Abstract:
Federal legislation in 1996 imposed severe restrictions on immigrant eligibility for public benefits, which created a chilling effect that discouraged even eligible immigrants and their families from accessing needed income, healthcare, and food. States recognized the harm to the community as a whole when some members are excluded from public benefits and have filled in some of these gaps. But the better solution is to reverse the 1996 federal restrictions and reform our public benefit programs for a future society that is increasingly older, and an older adult population that is increasingly immigrant.
Key Words:
immigrants, public benefits, SSI, Medicaid, housing
Maya
Maya is a 68-year-old Ethiopian immigrant who has recently moved to the United States. Her daughter and son in-law moved to the United States two years ago with their three young daughters, and are both pursuing careers in healthcare while working and attending school full-time. Maya immigrated to the United States under a family-based petition to look after her grandchildren while her daughter and son-in-law pursue their careers.
Although Maya is in decent health, the family worries about the future. As a Lawful Permanent Resident, Maya is prohibited under federal law from receiving Medicaid for five years. Because she has only worked as an unpaid caregiver, she does not have enough work credits to qualify for Medicare or Social Security. She qualifies for insurance subsidies under the Affordable Care Act (ACA), but Maya’s family has heard about past efforts to repeal the ACA, and is worried about its future. If Maya were to need help with income, she would not qualify for Supplemental Security Income (SSI) because she lives with her sponsor (her daughter), and some of her daughter’s income would be counted as income to her for SSI eligibility.
Thein
Thein is a 55-year-old asylee from Myanmar. His job at a meat-packing plant is physically demanding, so he can only work 30 hours per week. Also, the job offers no health insurance. He is the sole earner for himself, his wife, and their four children. Because his income and family size place him below the federal poverty level, he does not qualify for insurance subsidies under the ACA. As an asylee, he does not have to wait five years to receive Medicaid, but his state did not expand Medicaid under the ACA, so he is stuck in the “coverage gap.”
Thein has worked for several years without insurance, but as he hears about COVID-19 outbreaks at nearby plants he is worried about an outbreak at his job site. Thein is concerned not only for his own health, but also about exposing his family to the virus. Several workers who contracted COVID-19 are experiencing long-term symptoms that prevent them from returning to work. He has heard that workers who have lost their jobs have trouble applying for benefits. Thein is not sure how he could support his family if he contracts COVID-19.
Rafael
Rafael is a 58-year-old naturalized citizen who eight years ago came to the United States from Venezuela. He was a maintenance worker for several years before he became too disabled to work and now receives Supplemental Security Income (SSI). His rent increases each year by more than the cost-of-living increase in his SSI benefit, which means that with each passing year, he has less income for other basic living expenses. He is on a long waiting list for subsidized housing and worries that he will be pushed out of his apartment due to the rising rent before he can qualify for subsidized housing. Rafael also takes injections for rheumatoid arthritis, which must be refrigerated and administered at specific times each day, and does not know how he would be able to maintain this routine if he lost his home. Rafael values his autonomy and fears he will be forced into a nursing home if his condition worsens.
Maya’s, Thein’s, and Rafael’s experiences represent a few types of precarious situations in which older lower-income immigrants to the United States find themselves. In this article we draw on the above case examples to demonstrate some of the complexities involved in eligibility and access to public benefits among older immigrants in the United States. They provide context for the discussion that follows of the recent history of restrictions on public benefits for older immigrants, some of the choices and repercussions that have led to precarious aging, and directions for change.
‘His rent increases each year by more than the cost-of-living increase in his SSI benefit.’
Older immigrants face additional barriers not faced by non-immigrant older adults when accessing public benefits, which lead to increased and at times life-threatening precarity. There are limited options for older immigrant workers to obtain health coverage in jobs without health insurance. Even naturalized older citizens who qualify for benefits face precarity due to being disproportionately impacted by income inequality, hunger, and rising housing costs.
For older immigrants with long-term health conditions, the reality of harsh living conditions or homelessness can be particularly life-threatening. Older immigrants of color face these obstacles, while also enduring systemic racism from a series of discriminatory policies and practices that are embedded in our institutions. These ongoing, systemic hardships—income inequality, poor access to healthcare, housing insecurity, and systemic racism—are compounded by decades of harmful policies that further complicate and limit immigrants’ access to public benefits.
