Likos Afkas is a native of the Federated States of Micronesia, part of a cluster of islands in the Pacific where nuclear testing by the U.S. government during the Cold War left behind high rates of cancer.
Together with neighboring Palau and the Marshall Islands, the Federated States of Micronesia has a special compact with the U.S. under which its people, heavily recruited by the U.S. military, can live and work here indefinitely — but as noncitizens, they are denied certain federal benefits.
Afkas, 48, first came to the U.S. a year ago, suffering from diabetes and heart problems, and was immediately diagnosed with kidney failure that requires three-times-a-week dialysis. Last month, he was notified that he lacked sufficient job credits to continue receiving the Medicare coverage he’s depended on to cover some of his medical bills.
Now, like untold numbers of his countrymen and other immigrants, Afkas is taking stock of his health-care options as the clock counts down to the Oct. 1 opening day for enrolling in health coverage under the federal government’s Affordable Care Act (ACA). Coverage begins Jan. 1.
For him, the prospects aren't promising.
Ultimately, how he and other immigrants fare under this massive health-care overhaul will depend on many factors: their income, immigration status, how long they’ve lived in this country and — in the case of people like Afkas — their country of origin.
While his household income would otherwise qualify him for Medicaid, the primary option under ACA for delivering health coverage to low-income people, Afkas’ immigration status makes him ineligible.
He worries he'll be required to buy health insurance under the law or face a penalty -- neither of which he says he can afford. However, he is likely exempt from that requirement if the cost of insurance premiums would be more than 8 percent of his household income, or if he makes so little that he doesn't file a tax return.
Returning to Chuuk, his home state in Micronesia, is not an option, he said, because of the woefully inadequate health system there.
“If I go back home, I’d only be going back to die.”
The health-care-overhaul law, commonly known as Obamacare, targets people who lack health insurance — an estimated 1.09 million residents of Washington state.
It’s unclear what percentage of them are immigrants.
Studies have shown that in general, immigrants tend to be healthier than the rest of the population — they are younger and are subject to medical examination to obtain green cards — though many of the same studies also suggest they become less healthy over time.
“There are some people who have gotten used to being uninsured, so we need to provide a whole other level of information about why they’d even want to be insured now that it’s available to them,” said Michael McKee, health-services director of the International Community Health Services, whose clinics serve large numbers of immigrants.
“Part of it is also helping them understand the penalties,” he said. “That’s going to be totally new to everybody.”
As complicated as the law will be for the average American, immigrant advocates worry it will be even more daunting for those whose primary language is not English and for whom regular visits to a doctor are not a cultural tradition.
“We look at access to care and coverage as opportunities to address health disparities,” McKee said. “It’s incumbent on us to educate people on the importance of preventive care and healthy options so they can avoid some of the costly outcomes.”
Options for uninsured
Under the ACA, the majority of the state’s uninsured will be required to buy health-care coverage, or face a penalty.
They can purchase an individual insurance plan on their own or from the state-administered health-insurance marketplace, the Washington Health Benefit Exchange.
Those with the lowest income — about a third — will qualify for Medicaid, the free or near-free health-insurance program that will be expanded under Obamacare to deliver health care to the poorest Americans.
How and where immigrants fit into all this are questions many advocacy groups continue to unravel.
“I don’t think there’s any question the majority of immigrants will benefit from this,” said Jenny Rejeske, policy analyst for the National Immigration Law Center. “It’s going to require vigilance from advocates and people who want this to work. It’s not going to be perfect on day one.”
Mary Wood, section manager at Washington State Health Care Authority, said the rules related to immigrants’ eligibility for Medicaid under the health law haven’t changed: If their immigration status made them ineligible before the law took effect, they’ll remain ineligible.
U.S. citizens and legal permanent residents or green-card holders who have been in this country for five years or longer will be treated the same as U.S.-born citizens when it comes to coverage. They can apply for Medicaid under the program’s broadened guidelines if their income is low enough.
Other types of immigrants will also qualify regardless of how long they’ve been in this country: asylum seekers and refugees, special immigrants from Iraq and Afghanistan, victims of trafficking and immigrants who served in the armed services.
