The Affordable Care Act and California Immigrants: Implementing Policies and Practices for the Remaining Uninsured

Abstract
As the immigration reform debate unfolds in Congress, one contentious topic not on the table is health care coverage for the 11 million undocumented immigrants who might benefit from the passage of immigration reform legislation. The Affordable Care Act (ACA) will be fully implemented in 2014, but it will not cover undocumented immigrants. This research report, a result of analysis conducted by undocumented immigrant youth and their allies, outlines current health care policies and programs and examines the obstacles undocumented immigrant youth and families face when attempting to access these services. The report also offers innovative legislative, policy, and program recommendations aimed at expanding health care opportunities for all, including undocumented immigrants.
Key words: Affordable Care Act, ACA, Obamacare, health, health access, immigration, immigrants, immigration reform, undocumented, undocumented youth, undocumented immigrant youth, California, Deferred Action for Childhood Arrivals

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The Affordable Care Act and California Immigrants: Implementing Policies and Practices for the Remaining Uninsured

Introduction
The California Endowment, the UCLA Center for Labor Research and Educations Dream Resource Center, and MALDEF Property Management Corporation hosted a conference, We Own the Dream: Healthy ImmigrantYouth Development in Southern California, on January 28, 2013, in downtown Los Angeles. The convening brought together undocumented immigrant youth leaders, The California Endowment grantees from the Building Healthy Communities initiative, and immigrant rights, health care service, and community organizations in Southern California. The goal of the convening was to address current health care challenges, along with opportunities, for immigrant communities and in particular undocumented immigrant youth and their families.

Low-income immigrant families throughout the country frequently lack health care coverage and resources, and not enough is being done by local, state, and federal governments to address the problem. Undocumented immigrants face additional obstacles when trying to access health care and other public benefits because of their immigration status. While the ACA explicitly excludes undocumented immigrants from its coverage, nonprofit and community organizations engage in advocacy efforts and develop creative strategies to provide and expand services to these communities.

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The Affordable Care Act and California Immigrants: Implementing Policies and Practices for the Remaining Uninsured

Part 1: Policy Review

In the current political climate, immigration and health care are two of the most contentious policy issues. At their intersection, these two issues become even more controversial and complex. The ACA and immigration reform proposals in Congress will have a marked impact on access to health care for immigrantsboth documented and undocumentedin the United States for years to come. Since 1965, government-funded insurance for low-income and elderly Americans has been provided through Medicaid and Medicare, while a majority of Americans have coverage through their employers or private plans. Undocumented immigrants were ineligible for benefits under Medicaid or Medicare until the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) granted this population access to emergency care at hospitals. EMTALA prohibits hospitals from denying emergency medical care to anyone who cannot afford to pay (National Health Law Program 2008, 7). Immigrants access to other publicly funded health programs was reduced by the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), commonly known as welfare reform, though access varies from state to state (US Department of Health and Human Services 2012). Among other restrictions under PRWORA, lawfully residing, low-income immigrant adults must wait five years after obtaining lawful permanent resident status before they become eligible for Medicaid. The ACA will not change this policy.

The Affordable Care Act

The Patient Protection and Affordable Care Act of 2010, also known as the ACA or Obamacare, will have a major impact on health care access in the United States by extending coverage to 25 million Americans (Banthin and Masi 2013). The ACA is the biggest government expansion of the US health care system since Medicaid and Medicare began in 1965. By 2014, almost everyone residing in the United States will be required by law to have health insurance and will be penalized if they cannot maintain the minimum essential coverage. Those who already have insurance through their employers, a private policy, or through Medicaid or Medicare can continue with those options and do not have to take further action. Those currently without coverage can purchase from a health insurance marketplace and may be eligible for a tax subsidy to help with the cost or, in some states, may participate in the expanded Medicaid plan (Health Insurance Marketplace 2013). However, it is estimated that 31 million Americans will remain uninsured by 2023 (Banthin and Masi 2013). The majority of the uninsured will be disproportionately Latino, African American, and Asian Pacific Islander, including undocumented immigrant youth and families. In California alone, there will be an estimated one million uninsured undocumented Californians, 2733 percent of the uninsured population in the state (Health Access 2013, 3). Under the ACA, undocumented

