerns that since H.R. 3200 does not contain a mechanism to verify immigration status, the prohibitions on certain. noncitizens (e.g, nonimmigrants and unauthorized Lx The federal poverty level used for public program eligibility varies by family size and by whether the individual resides in the 48 contiguous states and the District of Columbia versus Alaska and Hawaii. For a two -person family in the 48 contiguous states and the District of Columbia, the federal poverty level (i.e., 100% of poverty) was $14,570. See 74 Federal Register 4200, January 23, 2009, http:/,Iaspe.hhs.gov/poverty/09fedreg.pdf 29 The actual provision reads: "an individual who is lawfully present in a State in the United States (other than as a nonimmigrant described in a subparagraph (excluding subparagraphs (K), (T), (U), and (v)) of section 101(a)(15) of the Immigration and. Nationality Act)." (H.R. 3200, §242(a)(1)) 301n addition, in the subtitle of H.R. 3200 pertaining to premium credits, §246 states, "Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States." '} For more information on the categories of nonimmigrants who are entitled to work in the United States, including their approved length of stay in the country, see CRS Report RL33977, Innmigratton of `Foreign Workers: Labor Market Tests and Protections, by Ruth Ellen Wasem, and CRS Report RL31381, I.S. Immigration Policv on Temporwy Admissions, by Chad C. Haddal and Ruth Ellen Wasem. 3' The Commissioner's responsibilities to administer the credits are outlined in § 142(a)(3) of H.R. 3200. Congressional Research Serzrice Treatment of'Noncitizens in H.R. 3200 aliens) receiving the credits may not be enforced. However, others note that under § 142(a)(3) of the bill, it is the responsibility of the Health Choices Commmissioner (Commissioner) to administer the "individual affordability credits under subtitle C of title II, including determination of eligibility for such credits." Thus, it appears, absent of a provision in the bill specifying the verification procedure, that the Commissioner would be responsible for determining a mechanism to verify the eligibility of noncitizens for the credits." Medicaid/CHIP H.R. 3200 as reported from the House Energy and Commerce Committee would make some changes to Medicaid and the State Children's Health Insurance Program (CHIP). In addition, the bill as reported from. the House Energy and Commerce Committee would amend the current irntnigration status -based restrictions (i.e., alien eligibility requirements) on receiving Medicaid or CHIP (discussed below) for citizens of the Freely Associated States. The bill. as reported by the House Energy and Commerce Committee would extend Medicaid coverage up to 1.33 1 /3% of poverty for populations that previously were not covered (e.g., childless adults and many parents). This extension of benefits could mean an increase in the number of noncitizens who already meet the immigration status requirements for Medicaid eligibility (e.g., .refugees, LPRs in the country more than. five years) who would be eligible .for Medicaid. In addition, this change could also mean that more noncitizens who meet the categorical and income eligibility standards for Medicaid but are barred due to their immigration. status (e.g., nonimmigrants, unauthorized aliens) would be eligible for emergency Medicaid (discussed. below).34 Notably, the House Energy and Commerce Committee added a section to H.R. 3200 that reiterates current law that unauthorized aliens are not eligible for fitll-benefit Medicaid coverage. 35 Nonci.tizen Eligibility for Medicaid/CHIP Currently, noncitizens' eligibility for federal Medicaid and CHIP benefits depends largely on their immigration status and whether they arrived (or were on a program's rolls) before August .12, 1996, the enactment date of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA). 16 Notably, the aliens must also meet the financial and categorical eligibility requirements for Medicaid or be targeted low-income uninsured children or eligible pregnant women eligible for CHIP.37 Most legal permanent residents (LPRs) entering after August 22, 33 For more information on existing systems and laws related to verification of immigration status, see CRS Report R40144, State .,Medicaid and CHAP Coverage of NoncitiLens, by Ruth Ellen Wasem. 34 The Emergency Medical Treatment and Active Labor Act (EMTALA) requires Medicare -participating hospitals to provide emergency medical services for all patients who seek care, regardless of their ability to pay or immigration status. (42 U.S.0 1395dd) While some argue that unauthorized aliens should not receive any type of taxpayer funded medical care, others contend that increasing the number of unauthorized aliens eligible for emergency Medicaid could decrease the amount of hospitals' uncompensated care. 3' H.R. 3'200 (§ 1783) as reported by the Energy and Commerce Committee contains a provisions stating, "Nothing 1n this title shall change current prohibitions against Federal Medicaid and CHIP payments under titles XIX and XXI of the Social Security Act on behalf of individuals who are not lawfully present in the United States." 