Recent History of Restrictions on Public Benefits for Older Immigrants
Prior to 1996, citizens and legal immigrants could receive public benefits if they met eligibility criteria for the benefit program, and even undocumented immigrants were eligible for some public benefits. Federal legislation enacted in 1996 and 1997, however, severely restricted eligibility for immigrants of all ages, including older immigrants.
Social and political circumstances in the 1990s partially explain how and why these restrictions came to be. In 1994, California voters enacted Proposition 187, which was intended to bar undocumented immigrants from state benefits, including public education. While most of the provisions were later struck down by the courts, Proposition 187 was a telling example of the anti-immigrant sentiment prevalent at the time.
Two years later, lawmakers would debate some of the most restrictive legislation in decades to limit immigration, including restrictions on access to public benefits. The 1996 legislation (Personal Responsibility and Work Opportunity Reconciliation Act of 1996) imposed severe restrictions on immigrant eligibility for public benefits, under a framework that created a distinction between “qualified” versus “not qualified” immigration statuses. But few immigration statuses were included in the “qualified” category, and individuals in the “not qualified” category were excluded from many public benefits.
As with much else in the area of immigrant eligibility, the rules are complex. For example, the “qualified” and “not qualified” categories do not follow a commonsense understanding of those words and do not necessarily determine whether someone is actually eligible for benefits. A “qualified” individual may still be ineligible for a specific benefit, while an individual in the “not qualified” category can be eligible for some benefits.
The distinction between “qualified” or “not qualified” is just the starting point. From there it is necessary to factor in other categories under which an immigrant falls and the rules of specific benefit programs. The most severe restrictions exist in the Supplemental Security Income (SSI) program, where few non-citizens are eligible, even if they are “qualified.” The high level of restrictiveness is of deep concern as SSI is the federal income support program for some of the nation’s most vulnerable individuals, those with very limited income and resources who are disabled, blind, or ages 65 and older.
While some immigration categories are more likely to be eligible than others, the rules vary program-to-program. Thus, navigating the system is difficult and time-consuming, even for advocates, as it is critical to scrutinize the rules for the particular program. For a more detailed look at the specific rules, see the chart from National Immigration Law Center, and its accompanying table.
Repercussions on Immigrants and Citizens, States and Localities
The repercussions of the 1996 changes were felt by individuals, by localities, and by states. Jurisdictions were already contending with pre-existing barriers to serving immigrants, including cultural differences and language competence, which hampered outreach into immigrant communities. The 1996 restrictions on benefit eligibility further hampered outreach by generating confusion and fear in immigrant communities. Immigrants and their families had concerns (and continue to have them today) around privacy; whether receiving public benefits would prevent them from improving their immigration status; and, for many older immigrants, how their immigration sponsor (often family members) might be negatively affected if they chose to receive public benefits.
Restrictive policies on immigrant access to benefits create a chilling effect that spreads far beyond those directly impacted, causing confusion, delays, and fear that deter older immigrants and U.S. citizens, as well as their families from accessing healthcare, income, and nutrition benefits for which they are eligible.
Given the complexity of immigration policies, these damaging consequences still occur even when information and education is provided to the public. Problems stemming from “public charge,” a policy that allows officials to deny an application for lawful permanent residence or entry into the United States if authorities determine an immigrant is “likely to become a public charge,” contributed to the confusion. Even though the law on public charge did not change in 1996, misapplication of the law immediately after the 1996 changes contributed to the chilling effect on immigrant access to benefits.
‘There was no way to target immigrants without causing the well-being of the entire community to suffer.’
This chilling effect spilled over to immigrants who were not affected by the 1996 restrictions and U.S. citizen children in families that include some members who are documented and some members who are undocumented. It is estimated that 6.1 million U.S. citizen children live in these “mixed status” families. Among these families, participation in health insurance dropped dramatically (Kaushal and Kaestner, 2005), also impacting children’s graduation rates from high school (Filindra, Wichowsky, and Condon, 2016).
