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George Washington University Researchers Say Study Results Point to the Need for Better Training of INS Hearing Officers on the Issue of Medicaid and Public Charge

The ability and willingness of immigrants to access Medicaid and health care services have been adversely affected by the enactment of the 1996 welfare and immigration reform laws according to the results of a study released today by the Center for Health Services Research and Policy (CHSRP) at The George Washington University Medical Center (GWUMC) School of Public Health and Health Services (SPHHS).

"It is clear from our research that immigrants too often are either excluded from benefits they desperately need or don't access benefits for which they are eligible out of fear that it will adversely impact their immigration status," noted Kathleen A. Maloy, JD, PhD, the study's principal investigator and Associate Research Professor at GWUMC SPHHS.

One significant barrier identified by the study is the fear that an immigrant's legitimate use of Medicaid will jeopardize that immigrant's ability to become a legal permanent resident or US citizen. The Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA) of 1996, one of the two laws whose impact the researchers examined, established certain procedures for determining the admissibility of immigrants and the INS later issued a clarification related to the issue of Medicaid use and public charge.

"Despite the federal clarification about public charge-which stated that any use of Medicaid (except long-term care) and CHIP would not by itself subject an immigrant to the risk of being labeled a public charge-we frequently heard reports in our research that immigration lawyers are advising their clients not to use Medicaid in order to avoid any risk of problems," noted Dr. Maloy. "There is a clear sense among both immigrants and immigration attorneys that the INS' own staff, especially hearing officers, are not aware of or are not following this policy and instead punishing immigrants for using Medicaid."

"These findings highlight the critical need for a major initiative by immigration advocates and lawyers to push the INS to better communicate its policy internally and to better train hearing officers so that immigrants' rightful use of Medicaid is no longer a threat to residency or citizenship status," said Maloy.

Maloy and other researchers talked with 225 immigrants in four major cities who reported numerous barriers to accessing Medicaid and frequent need to delay or forego care. The researchers found two general categories of barriers to access:

  1. barriers related to immigrant status and the 1996 laws, including fear of the INS, concerns about public charge, and changed eligibility criteria; and
  2. barriers related to their vulnerable and low-income population status, including culture and language, inaccessible locations for applying, complex application procedures, and inability to pay for health care services.

The study, entitled "Effect of the 1996 Welfare and Immigration Reform Laws on Immigrants' Ability and Willingness to Access Medicaid and Health Care Services, was designed to investigate concerns that the combined effects of IIRIRA and the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) would reduce immigrants' legitimate use of Medicaid and health care. The study was conducted at four sites in: Chicago, IL; Metropolitan Washington, DC; San Diego, CA; and Brownsville, TX.

"We concluded that the implementation of the 1996 laws increased the uninsured population, exacerbated demands on the safety net, and heightened fears about using Medicaid," commented Sara Rosenbaum, JD, Director of the CHSRP and Harold and Jane Hirsh Professor of Health Law and Policy.

PRWORA established new, complex eligibility rules for public benefits for legal immigrants and made several categories of previously eligible legal immigrants ineligible for most federal public benefits. The law created more uninsured US residents by denying Medicaid access to previously eligible post-enactment legal permanent residents. The result has been additional strains on the provider safety net, making access to care more difficult for all groups of the uninsured-citizens and immigrants alike.

The researchers recommendations for how federal and state officials and policymakers can address the health care access problems faced by immigrants include:

  1. improve outreach and education efforts to clarify scope of public charge, and include a particular focus on INS staff at all levels and immigration attorneys;
  2. simplify Medicaid application procedures;
  3. improve and establish systematic outreach and education efforts about who is eligible for Medicaid;
  4. address the cultural and linguistic barriers to accessing Medicaid and health care services;
  5. provide more support and financial assistance to safety net providers;
  6. provide more support for public health outreach and education to vulnerable populations; and
  7. expand Medicaid out-stationed and alternative enrollment locations.

"It is noteworthy," stated Dr. Maloy, "that most of the recommendations are not unique to immigrants but would be part of strategies to improve Medicaid enrollment and/or expand access to health care for citizens and noncitizens alike."

The study was funded by The Robert Wood Johnson Foundation as part of the Foundation's commitment to funding research examining the impact of welfare reform on access to Medicaid and health care services. The study is available on-line at under "What's New" or can be ordered by calling the Center for Health Services and Policy, The George Washington University Medical Center School of Public Health and Health Services at 202-530-2337.

Founded in 1824, The George Washington University Medical Center is a nationally recognized, interdisciplinary academic health care center comprising the University Hospital, the GW Medical Faculty Associates, the School of Medicine and Health Sciences, the School of Public Health and Health Services, and the GW Health Plan. To learn more about the GW Medical Center, visit .

The GWUMC School of Public Health and Health Services (SPHHS) is the only School of Public Health in the nation's capital and the first school to formally combine public health and health services. SPHHS offers dynamic research, education, and service programs through five departments: Environmental-Occupational Health, Epidemiology-Biostatistics, Health Services Management and Policy, International Public Health, and Prevention and Community Health.

The SPHHS' Center for Health Services Research and Policy conducts sponsored research and policy analysis on complex health policy issues. Capitalizing on the unique resources and environment created by its location in Washington, DC, the Center identifies, monitors, and analyzes emerging issues in federal health law and policy and evaluates the impact of changing federal policies on states, communities, and the health care system.

Reprinted with Permission