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The Affordable Care Act and California Immigrants: Implementing Policies and Practices for the Remaining Uninsured

immigrants remain ineligible for federal coverage or public benefits, including Medicare, nonemergency Medicaid, and the Childrens Health Insurance Program (CHIP) (National Immigration Law Center 2013). Undocumented immigrants are not allowed to purchase private health insurance in the state insurance marketplace, nor are they eligible for lowered copayments or premium tax credits. Those born in the United States and lawfully present children of undocumented parents may purchase from the state insurance marketplace and are eligible for premium tax credits and Medicaid or CHIP in states that have chosen that option to cover children (National Immigration Law Center 2013). Low-income undocumented immigrants remain eligible for emergency Medicaid under federal law and may also seek nonemergency medical services at safety-net hospitals, community clinics, and free clinics. Those who are lawfully present1 in the United States are eligible for the new affordable coverage options starting January 1, 2014. Lawfully present immigrants are subject to the individual mandate and related tax penalty, may be exempt from the individual mandate if they meet specific exemptions or are low-income, are eligible for premium tax credits and lower copayments, and may enroll in a qualified health plan through the state insurance exchanges (National Immigration Law Center 2013). Lawfully present immigrants are also eligible for the Pre-Existing Condition Insurance Plan and the Basic Health Plan, if the latter plan exists in their states. In addition, since 2009, lawfully present immigrant pregnant women and children can benefit from Medicaid and CHIP in states that provide these benefits, without the five-year eligibility bar. The many and complicated restrictions of ACA placed on the immigrant community raise numerous concerns. One is access to health care for mixed-status families. It is estimated that one in every four children in the United States (approximately 18.4 million), are from an
1 The US Department of Health and Human Services has defined lawfully present as those classified as qualified immigrants by US Code Title 8 and other non-US citizens who have authorization to work and live in the United States, such as refugees, asylum recipients, survivors of domestic violence, and other humanitarian immigrants.

immigrant family,2 and 4.5 million are US-born citizen children with undocumented parents (Wiley 2013). Children of undocumented parents are more likely to be uninsured than children born to US citizens. Even if a child of undocumented parents is insured, affordability could still be an issue as certain services and medications require out-ofpocket payments (Ryan 2009). Immigrant families report that there are other deterrents from seeking medical services, such as language barriers, unequal treatment by the health care system, and the fear of deportation of parents or other family members (Ryan 2009). It is projected that 43,000 US-citizen children will see a decline in their health due to the detention or deportation of a parent or family member (Wiley 2013). Because of these concerns, current immigration reform efforts must include the provision of health care benefits for all immigrant families. Excluding health care access for newly legalized individuals could also set a precedent for future immigration reform proposals that would embolden state lawmakers to discriminate against immigrants when legislating access to services. Lastly, these restrictions support the myth that undocumented immigrants come to the United States to take advantage of public benefits, rather than to reunite with family or seek job opportunities. In fact, studies estimate that immigrants contributed $115.2 billion more to the Medicare Trust Fund than they used between 2002 and 2009 (Zallman 2013, 1156).

Deferred Action for Childhood Arrivals and the Affordable Care Act
On June 15, 2012, President Obama announced that the Department of Homeland Security would grant two-year deferred action status to young undocumented immigrants who meet certain eligibility criteria. Deferred Action for Childhood Arrivals (DACA) grantees may obtain employment authorization and are protected from deportation during a renewable two-year period. In addition, these youth may qualify for certain state benefits, such as drivers licenses and in-state tuition, though these vary from state to state.
2 These children, also referred to as immigrant children, are either US- or foreign-born, with at least one parent who is foreign-born.