The importance of ensuring that everyone, regardless of status, has access to care and support is readily apparent. Not having this access harms the individuals who are excluded, depriving them of resources to meet basic needs for rent and utilities, needed medical care, and nutritious food. Less recognized is the harm to family members who are eligible immigrants and U.S. citizens, and the broader community to which they all belong.
As repercussions of the restrictions played out in the years after 1996, the geographic distribution of immigrants in the United States was changing. Immigrants moved from being concentrated in a few states to living all over the country. States and localities throughout the United States confronted the reality that harming immigrants would also harm citizens, and that there was no way to target immigrants without causing the well-being of the entire community to suffer.
Public benefits help a broad swath of society—immigrants and citizens alike. A recent study revealed that three in ten U.S.-born citizens received Medicaid, Supplemental Nutrition Assistance Program (SNAP), Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), or housing assistance in just a single year, and around half of U.S.-born people participated in at least one of these programs in a twenty-year period from 1997 to 2017 (Trisi, 2019).
Program participation also can save lives, in addition to reducing costs, with greater Medicaid eligibility having been found to save the lives of more than 19,000 adults ages 50 to 64 across a four-year period in states that expanded Medicaid eligibility (Broaddus and Aron-Dine, 2019). Greater Medicaid eligibility also has been found to increase tax revenue from individuals (Brown, Kowalski, and Lurie, 2019), and spending on SNAP for older adults was found to reduce hospitalization costs (Samuel et al., 2018).
In the face of these realities, Congress began to fill in some of the gaps. From 1997 to 2002, Congress restored SSI and SSI-related Medicaid for some individuals who were in the United States at enactment of the 1996 law, restored food stamps eligibility for some individuals who were in the United States at enactment of the 1996 law, and restored food stamps eligibility for individuals five years after their entry to the U.S. (Balanced Budget Act of 1997; Agricultural Research, Extension, and Education Reform Act of 1998; Farm Security and Rural Investment Act of 2002).
States Have Made Different Choices in the Years Since 1996
States began to make different choices as well. While the apparent aims of the 1996 changes were to exclude immigrants from public benefit programs, with a reduction in the benefit rolls representing achievement of that aim, community well-being was in tension with those aims. Such community well-being values led many jurisdictions to mitigate the harms of the 1996 restrictions by devising state and local public benefit programs.
From a governance perspective, states and localities recognized that ensuring basic stability for all residents is good for the well-being of the state. Wider access to basic public goods promotes a stronger state. Particularly when it comes to healthcare, about half of states now use state funds to fill in the gaps created in federal law, particularly to cover pregnant women and children (National Immigration Law Center, 2020a). Illinois now has healthcare for older adults, regardless of status, and other states like Washington have medical assistance for lawfully residing older adults who are not eligible for federal Medicaid. California has a generous Medicaid program, which includes long-term care regardless of status.
Even with income supports where public policy can be more challenging, six states provide nutrition assistance to immigrants who are not eligible for SNAP benefits (National Immigration Law Center, 2021a). More than twenty states use state funds to fill in gaps in TANF (National Immigration Law Center, 2020b). Five states use state funds to fill in gaps in SSI, with programs in California and Maine providing assistance at the SSI-benefit level to immigrant categories that had lost eligibility for SSI in 1996 (National Immigration Law Center, 2020c).
Harmful Policies Directly Lead to Precarious Aging
Unfortunately, even as many states have filled in at least some of the gaps, many gaps remain, resulting in detrimental outcomes. About 45 percent of undocumented immigrants, and nearly a quarter of lawfully present immigrants, are uninsured (Kaiser Family Foundation, 2020). During the COVID-19 pandemic, obstacles to healthcare access are especially concerning as a matter of public health. Confusing eligibility rules for lawfully present immigrants also can serve as a significant barrier. Lawful Permanent Residents like Maya who arrive through family-based petitions are barred from Medicaid for five years, even if she otherwise qualifies based on her age, limited assets, and income (National Immigration Law Center, 2021b). Thein, on the other hand, would qualify for Medicaid because he entered as an asylee and thus is not subject to the five-year bar.