They will be among an estimated 250,000 people who state officials estimate will become newly eligible under the expanded Medicaid limits for those with incomes up to 138 percent of the federal poverty level — or $15,856 for a single person.
Meanwhile, other legal immigrants — those with higher incomes or those here for fewer than five years, people temporarily in this country, such as students and work-visa holders, as well as people like Afkas — won’t qualify for Medicaid.
They may, however, purchase insurance from the exchange, using the Washington Healthplanfinder.
Those among them with incomes between 139 and 400 percent of the federal poverty level — $45,960 for a single person — will qualify for subsidies and tax credits to help cover insurance premiums.
And all low-income children, regardless of their immigration status, will be covered under any number of federal and state health care programs.
For adults in the country unlawfully, the government has little to offer.
While most undocumented immigrants work in jobs that do not provide health insurance, it is estimated that 25 percent of them do have coverage.
Still, undocumented immigrants account for about 14 percent of Washington state’s uninsured. And those with no coverage — an estimated 127,530 — will continue to go without.
Undocumented adult immigrants are unable to participate in Medicaid or Medicare and that won’t change. They are also ineligible to purchase from the health exchange. But unlike most other groups, they won’t face a penalty for not having insurance.
There is coverage available for low-income women during pregnancy regardless of their immigration status, and like everyone else, undocumented immigrants continue to qualify for emergency care under federal law.
And those whose incomes would otherwise entitle them to Medicaid but for their immigration status can qualify for emergency Medicaid for emergent conditions, such as heart attacks.
And then there are people like Afkas, whose status most Americans do not know.
Micronesia, Palau and the Marshall Islands are former United Nations trust territories, which the U.S. Navy administered between 1947 and 1951.
Today, they are sovereign nations, each with a Compact of Free Association with the United States under which their people can work and live in this country indefinitely, though they are neither U.S. citizens or nationals.
In 1996, when Congress reformed welfare, it barred most legal immigrants from Medicaid and other federal health programs for the first five years of residency. It also indefinitely barred those from the compact states from receiving Medicaid.
Many use their immigration privilege to seek treatment — mostly state-funded — for the cancer and other health problems plaguing their countries, usually in Hawaii, but increasingly in places like Washington state, said Xavier Maipi, who runs a nonprofit agency to advocate for residents from compact countries.
An estimated 2,000 — mostly Marshallese and Micronesians — live here.
Afkas lived on the island state of Chuuk in Micronesia before he came to the Seattle area a year ago, his health failing.
Already suffering heart problems and diabetes, he was diagnosed with kidney failure at Seattle’s Harborview Medical Center, whose reputation as a source for indigent care he and others say has become well known in the islands.
The medical bill for his monthlong stay totaled $100,000, which Medicare covered.
But in July, Afkas was notified he lacked sufficient job credits to continue receiving $700 in monthly Supplemental Security income and Medicare.
He’ll continue to receive weekly dialysis through a state program geared to those whose immigration status disqualifies them for Medicaid but will have to go uncovered for everything else.
Afkas’ wife earns a small amount to provide home health care for him from another part of the same program that covers his dialysis. “Right now, I don’t know what I’m going to do,” he said.
Like many people, he doesn’t know much about the Affordable Care Act and hasn’t given it much thought. Paying for health insurance — any amount — isn’t in the household budget.
“Many of these folks are simply trying to survive,” Maipi said. “For health care, they go to the emergency room — and usually that’s when they’re at death’s door.”
'A lot of questions'
Immigrant advocates know they face a daunting task preparing clients and constituents for the coming change.
While information about the exchange will be available in eight different languages, the website the public will use to sign up for care will be available only in English and Spanish.
“Many of our clients are refugees and immigrants and 60 percent of them have limited English proficiency,” McKee said.
Health clinics like his and other federally funded health centers that now serve anyone who walks through their doors will continue to do so — regardless of their insurance status or ability to pay.
“This is the largest sea change in public policy since Social Security,” McKee said.
“Everyone wants to get it right. And at the end of the day, there will be a lot of questions and the hope is that we can, with this first run, enroll as many people who will benefit.”
Seattle Times reporter Carol M. Ostrom contributed to this report.