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The Affordable Care Act and California Immigrants: Implementing Policies and Practices for the Remaining Uninsured

Although DACA recipients are considered lawfully present in the United States, Obama issued a policy change in August 2012 that excludes them from the affordable health insurance options available through the Affordable Care Act. Prior to this policy change, DACA grantees under the age of 21 qualified for low-cost health insurance through their states Medicaid program or CHIP , if their states elected to extend coverage to immigrant children through the Childrens Health Insurance Program Reauthorization Act. With the 2012 policy change, DACA grantees are considered undocumented for health insurance purposes and are no longer eligible for Medicaid, CHIP , or the new health insurance options provided by the ACA (National Immigration Law Center, 2012). This change does not affect individuals granted deferred action through policies other than DACA. DACA recipients can obtain health insurance through their employers if it is available, or they can purchase full-price health insurance outside of the marketplace, though they will not be eligible for the federal premium tax credits. It is not known if DACA recipients will qualify for the Basic Health Plan (BHP) if it is available in their states. In short, most DACA beneficiaries will only be able to access the limited health care programs that are available to anyone regardless of immigration status. These programs include free community clinics, public safety-net hospitals, the Emergency Medicaid program, emergency hospital care, and public health services. In some states like California, DACA beneficiaries may be able to access statefunded health programs such as Medi-Cal, if they meet the eligibility criteria (Richard 2013).

2013). The resulting lack of preventative care will put a further strain on emergency care, safety net programs, and community health centers. Furthermore, US citizen children of immigrant parents who would qualify for these public benefits are often times left uninsured due to fears, misinformation and barriers parents hold (US Department of Health and Human Services 2012). Parents often times postpone the registration for their childrens health care due to fear of exposure of their own immigration status to government authorities. In some instances, immigrant parents believe that their US citizen children are not eligible for such benefits because the parents do not qualify. Language and cultural barriers for the parents also affect the native-born childrens prospects of receiving appropriate health care services. According to the Migration Policy Institute report, 17 % of US citizen children with non-citizen parents are uninsured in the country, compared to 12% of those with US citizen parents (Ku, Jewers 2013). As implementation of the Affordable Care Act takes place in California, it is imperative that education efforts are focused on mixed-status families to ensure that those who do qualify for insurance program make use of it.

California, DACA, and the ACA

California is home to more than 25 percent of DACA-eligible youth (Hill and Hayes 2013). DACA grantees may be able to qualify for expanded benefits due to take effect on January 1, 2014, and for Medi-Cal, a state-funded program created in 1995 by California policymakers in response to the restrictions on Medicaid created by PRWORA. An estimated 73,000 DACA grantees who meet the Medi-Cal requirements may be able to access those benefits (Richard 2013). With the largest population of undocumented immigrants in the country, California will be an example for other states. Advocates will be keeping an eye on California health care policies and how they impact the undocumented population.

California and the Affordable Care Act

As a result of the Affordable Care Act, an estimated 4.7 million Californians will gain access to health care coverage through the Medi-Cal expansion plan or through the states Health Insurance Marketplace, Covered California. California has the largest undocumented immigrant population in the country, an estimated 2.6 million people, 23 percent of the nations total. Some will be covered through their employers, and this could extend to their children; however, an estimated one million undocumented immigrants in the state will be excluded from these benefits (Hill and Hayes

Safety-Net Programs
Safety-net program is a loose term for any source of health care for the uninsured, such as free services at local clinics and public hospitals.

