Immigrant Health Care Access and the Affordable Care Act

Published date01 November 2014
Date01 November 2014
Sanjay K. Pandey is Shapiro Chair of
Public Policy and Public Administration in
the Trachtenberg School of Public Policy and
Public Administration, George Washington
University. His research interests lie in public
management and health policy. He received
the 2013 NASPAA/ASPA Distinguished
Research Award, and two of his coauthored
articles were recently recognized as being
among the top 2 percent of all articles
published in Public Administration
Review’s 75-year history.
Joel C. Cantor is director of the Center
for State Health Policy and Distinguished
Professor of Public Policy at Rutgers
University in New Brunswick, New Jersey.
His research focuses on regulation of health
insurance markets, health services delivery
system performance, and evaluation of
health reform. He is member of the editorial
board of Inquiry. He received his doctorate
in health policy and management from
Johns Hopkins University in 1988.
Kristen Lloyd is senior research analyst
in the Center for State Health Policy at
Rutgers University. She works extensively
with population-based surveys f‌i elded by
the center to answer public policy questions
of local and national interest. She received
her master’s degree in public health in 2008
from the former University of Medicine and
Dentistry of New Jersey.
Immigrant Health Care Access and the Affordable Care Act 749
Public Administration Review,
Vol. 74, Iss. 6, pp. 749–759. © 2014 by
The American Society for Public Administration.
DOI: 10.1111/puar.12280.
Sanjay K. Pandey
George Washington University
Joel C. Cantor
Kristen Lloyd
Rutgers University
In spite of major coverage expansions under the Patient
Protection and Af‌f ordable Care Act (ACA), a large
proportion of immigrants will continue to remain
outside the scope of coverage. Because various provisions
of the ACA seek to enhance access, advancing knowledge
about immigrant access to health care is necessary.
e authors apply the well-known Andersen model on
health care access to two measures—one focusing on
perceptions of unmet health care needs and the other
on physician visits during the last year. Using data
from the New Jersey Family Health Survey, the authors
f‌i nd that prior to implementation of the ACA cover-
age expansions, immigrants in New Jersey reported
lower levels of unmet health care needs despite poorer
self-rated health compared with U.S.-born residents.
e article concludes with a discussion of the use of
Andersen model for studying immigrant health care
access and the broader implications of the f‌i ndings.
For more than 50 years, expanding health insur-
ance coverage has been the central plank of
reformers seeking to reshape the U.S. health
care system.  e case for broadly expanding coverage
has been presented both as a social justice imperative
and as a pragmatic cost-saving measure. Although
President Lyndon B. Johnson greatly advanced
this cause by signing the Medicaid and Medicare
programs into law in 1965, universal coverage was
not achieved even after their implementation.  e
Patient Protection and Af‌f ordable Care Act (ACA)
of 2010, the signature domestic policy achievement
of President Barack Obama’s f‌i rst term, advanced the
reformers’ historic quest for universal coverage (see
ompson 2013 for an overview).
Even though the ACA does not enact universal health
care, it squarely addresses the
problem of unequal access.
Specif‌i cally, key provisions such
as advance premium tax credits,
cost-sharing subsidies, and the
Medicaid eligibility expansion
directly target af‌f ordability of
health insurance. Additionally, guaranteed issue rules
and other health insurance market regulations address
access disparities.
Nevertheless, a signif‌i cant proportion of adults remain
outside the ACA coverage expansion because of their
immigration status. Undocumented immigrants are
summarily excluded from all coverage expansion
provisions in the ACA.  e foreign born who do not
meet the f‌i ve-year residency requirement are ineligible
for Medicaid. Although they are eligible for health
insurance exchange subsidies, exchange plans are not
as comprehensive as Medicaid, and unfamiliarity with
private health insurance may make it dif‌f‌i cult to navi-
gate the health care system. Together, the prevalence
of these two immigrant groups (recent arrivals and the
undocumented) imposes limits on the ACA’s potential
to advance health care access for immigrants.
Although the ACA contains measures to bolster facili-
ties that provide services to vulnerable populations,
it will take several years for the net impact of these
measures to become apparent. Hospitals receiving the
disproportionate share hospital (DSH) subsidy—an
important part of the safety net—provide services to
uninsured immigrants, among others. Because of the
increased coverage and carefully crafted DSH reduc-
tion methodology, these hospitals are expected to
be resilient in dealing with long-term DSH subsidy
reductions, set to be phased in starting in 2014 (Hurt
2013; Riley, Berenson, and Dermody 2012).  e ACA
also provides additional capacity-building funds that
are expected to strengthen community health clinics
serving vulnerable populations, including immigrants.
Despite these measures, the sheer size of the immi-
grant population—both those
who are completely outside
the ACA and those who face
barriers that U.S. citizens
may not—stand in the way of
the ACA’s goal of solving the
problem of unequal access.
Immigrant Health Care Access and the Af‌f ordable Care Act
e foreign born who do not
meet the f‌i ve-year residency
requirement are ineligible for

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