16 P.L. 104-193, also called the Welfare Reform Act. In general, Title XXI of the Social Security Act defines a targeted lovr-income child for CHIP eligibility as one who is under the age of 19 years with no health insurance and who would not have been eligible for Medicaid under the (continued... ) Congres!hdonal Research Service Treatment of .Noncitizens in H.R. 3200 1996, axe barred from Medicaid and CHIP for five years, after which they are eligible for CHIP and eligible for Medicaid at state option. States may also choose to use state and federal Medicaid and CHIP funds to cover pregnant women and children who are LPRs within the first five years of arrival." In addition, states have the option to use state funds to provide medical coverage for other LPRs within five years of their arrival in the United States. Refugees and asylees39 are eligible for Medicaid and CHIP for seven years after arrival. After the seven years, they may be eligible for Medicaid and CHIP at the state's option. LPRs with a substantial (1 0-year) U.S. work history or a military connection are eligible for Medicaid and CHIP without regard to the five-year bar. LPRs receiving Supplemental Security Income (SSI) on or after August 22, 1996, are eligible for Medicaid because Medicaid coverage is required for all SSI recipients.4►' All aliens regardless of status who otherwise meet the eligibility requirements for Medicaid are eligible for emergency Medicaid. Emergency Medicaid Emergency Medicaid may pay for the care of unauthorized aliens, nonimmigrants, and LPRs within the first five years of arrival. (or longer if the state does not exercise the option to provide cover. age for LPRs after the five years) for emergency conditions if they meet the other eligibility requirements of. the Medicaid program.41 Specifically, aliens who are otherwise eligible for Medicaid except for their immigration status (e.g., unauthorized aliens, nonimmigrants) may receive ``medical assistance under Title XIX of the Social Security Act ... for care and emergency services that are necessary for the treatment of an emergency medical condition (as defined in Section. 1903(v)(3) of such Act) of the alien involved and are not related to an organ transplant procedure.„42 (...continued) rules in e:tTect in the state on March 31, 1997. States can set the upper income threshold for targeted lour -income children up to 200% of the federal poverty level (FPL) or 50 percentage points above the applicable pre -CHIP Medicaid threshold. 38 Prior to the Children's Health Insurance Program Reauthorization Act of 2009 (P.L. 111-3, signed into law on February 4, 2009), states had to use their own money to cover any LPRs within the first five years after entry. 39 Refugee and asylee status require a finding of persecution or a well-founded fear of persecution in situations of "special humanitarian concern" to the United States. Refugees are admitted from abroad. Asylum is granted on a case - by -case basis to aliens physically present in the United States who meet the statutory definition of "refugee." 4Q For more information on specific eligibility criteria, see CRS Report R40144, State !'Medicaid and CHIP Coverage of Noncilifem, by Ruth Ellen Wasem, and CRS Report RL33809, Noncitizen Eligibility for Federal Public Assistance: Polio- Overvleiv and Trends, b_v Ruth Ellen Wasem. 41 In other words, aliens who except for their immigration status would be eligible for Medicaid by being in a Medicaid -eligible category such as children and pregnant women and by meeting the state residency and income requirements are eligible for emergency Medicaid. 42 The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996; P.L. 104-193, §401(a)(1)(A). Section 1903(v)(3) defines "emergency medical condition" as ',.a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in —{A) placing the patient's health in. serious ,jeopardy, (B} serious impairment to bodily functions, or (C} serious dysfunction of any bodily organ or past." Congressional Research Service Treatment of Noncitizens in H.R. 3200 Extension of Medicaid Coverage to Citizens of the Freely Associated States Currently under PRWOR.A, citizens of the Freely Associated States (i.e., citizens of the Republic of the Marshall Islands (RMI), the Federated States of Micronesia (FSM), and the Republic of Palau) are not eligible for full -Medicaid or CHIP. Prior to PRWORA, citizens of the Freely Associated States were not barred from Medicaid. Under § 1736 of H.R. 3200 as reported by the House 'Energy and Commerce Committee, citizens of the Freely Associated States would be eligible for full -Medicaid (without regard to the five-year bar) if they are (1) lawfully residing in the United States (including territories and possessions of the United States) in accordance with the Compacts of Free Association between the Governments of. the Federated States of Micronesia, the Republic of. the Marshall. Islands, and the Republic of Palau; and (2) are otherwise eligible for such coverage. Author Contact Information Alison Siskin Erika K. Lunder Specialist in hnmigration Policy Legislative Attorney asiskin6*'crs.loc.gov, 7-0260 elunder d`crs.loc.gov, 7-4538 Acknowledgments Chris Peterson and Hinda Chaikind contributed to this report Key ]Policy Staff Area of Expertise Name Phone E-mail Alien/Noncitizen eligibility for health Alison Siskin 7-0260 asiskin@crs.loc.gov care including Medicaid and CHIP Alien/Noncitizen eligibility for public Ruth Ellen Wasem 7-7342 rwasem@crs.loc.gov benefits Health Insurance Exchange, premium Chris Peterson 7-4681 cpeterson@crs.loc.gov and cost -sharing credits Individual mandates to obtain health Hinda Chaikind 7-8913 hchaikind@crs.loc.gov insurance Medicaid and CHIP eligibility Evelyne Baumrucker 7-8913 ebaumrucker@crs.loc.gov Elicia Herz 7-1477 eherz@crs.loc.gov Taxation and noncitizens Erika Lunder 7-4538 elunder@crs.loc.gov Edward Liu 7-9166 eliu@crs.loc.gov Congressional Research Service 8