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The Affordable Care Act and California Immigrants: Implementing Policies and Practices for the Remaining Uninsured

These programs typically operate by identifying the poorest uninsured immigrants and assigning them membership numbers. Membership allows them to receive basic care from their assigned doctors. These programs are not to be confused with health insurance; safety-net programs only provide access to limited resources, rather than an entitlement to a defined standard of care. Low Income Health Programs (LIHP), offered in 53 out of 58 counties, cover over 550,000 Californians who cannot acquire health insurance and are part of a statewide infrastructure to address the needs of the uninsured (Health Access 2013, 2). Although limited, these programs offer preventative and primary care services and are a more

comprehensive option than emergency care only. However, this program is set to expire at the end of 2013 due to legislative inaction (Health Access 2013, 1). These safety-net and county programs are crucial for uninsured undocumented immigrants who would otherwise have no access to nonemergency medical care. But these resources are limited, and accessing them is difficult because of language barriers and lack of information about them in immigrant communities. As the nation and states prepare to implement the ACA, it is uncertain what will happen to these programs that are so essential for the undocumented and low-income populations.

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The Affordable Care Act and California Immigrants: Implementing Policies and Practices for the Remaining Uninsured

Part 2: Policy Recommendations

Ensuring that undocumented immigrants in the United States are integrated into the health care system will not be easy, especially given how contentious these issues are today. Those who advocate for health care and immigrant rights must address the intersectionality of these issues. While advocates push for a comprehensive immigration reform bill that would address the lack of access to health care for US immigrants, there are other possible plans that would ensure access to health care for everyone, regardless of immigration status. The following recommendationsranging from national policies to institutional plans to day-today practicesare based on the lived experiences of undocumented immigrant youth and health care and immigrant rights advocates. healthier than their US-born counterparts (Zallman 2013, 1157). Immigrant integration into the health care system would potentially increase the health insurance pool and bring costs down for everyone. In addition, creating preventative care options for immigrants would mean lowering emergency care costs and avoiding chronic illnesses that lead to costly procedures and treatments in the long run.

Mid-Term Solution: Bi-National Health Insurance Programs

Bi-national programs offer a mid-term solution that would give access to medical services to undocumented immigrants who would otherwise have no health care. Kasi Chadwick (2012, 124) created a cross-border pilot program, Salud Migrante, which provides Mexican guest workers with ambulatory and emergency health care services through community clinics in the United States and comprehensive coverage through the government-run health care program Seguro Popular in Mexico. The program is funded by a $30 per worker per month fee assessed by the Mexican government. Amelia Valenzuela (2012) recommends a similar approach for border states. Because of their unique location and demographics, these states can help alleviate the costs of uncompensated care by increasing the number of insured Mexican immigrants living within their borders. First, states can establish private bi-national health insurance

Long-Term Solution: Immigration Reform

Any just and humane immigration reform proposal must ensure the full integration of undocumented immigrants, including equal access to health care and an end to the five-year waiting period for recent lawful permanent residents. The waiting period creates second-class citizenship status for that population and puts an unnecessary strain on emergency health services. There are benefits for everyone to an expansion of health care. Studies show that immigrants use fewer health care services and tend to be younger and

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The Affordable Care Act and California Immigrants: Implementing Policies and Practices for the Remaining Uninsured

programs with Mexico for documented Mexicans. Second, states can cooperate with the Mexican government to facilitate Mexican-sponsored health care for undocumented Mexicans. One limitation of these programs is that they would provide health services only to people of Mexican origin and exclude immigrants from other countries. It is also uncertain how these programs would operate under the ACA and the marketplace.

assisting with paperwork, providing empathetic care, and linking patients to community resources. Because of the possible repercussions of the disclosure of their undocumented status, patients may delay seeking services and may be fearful once they do. Health care providers can help allay these fears and make sure their policies and practices do not create additional obstacles for immigrants.