These arbitrary distinctions prevent some immigrants from promptly accessing healthcare, resulting in troubling outcomes for immigrants later in life (Population Reference Bureau, 2013). Among adults ages 65 and older, foreign born immigrants identifying as Latino/a, Black/African-American, or Asian reported more chronic diseases, reduced Activities of Daily Living, and poor mental health compared to U.S.-born older adults (Du and Yu, 2016).
Decades of reduced healthcare access ultimately culminates in advanced age when considering long-term care options. Chronically uninsured and underinsured adults are more likely to end up in a nursing home, and have longer nursing home stays instead of receiving home- or community-based care. Plus, nursing homes with a large share of residents of color tend to be lower quality due to high staff turnover and poor facilities, thus exacerbating poor health outcomes and quality of life for low-income older immigrants (Lowenstein, 2015).
Like Rafael, most older adults prefer “aging in place,” meaning they receive long-term care services while living in their own home, as opposed to entering a nursing facility. Yet, in addition to healthcare disparities and eligibility determinations, housing disparities also prevent older immigrants from accessing supportive housing or in-home care through Medicaid Home & Community Based Services (HCBS).
Homelessness and housing insecurities increase the likelihood of hospitalizations and reduced life expectancy (Kushel, 2012). While many older immigrants may rely upon the informal support of family members for housing, informal caregiving is not an adequate substitute for paid, professional aides through Medicaid or Medicare. Family caregivers likely do not have training like professional aides and often work outside the home, thus they cannot provide adequate support for an older adult, particularly for those requiring intense and complex medical care (Gershon and Carlson, 2018). Older immigrants, with or without family support systems, live in fear and anxiety over their lack of options for safety net programs (Farrell, 2016).
The challenges facing older immigrants will only be magnified as aging immigrants become a larger portion of the U.S. population. The U.S. Census Bureau projects immigrants ages 65 and older will make up nearly a quarter of the entire ages 65 and older population by 2060, compared to the about 14 percent currently (Mizoguchi et al., 2019). While historically older immigrants entering the United States in the early twentieth century were overwhelmingly European, the number of older European immigrants has declined significantly (Mizoguchi et al., 2019). Older immigrants now predominantly arrive from Asian and Latin American countries, with those trends expected to grow in the coming decades. As the population grows, older immigrants serve an increasingly crucial role in society.
Vital Roles of Immigrants
Immigrants historically have performed vital roles in building our nation and continue to be prominent contributors in strengthening America’s resilience and capacity. Most recently, we have witnessed and benefitted from immigrants’ strong presence as essential frontline workers during the COVID-19 pandemic, and as caregivers and healthcare workers. Immigrants make up nearly one in five of all essential workers and are more likely to work in agriculture, housing, and food production services (FWD.us, 2020).
Xenophobic rhetoric, however, has downplayed the critical role immigrants play in the United States economy, and the uneven risks faced by immigrant workers often are overlooked. Workers like Thein are 50 percent more likely to contract COVID-19, given their risk of exposure on the frontlines (Clark et al., 2020). Despite these grave risks, immigrants continued to fulfill commitments through crucial jobs during the national crisis with reduced pay and limited protections (Straut-Eppsteiner, 2020).
Older immigrants’ contribution to informal, unpaid family caregiving as well as paid, formal caregiving is vital to society. Caregiving is an essential role in the U.S. economy, enabling individuals to pursue vital careers, as was the case with Maya. Without Maya serving as an informal caregiver, her daughter and son-in law would have been unable to pursue their professions.
‘Regulatory burdens on states around verification of immigration status further harms older immigrants.’
In addition to addressing childcare needs, older immigrants support older adults. In 2017, immigrants accounted for more than 18 percent of all U.S. healthcare workers, and 30 percent of all long-term care workers. Immigrants working in healthcare are more likely to be older than their U.S.-born counterparts, and more likely to have completed a four-year college degree (Carroll, 2019). The role of older immigrants in healthcare and long-term care is critical given the limited number of providers available to provide care to our aging population due to historically low wages, high turnover, and few benefits. Without a strong workforce, older adults on Medicaid HCBS will be unable to receive necessary care (Machledt, 2020). The precarity older immigrants face due to barriers in accessing healthcare and other benefits does not reflect their contributions to systems of care, including formal and informal caregiving.
