Immigrant Healthcare Coverage Expansion Lowers Child Uninsurance

Expanding immigrant healthcare coverage for noncitizen children can lead to a decrease in the children uninsurance rate without having a significant effect on employer-sponsored health plans, a Health Affairs study found.

In 2020, approximately four percent of children with US citizenship were uninsured, a statistic which had started growing in 2018. Experts estimated that around a third of all undocumented children were uninsured along with nearly a fifth of all documented children (18 percent).

The researchers examined the enrollment outcomes from California’s Health4All Kids CHIP and Medicaid (Medi-Cal) expansion using 2012 through 2018 cross-sectional American Community Survey (ACS) data. They noted that California was one of seven states that applied state funding to expanding noncitizen children’s coverage.

The program itself was two-pronged: it expanded Medicaid coverage for eligible children and in some California counties it formed a Healthy Kids program that offered coverage for children who were undocumented or otherwise ineligible for public payer coverage. Previous studies linked these efforts with improved health outcomes for enrollees.

Notably, this was not California’s first attempt at expanding healthcare coverage for noncitizen children. Its predecessor was the Kaiser Permanente Child Health Program which continued to play a role in boosting public payer coverage for this population as the Healthy Kids program took effect.

"Low-income undocumented children who were not eligible for Healthy Kids or Kaiser Permanente Child Health Program coverage may have been uninsured before the statewide expansion. Further, even children who were eligible for one of these programs may have faced enrollment barriers because of program restrictions, coverage premiums, or lack of program awareness,” the researchers explained. 

“For these reasons, and given the high uninsurance rates among low-income noncitizen children before 2016, we anticipated that California’s expansion would be associated with substantial increases in both any coverage and Medi-Cal coverage.”

The study’s results appeared to confirm these suspicions. Researchers found that healthcare coverage for children in California improved nine percentage points for any form of coverage and 12 percentage points for Medi-Cal coverage.

For noncitizen children, the expansion led to a 34 percent drop in uninsurance after the coverage expansion. As a result, disparities in coverage between low-income noncitizen children and and low-income citizen children declined as well by around 56 percent.

The Health Affairs study could only present the immediate effects of expanding coverage for noncitizen children. However, the researchers pointed to other studies that showed improvements in patient outcomes over time due to coverage expansions. Some studies found that children who were covered through coverage expansions had better health as adults.

The impact of California’s coverage expansion on employer-sponsored health plan coverage was not statistically significant.

Not all California counties had the same starting point for the Healthy Kids coverage expansion. Many counties had already implemented strategies to increase public payer enrollment for noncitizen children. 

The researchers found that these counties saw better outcomes after the Healthy Kids program went into effect than counties that had not attempted other coverage expansion strategies before the Healthy Kids program. They speculated that this was due to the counties’ experience in expanding coverage and to implementing multiple strategies at once.

“As the US recovers from the pandemic, efforts to increase children’s coverage rates should consider not only eligibility policies but also how to build on outreach and enrollment strategies that have demonstrated success in the past,” the researchers urged.

Health insurance coverage for immigrants has been a source of contention in healthcare policy, whether immigrants were documented or undocumented. 

Immigrant healthcare coverage is an important factor in the national coverage rates. In 2019, researchers found that immigrants were particularly vulnerable to uninsurance. Documented immigrants were twice as likely to be uninsured compared to US citizens and undocumented immigrants were nearly five times more likely than citizens to have no coverage.

The Trump administration sought to promote immigrant self-sufficiency and attract immigrants with strong economic backgrounds by issuing the public charge rule, which barred immigrants from receiving public services including Medicaid and CHIP coverage and Supplemental Nutrition Assistance Program (SNAP) benefits. 

However, opponents argued that forcing children immigrants to drop out of public payer enrollment could have negative implications for their current health, but it could also have long-lasting impacts on their health as into adulthood.

Although the public charge rule is no longer in effect, Urban Institute researchers found that it continues to influence insurance rates among immigrants today.