Programmatic Recommendations
The following recommendations are provided by the Collective of Immigrant Resilience through Community-Led Empowerment (CIRCLE) Project based on the experiences of the projects members and partnerships with community health organizations that support immigrants and uninsured populations in Southern California. CIRCLE is a project of the UCLA Labor Centers Dream Resource Center and provides talking circles for immigrant youth to speak out about the stressors related to their undocumented immigrant identity. 1. Commitment to Social and Health Justice In the summer of 2011, CIRCLE organized a convening to assess the wellness needs of immigrant youth. Participants shared that they felt safer going to a community clinic that incorporated a social justice framework into its service delivery and organizational mission. 2. Assessment of Current Program Practices It is crucial to assess a programs practices and policies in relation to paperwork, referrals, and services to minimize the barriers for immigrants who seek health services.
Forms, Intakes, and Triages Intake forms or triages that seek to gather basic information, the presenting health problem, and health history can cause stress and anxiety for immigrant patients. Immigrants may be unable or afraid to provide information like social security numbers, citizenship status, and methods of payment. Modifying intake forms is an initial step to making immigrants feel welcome. Make sensitive questions optional, and provide payment options that include free or low-cost services. If these are not available, link patients to outside service agencies that can assist.

State and Local Policy Recommendations

California should continue its local safetynet programs. Especially for states with larger immigrant populations, the continuation of programs that offer preventative care will reduce the use of expensive emergency services and lower overall health care costs. California should also consider providing state tax credit to those who cannot purchase insurance. The California Immigration Policy Center reports that immigrants, including undocumented immigrants, in California alone pay an estimated $2.7 billion in sales, income, and property taxes. State tax credits could free up health care funds for tax-paying immigrants who are left out of the ACA marketplace.

Advocacy from Health Professionals

Health professionals, including doctors, nurses, therapists, counselors, and healers, must be advocates for immigrant communities, regardless of status. Health advocates can help people understand the need for universal health care access for all immigrants. Patients personal stories and experts opinions make a difference in policy debates and public sentiment. Advocates can send state representatives letters detailing the need to cover all Californians, including undocumented immigrants, share their clinical expertise in working with immigrant communities, and outline the challenges of providing these services. Health professionals can support organizations leading the efforts to advance health access and take on this role themselves if necessary. On a clinical level, health care providers can help patients access often complex systems of care by

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The Affordable Care Act and California Immigrants: Implementing Policies and Practices for the Remaining Uninsured

Referral Services Referrals should include legal services and clinics that cater to immigrants, such as immigrant rights centers and organizations that provide physical or mental health services for the specific issues facing undocumented immigrants, counseling for victims of human trafficking, and safe spaces for queer undocumented youth. Counseling Services Consider providing safe spaces for immigrants who seek counseling. The CIRCLE Project provides opportunities for immigrant youth to speak freely about the stressors related to their undocumented immigrant identity. The talking circles create healing spaces for youth and act as a link for those who need professional counseling. For more information about how to implement a talking circle, contact the CIRCLE Project at undocucircle@gmail.com.

legislation, current health practices, and policies that affect undocumented immigrants. These staff can also provide support or training for other staff who have concerns or need more information on how to support immigrant communities. 5. Create Safe Spaces for Intersecting Identities Undocumented immigrants may have other issues to address besides just their status. Intersecting identities can include gender, sexual orientation, age, ability, and race or ethnicity. For example, the undocumented male experience differs from the undocumented female experience; immigrant youth who are forced to enter the workforce or who are heads of households do not necessarily relate to college students in the Dream movement; undocumented queer youth, or undocuqueers, see their identities as a double closet, forcing them to come out to friends and family as both undocumented and queer. Undocuqueers may not find support from family members and friends for either of these stigmatized identities. Finding a safe space that supports intersecting identities can be challenging for any of these groups. A safe space is not always a physical space; it can be a person who listens, an allocated time to talk, a hotline that gives immigrants an opportunity to seek help without any barriers. Staff members who have an understanding of different intersecting experiences will have a better grasp of the needs of undocumented immigrant communities and be able to create a safer, more welcoming environment. Creating a hotline is a great way to provide a service that is cost-effective and manageable.

