Immigration status impacts Medicaid enrollment in non-ACA-expansion states

Medicaid expansion associated with the Affordable Care Act (ACA) has provided millions of people with health insurance. But does immigration status affect enrollment, both in states that expanded Medicaid and those that did not?

Recent research found, in expansion states, no significant differences in Medicaid coverage between mixed-status households (meaning one that likely included undocumented immigrants) and non-mixed-status households. But in states that did not expand Medicaid, coverage rates were lower for individuals in mixed-status households compared to the non-mixed-status population.

The study, written by Michael S. Cohen and William L. Schpero, two PhD candidates at the Department of Health Policy and Management at the Yale School of Public Health, was published online March 5 in Health Affairs.

“[The research] provides suggestive evidence that immigration status dampened the woodwork effect, whereby state Medicaid expansions increased enrollment in nonexpansion states among people otherwise eligible for, but previously not enrolled in, Medicaid,” wrote Cohen and Schpero.

A 2013 memo from Immigration and Customs Enforcement (ICE) stated any application data from Medicaid and ACA state marketplaces would not be used for enforcement purposes, meaning undocumented individuals should be free to access such health insurance where available. But enhanced enforcement of immigration laws may lead to undocumented people to avoid interactions with the health insurance markets.

“Evidence of ‘chilling effects’ on Medicaid enrollment for a specific set of states highlights the important role of the policy context in mediating take-up of public benefits,” the authors wrote. “Governments in nonexpansion states were broadly more likely to take legislative actions that enhanced enforcement of immigration laws, restricted immigrants’ access to public services, or placed additional administrative burdens on immigrants applying for public benefits, as reflected in scores on the Immigrant Climate Index.”

Cohen and Schpero examined low-income populations between 18 and 64 years old with at least five years of residency in the United States. They used data from the 2009-15 American Community Survey to determine the likelihood of a household having an undocumented immigrant by examining military service, professional licensing and involvement in Supplemental Security Income programs.

Key results of analysis included:

• Coverage rates for low-income people in mixed-status households in expansion states went from 33.1 percent in 2009 to 46.3 percent in 2015.
• Coverage for low-income people in non-mixed-status households in expansion states went from 30.3 percent in 2009 to 45.7 percent in 2015.
• In nonexpansion states, 15.9 percent of mixed-status households were enrolled in Medicaid in 2009 compared to 21.4 percent of non-mixed-status households.
• In 2014, Medicaid enrollment for mixed-status households was 1.7 percent less than it was for non-mixed-status households. This differential change increased to 3.1 percentage points in 2015.

“Common barriers included the complexity of the application process and eligibility rules; confusion about application requirements, including the need for proof of citizenship and Social Security numbers; and lack of access to supporting documentation,” Cohen and Schpero wrote. “Language was deemed to be a particularly significant barrier, with many program administrators identifying a need for additional bilingual staff members and informational materials.”

Fears of mistreatment and possible deportation also may keep undocumented people from exploring health coverage.