Audit finds Illinois non-citizen health care outstripped cost estimates
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Hannah Meisel
Capitol News Illinois
SPRINGFIELD – A pair of health care programs that benefit non-citizens – one of which is already on Gov. JB Pritzker’s budgetary chopping block – far outstripped its original estimated price tag and cost the state of Illinois $1.6 billion through last summer, according to a new audit of the programs published Wednesday.
The report also found more than 6,000 people enrolled in the state-funded programs were classified as “undocumented” despite actually having social security numbers. Some of those people were green card holders who would have instead qualified for health coverage like Medicaid or traditional insurance.
The audit, which lawmakers requested in late 2023, comes one week after Pritzker delivered his annual budget proposal to the General Assembly. The governor’s plan would defund the newer of the two programs, which is aimed at non-citizens aged 44 to 64, while leaving in place the smaller program for noncitizen seniors aged 65 and older.
Asked about the audit at an unrelated Chicago news conference Wednesday, Pritzker defended the Department of Healthcare and Family Services’ work on redeterminations in the program over the last year, which has brought down total enrollment in addition to the administration’s freezes on enrollment in the programs in 2023.
“It’s some evidence, anyway, that there are an awful lot of people out there who need coverage, who aren’t getting it, or who will do anything to get it,” Pritzker said after reiterating his support for universal health care coverage. “And I think that’s a sad state of affairs in our society.”
Republicans, who’ve long criticized both the programs’ ballooning costs and what they’ve characterized as a lack of transparency, said the audit proves them right about Illinois’ first-in-the-nation programs.
“We’re the only state that puts this burden on Illinois tax on their own state taxpayers taking this on and to not run it properly and to have these large cost overruns, that’s how you end up with a budget deficit,” Senate Minority Leader John Curran, R-Downers Grove told reporters Wednesday at the Capitol. “That’s what’s crowding out spending on education. That’s what’s crowding out spending on other components of the state budget. That’s why we need an audit.”
Vastly underestimated costs
When progressive lawmakers first pushed for the creation of the Health Benefits for Immigrant Seniors, or HBIS, program for non-citizens aged 65 and older in the first few months of the COVID-19 pandemic, officials relied on advocates’ $2 million cost estimate for the program’s first year. Though that projection was later doubled to $4 million as the program was being set up in the latter half of 2020, the actual cost ended up at more than $67 million after HBIS began accepting enrollees in December of that year.
But while actual costs for the seniors’ program in its first three years – $412 million – ended up being 84% higher than original estimates, the price tag for the expanded program for adults aged 44 to 64 was many times larger.
The Health Benefits for Immigrant Adults, or HBIA, program covered noncitizen adults age 55 to 64 and was later expanded to cover those as young as 44. It cost $485.3 million over its first two years – roughly 284% more than the combined original estimate for both programs.
The programs were designed with the same income eligibility thresholds as Medicaid. But since federal Medicaid dollars can’t be spent on many types of non-citizens, the state has had to foot the bill itself instead of receiving a roughly 52% federal match like it does for traditional Medicaid coverage.
The audit noted that HFS began seeking federal reimbursement for some emergency services last year, which would be retroactive to mid-2022. But Pritzker last week said part of the reason he was proposing axing the program for adults – which would save an estimated $330 million next year – was due to the Trump administration signaling it would soon halt that reimbursement.
Enrollment has also far outstripped original estimates, especially in the program for adults aged 44 to 64. For fiscal year 2023, nearly 54,000 adults enrolled in the program – about twice the original projection of 26,800.
In 2023, after the Pritzker administration acknowledged the programs’ cost had grown to $1.1 billion, the governor asked the General Assembly for authority to impose spending controls. After lawmakers followed his request, Pritzker quickly paused enrollment in the program for adults in July of 2023, followed by a pause in the program for seniors in November of that year.
The programs have not accepted any new enrollees since those pauses and redetermination efforts have decreased their headcounts in the last year. The audit cited an enrollment decline in the adults’ program from a high of 53,936 in fiscal year 2023 to 41,537 in fiscal year 2024, which ended June 30.
The day after the second enrollment pause in November 2023, lawmakers approved a resolution calling for an audit of the programs, which authorized Auditor General Frank Mautino’s office to begin work on the report published Wednesday.
Pritzker last week proposed defunding the program for adults, telling reporters that those aged 44 to 64 are still of working age and could get jobs with health care coverage.
Axing the program renews a disagreement between the governor and progressive members of the General Assembly’s Latino Caucus, who opposed enrollment pauses and efforts to require co-pays for program participants.
But the governor framed his proposal as one of shared sacrifice.
“If you come to the table looking to spend more, I’m going to ask you where you want to cut,” the governor told lawmakers in his Budget Address. “I have made difficult decisions – including to programs I have championed, which is hard for me, just as I know some of the difficult decisions you will have to make will be hard for you.”
Mis-enrollments
The audit also found inconsistencies in enrollment data, sometimes relying on misreporting from program participants.
Of the 6,098 enrollees with social security numbers who’d been mislabeled as undocumented, nearly 400 people had been in the U.S. for the five years it takes for legal permanent residents to qualify for Medicaid, according to the audit. Meanwhile, other green card holders who hadn’t yet reached that five-year threshold but were enrolled in the state-run programs would have been eligible to purchase health coverage from the Affordable Care Act’s insurance marketplace.
HFS last spring issued new rules clarifying that those non-citizens were not eligible for the state health coverage programs, and the agency’s redetermination process has identified and dis-enrolled many.
Others who had social security numbers are in the U.S. legally but are not eligible for green cards. The HBIA and HBIS programs were designed to cover them but were not intended to cover asylum-seekers who’ve been sent to Illinois from southern border states in recent years.
Those mis-enrollments, which also included nearly 700 people who received coverage under the program for non-citizens 65 and older despite being too young to qualify, drove some of the ballooning costs in the health care initiative. But the audit points to the Pritzker administration relying on vastly underestimated figures when setting up the programs in 2020, 2021 and 2022.
“Actual enrollment and actual costs exceeded the initial program estimates for both the HBIS and HBIA program,” the audit said.
Jade Aubrey contributed.
Capitol News Illinois is a nonprofit, nonpartisan news service that distributes state government coverage to hundreds of news outlets statewide. It is funded primarily by the Illinois Press Foundation and the Robert R. McCormick Foundation.