3. In-Service Training for Professional Staff Provide in-service trainings for staff on how to work with undocumented immigrants, provide adequate services, and be an advocate for immigrant rights. The CIRCLE Project offers workshops and inservice trainings countywide for mental health professionals, school counselors, social workers, and other health care providers who work with undocumented immigrant communities and families. 4. Identify Key Staff Identify staff with experience or a passion for working with immigrant families. Provide resources, time, and flexibility for key staff to modify referral lists, create and update tools for working with immigrants, and stay informed on immigration

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The Affordable Care Act and California Immigrants: Implementing Policies and Practices for the Remaining Uninsured

Conclusion
It is estimated that there will be one million uninsured, undocumented Californians in 2014. (Health Access 2013, 3).
It is imperative that California be at the forefront in creating policies and practices that provide access to health care for all its residents. California needs to implement immigrant-friendly policies that facilitate access to primary care, long-term care, and care for immigrant children. The state needs to seek out additional funding sources, engage with organizations that work with immigrants, and advocate for long-term solutions like immigration reform. In addition, local health organizations must take steps to provide better health access for all immigrants, from expanding referral services to providing inservice trainings for staff. California has the potential to be a model health care provider for all its residents, including the undocumented immigrant community.

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The Affordable Care Act and California Immigrants: Implementing Policies and Practices for the Remaining Uninsured

Authors
Alma Castrejon was born in Mexico City and came to the United States at the age of seven. In 2008, she graduated from UC Riverside with BA degrees in Political Science - International Relations and Chicano Studies. While at UCR she founded Providing Opportunities, Dreams and Education in Riverside (PODER), a support group for undocumented students on campus. In 2011, Alma received her MA in Education at CSU Long Beach. She has been a member of Dream Team Los Angeles (DTLA), a community group that advocates for immigrant rights, since 2009; she is also an active member of Graduates Reaching a Dream Deferred (GRADD), a group of undocumented graduate students that addresses the needs of immigrant students interested in pursuing graduate education. Betzabel Estudillo is California Immigrant Policy Centers Health Policy Coordinator based in Los Angeles. Previously, she was the Community Coordinator for the CLEAN Carwash Campaign organizing immigrant carwash workers in Los Angeles. While in graduate school she interned with the Los Angeles County Department of Mental Health analyzing health policies and providing best practices when working with immigrants. She has also been a community organizer in multiple immigrant youth groups including IDEAS at UCLA, DREAM Team Los Angeles, Graduates Reaching a Dream Deferred (GRADD) and the CIRCLE Project. She obtained her M.S.W from the University of California Los Angeles, Luskin School of Public Affairs and a B.A. in Political Science from the University of California Los Angeles. Jorge Gutierrez is currently serving as the project coordinator for the Queer Undocumented Immigrant Project (QUIP), a project by the United We Dream Network. QUIP is a national project that focuses on empowering, organizing and mobilizing Queer undocumented youth and LGBTQ immigrant communities. Jorge received his BA degree in English from California State University, Fullerton and has been organizing with community organizations including the Orange County DREAM Team (OCDT), DeColores Queer Orange County and Dream Team Los Angeles (DTLA). Claudia Ramirez is undocumented and unafraid, Queer and unashamed. As an undocumented and Queer organizer, Claudia has been an advocate of intentional intersectional organizing between the LGBTQ and Undocumented communities. Claudia is currently a coordinator of the CIRCLE Project, which provides spaces for immigrant youth to address and cope with the unique experiences of growing up undocumented and continuing to be undocumented in a time of highly vocal anti-immigrant sentiment. The projects mission is to promote communal support, collective healing and self-empowerment where immigrant youth can discuss their ongoing stressors and successes, and make professional referrals when necessary. Her strengths and passions come from a strong commitment to the advancement of her community and a belief in justice and equality for all communities.

