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DC Exchange a Window on How Immigrants View Health Law

By John Reichard, CQ HealthBeat Editor

October 9, 2013 - Perhaps more than any other insurance exchange in the country, DC HealthLink brings society's haves and have-nots to a single marketplace. While much has been made of the fact that the district's exchange will serve members of Congress and their staffs, there's another potential large customer base: Washington's Hispanic immigrant community.

An event this week at the Carlos Rosario International Public Charter School in the District's Columbia Heights neighborhood offered a look at the many questions immigrants must sort through as they face the health law requirement that they have health insurance in 2014.

Should they shop on the exchange? Would they get subsidies? Do they qualify for Medicaid? Will federal authorities identify them as illegal immigrants if they try to sign up for coverage? What should they do if—as is true in many cases—some family members are in the United States legally and some are not?

Urging the audience of several hundred to enroll in coverage were speakers including D.C. Delegate Eleanor Holmes Norton; Diane Lewis, chair of the board that oversees DC HealthLink; Alicia Wilson, director of La Clinica del Pueblo, a community health center; and Angela Franco, head of the Greater Washington Hispanic Chamber of Commerce.

Theirs was an enthusiastic audience. Carlos Rosario is the nation's first charter school for adult immigrants. It has about 2,000 students, typically working people in their 20s, 30s, and 40s who are taking time outside of their jobs to enroll in classes that enable them to learn English, study for their high school graduate equivalency, and get certain job skills.

It also appeared to be an audience driven by a spirit that's unfamiliar or at best a distant memory to Americans long since settled in the U.S. – the desire to build a better life than those they'd left behind in their native countries. Speakers said the health law offered them an important building block to do so.

But questions posed by the audience made it clear that they have yet to be sold on the new law (PL 111-148, PL 111-152). They share the same uncertainty as others who live here about whether it will help or hurt them. Maria Gomez, a nurse, a health law assister and the founder of Mary's Center, a D.C.-based provider of maternal and child care, sought to inspire the audience to take advantage of the new law and to support the exchange as they try to climb the economic ladder through education. "I'm you. You're me. We walk in the same lives," she said.

"That's what the immigration world is about, right? To give ourselves, and our children, and our grandchildren a different life than what we had back home. So to that I say, savor every moment, seize every word that comes out of the teacher's mouth, and just fly, fly high."

Beyond inspiration, the students wanted facts. One of their biggest questions was what would happen under the health law to the DC Healthcare Alliance, which provides free doctor, hospital, and other care to uninsured city residents with incomes below 200 percent of the federal poverty line. That includes undocumented residents.

"Will I have to get other insurance?" one questioner asked.

"The answer is more complicated than I'd like it to be," said Wilson, who noted that a large percentage of La Clinica del Pueblo's patients are covered by the Alliance program. "If you do not have legal status in the United States, meaning you don't have a valid Social Security number, we are suggesting that you stay on the DC Healthcare Alliance because you will not be able to enter the health exchange and get insurance.

"If you have a legal Social Security number but you are not eligible for Medicaid because you are not a U.S. citizen or a legal permanent resident for more than five years, you have a choice," she said. "You can enter the exchange, or you can stay on the Alliance.

"However, the Alliance so far is not named a qualified health plan. So when you pay your taxes every year, you would still be facing a penalty for not having qualified insurance. For most cases, it makes more sense for people to go into the marketplace and choose insurance provided by a private company, pay for that, versus stay on the Alliance." But Wilson cautioned that it's an individual financial decision.

Norton emphasized that "if you do not have legal status please stay in the Alliance." But she warned that funding for the Alliance is no sure thing. It is 100 percent funded by the residents of the District of Columbia with no assistance from the federal government. The District is facing ongoing cuts from sequester provisions of the budget control law (PL 112-25)—for up to nine years—and "may not be nearly in the position that the health exchange is."

And the exchange offers subsidies, she underscored. "I want to invite all who in fact can go on the DC health exchange to do so. The more people who are on DC HealthLink, the less expensive insurance will be. That is the whole theory" of the health law. "Get everybody in the same pool."

Other questioners wanted to know whether the website was available in Spanish and where they could go for help if they did not know how to use a computer. Wilson said that the site should be available in Spanish in December "and we hope very soon after other languages." In-person assisters can help. "At La Clinica del Pueblo we have nine people who are trained to facilitate enrollment in Spanish and in English and we have access to interpreters who can help as well."

Another question: "Will Obamacare take money out of my paycheck?" That brought titters from the students. Franco said if the employer offered coverage some part of the premium would come out of their paychecks. "If you don't get insurance and you can get insurance, that's when you get a penalty," she said. But "if you have your documents in place ... then we encourage you to look at the exchange because that's when you get a tax benefit"—subsidies to help buy coverage.

Norton cautioned that paying lower premiums would mean paying higher deductibles.

Wilson said "what we have calculated is the risk of not having insurance. It's so much more expensive than the cost of paying for insurance," she said. Coverage "can be as low as $90." She said "it's a lot less expensive to have insurance than to have an accident and spend thousands and thousands of dollars in the emergency room."

Others wanted to know if coverage was only for basic for primary care or also for specialists and surgery, the size of penalties, who qualifies for Medicaid, and whether to apply on exchanges if a child in the family is a citizen but others are undocumented.

People with more than five years as permanent legal residents can qualify for Medicaid if they have incomes up to 200 percent of the federal poverty level in Medicaid. Wilson said the 200 percent is the highest threshold it can be under the law.

Norton said the penalty starts as low as ninety dollars "but this penalty grows and is the worst option."

Wilson noted that "most of the immigrant families in the District are what we call mixed status families where one member has citizenship, one member has a work visa, somebody's on TPS [temporary protected status] and a child is a citizen. In these very complicated situations it's very important for the applicant to talk to an in-person assister."

When people enter their information it pings through to various sites, including Immigration and Customs Enforcement, she said in an interview afterwards. "People risk some exposure if they are going through and say: "I'm undocumented, look at me, hello, hello.'" That's why it's important to use an in-person assister, she said.

Wilson said during the event that people with TPS status do qualify to go to exchanges. But to a questioner who paid taxes using a taxpayer identification number, she said that does not qualify as a Social Security number to enter the exchange.

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