Looking Ahead to a New Administration and a Post-COVID World
With a new federal administration in place, we have an opportunity to redress past legislative mistakes and reform public benefits programs for the future. In a reimagined economic and healthcare support system that protects public health and helps secure an economic recovery, it is essential that we ensure that everyone, regardless of their status, has access to care and support. One initial step would be to restore pre-1996 standards of immigrant eligibility. In a society of citizens and immigrants with varied statuses living in a communal economy, a confusing and fear-inducing patchwork of eligibility leads to fewer people who need help actually getting that help, which defeats the purpose of these vital public programs.
Regulatory burdens on states around verification of immigration status further harms older immigrants. States are required to verify the immigration status of beneficiaries receiving public assistance programs like Medicaid, SSI, and SNAP (Kaiser Family Foundation, 2007). The verification process can be costly to states, burdensome for beneficiaries seeking to provide the information, and often leads to wrongful terminations and denials due to technical errors. Immigration verification should be simplified to avoid costly errors for older immigrants.
The COVID-19 pandemic magnified the importance of older immigrants to our infrastructure (FWD.us, 2020). Looking ahead in a post-COVID world and with a new administration, barriers to immigrants’ access to healthcare must be removed. While the 1996 restrictions created a significant burden for older immigrants, recent harmful regulatory actions must also be remedied. The previous administration sought to expand the number of public benefits that could be considered under the “public charge” rule, which puts some immigrants at risk of being deemed “inadmissible” if they access certain government benefits (Justice in Aging, 2020). The administration also revoked anti-discrimination protections for individuals with Limited English Proficiency under Section 1557 of the Affordable Care Act. While the public charge rule changes have now been reversed (Department of Homeland Security, 2021), Section 1557 protections remain revoked and should be reinstated to provide security for older immigrants.
In addition to removing these barriers, the United States must affirmatively provide additional security for older immigrants. Tedious state Medicaid eligibility requirements prevent eligible immigrants from accessing Medicaid in a timely manner, if at all. Expanding Medicaid HCBS provides older immigrants with the dignity of aging in place. Promoting pay equity among immigrants in essential services like healthcare is also necessary to protect our aging population, particularly in Medicaid HCBS and other long-term care settings, and provides security for immigrant workers as they enter retirement.
We should also reform the public benefits programs that address economic security for older adults. This should include strengthening SSI and Social Security by updating the SSI resource limits and income disregards, which have remained the same for 40 years even as the cost of living has increased steadily over that time; eliminating SSI rules that reduce or withhold benefits when an individual gets help with living costs or transfers an asset (even small amounts of money to a family member); increasing federal SSI benefits to 100 percent of the Federal Poverty Level; and increasing the Social Security minimum benefit to 125 percent of the Federal Poverty Level.
Conclusion
Looking ahead means seeking a better purpose and outcome of federal policies on immigrant eligibility for public benefits. Rather than introducing policies that make people afraid to access healthcare, nutrition, or income assistance, national policy should provide individuals and communities with the resources to ensure that people are healthy, fed, and safe. Increasingly, people and institutions are recognizing inclusion as an important value and a necessary outcome of interconnected communities. The pandemic has provided insistent lessons in how we are interconnected not just as localities and states, but truly globally, and lessons in why we need to provide access to all.
The disproportionate impact of COVID-19 on immigrants generally and immigrant elders specifically can help inform the work of reforming our public benefits system, by highlighting areas where our current systems have gaps. For those working with immigrant older adults, it is important to document the harm and fear caused by restrictions on eligibility for immigrants, as well as the benefits when low-income elders have access to safety net programs. Through this work, we can enter a post-COVID world with federal policies that value the contributions of immigrant older adults and ensure that they can thrive.
Trinh Phan is a senior staff attorney at Justice in Aging in its Oakland, California, office. Gelila Selassie is a staff attorney at Justice in Aging at its Washington, DC, office.
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