Contributors / Advisors:
Carlos Amador, Project Manager: Dream Resource Center UCLA Labor Center Araceli Campos, Corporate Counsel Mexican American Legal Defense Fund and Educational Fund (MALDEF) Alvaro Huerta, Staff Attorney National Immigration Law Center (NILC) Mike Lee, Contributor Law Clerk Fellow Julie Monroe, Project Director UCLA Labor Center Freddy Pech, Report Design Contributor Imelda Plascencia, Project Coordinator: Dream Resource Center CIRCLE Project Thomas A. Saenz, President Mexican American Legal Defense and Educational Fund (MALDEF)

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The Affordable Care Act and California Immigrants: Implementing Policies and Practices for the Remaining Uninsured

References
Banthin, Jessica, and Sarah Masi. 2013. CBOs Estimate of the Net Budgetary Impact of the Affordable Care Acts Health Insurance Coverage Provisions Has Not Changed Much Over Time. Congressional Budget Office. http://www.cbo.gov/publication/44176. Chadwick, Kasi. 2012. An Overview of the Implications of the Patient Protection and Affordable Care Act for Low-Income Hispanics in Texas: A Case for Cross-Border Health Care Models. Houston Journal of Health Law & Policy 13: 103129. Health Access. 2013. Continuing Californias Commitment to the Remaining Uninsured: A Concept Paper on Extending the County Low-Income Health Programs (LIHPs) to Provide Safety-Net Coverage for the Remaining Uninsured in California. http://www.health-access.org/files/expanding/Remaining%20 Uninsured%20Concept%20Paper%205-8-13.pdf Health Insurance Marketplace. 2013. https://www.healthcare.gov/. Hill, Laura, and Joseph Hayes. 2013. Just the Facts: Undocumented Immigrants. Public Policy Institute of California. http://www.ppic.org/main/publication_show.asp?i=818. Ku, Leighton and Jewers, Mariellen June 2013. Health Care for Immigrant Families: Current policies and issues. Migration Policy Institute. http://www.migrationpolicy.org/pubs/COI-HealthCare.pdf National Health Law Program. 2008. Medi-Cal Services for Immigrants, Including Non-citizens and Undocumented Immigrants. In Overview of the Medi-Cal Program. http://healthconsumer.org/MediCalOverview2008Ch14.pdf. National Immigration Law Center. 2012. Health Care for DACA Grantees. http://www.nilc.org/factshealth.html. National Immigration Law Center. 2013. Immigrants and the Affordable Care Act (ACA). Last updated March 2013. http://www.nilc.org/immigrantshcr.html. Richard, Chris. 2013. California Law Helps Undocumented Immigrants Get Health Care. California Health Report. http://www.healthycal.org/archives/12445. Ryan, Kara. 2009. Access to Health Care for Mixed-Status Families. http://www.nclr.org/index.php/ publications/preliminary_findings_focus_groups_on_access_to_health_care_for_mixed-status_ families/. US Department of Health and Human Services. May, 2012. Barriers to Immigrants Access to Health and Human Services Programs. Office of the Assistant Secretary for Planning and Evaluation Issue Brief. http://aspe.hhs.gov/hsp/11/ImmigrantAccess/Barriers/rb.pdf US Department of Health and Human Services. 2012. Overview of Immigrants Eligibility for SNAP , TANF , Medicaid, and CHIP . Office for the Assistant Secretary for Planning and Evaluation Issue Brief. http://aspe.hhs.gov/hsp/11/ImmigrantAccess/Eligibility/ib.shtml. Valenzuela, Amelia. 2012. Affordable Health Care Coverage for Mexican Immigrants in the Southwest: State-Initiated Reform in the Private and Public Sectors. Arizona State Law Journal 44: 1777. Wiley, Dinah. 2013. New Study Findings on Mixed-Status Immigrant Families: Threat of Family Separation Affects Health of the Children. Say Ahhh! (blog). Georgetown University Health Policy Institute Center for Children and Families. http://ccf.georgetown.edu/all/new-study-findings-on-mixedstatus-immigrant-families-threat-of-family-separation-affects-health-of-the-children/. Zallman, Leah, et al. 2013. Immigrants Contributed an Estimated $115.2 Billion More to the Medicare Trust Fund than They Took Out in 200209. Health Affairs 32(6): 11531160.

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The Affordable Care Act and California Immigrants: Implementing Policies and Practices for the Remaining Uninsured