The voices of Urban Institute's researchers and staff
December 6, 2018

Penalizing immigrants for obtaining Medicaid coverage puts child and family well-being at risk

The administration has proposed an expansion of the “public charge” rule that would make it more difficult for applicants whom officials deem likely to rely on public assistance to obtain lawful permanent residence (a “green card”) or a temporary visa. Among other changes, the rule would expand public charge determinations to include an applicant’s enrollment in the Medicaid program. Adding Medicaid to the list of public charge benefits that would be considered may force immigrants to choose between health insurance coverage and a future green card—with adverse consequences for parents and their children.

There is significant evidence documenting spillover benefits of parental Medicaid coverage on children’s health and well-being. Children whose parents are covered by Medicaid are more likely to be insured and more likely to receive an annual well-child visit than children with uninsured parents. Parental Medicaid coverage also improves access to care for parents and financial well-being, which, in turn, benefit their children.

The proposed expansion of public charge would not apply to US citizens, nor would it consider a child’s benefit use in a parent’s public charge determination. Yet US-born citizen children, who make up nearly 90 percent of all children in immigrant families, would likely still be affected by the rule, especially if they have a noncitizen immigrant parent. A new Urban Institute analysis finds that more than 10 million citizen children were living with one or more noncitizen parents in 2016.

These citizen children’s families could face increased challenges if their parents disenroll from Medicaid or do not seek coverage for which they qualify because of public charge concerns. Additionally, 6.8 million citizen children with one or more noncitizen parents were enrolled in Medicaid/CHIP in 2016. If “chilling effects” of the new rule were to result in disenrollment among these children, their uninsurance levels would likely rise, reducing their access to health care and limiting their health and well-being.

The proposed rule could cause coverage losses for parents

Urban’s recent analysis also shows that 2.2 million Medicaid/CHIP-enrolled citizen children live with one or more noncitizen parents covered by Medicaid. The proposed rule could lead eligible noncitizen parents who intend to one day apply for a green card to disenroll from, or forgo enrolling in, Medicaid out of concerns that it might have negative consequences for their future immigration prospects.

In addition, parents and other members of immigrant families may forgo Medicaid coverage because of confusion or fear about the public charge rule, which may also affect children’s well-being. Such chilling effects were observed following the immigration and welfare reforms of 1996.

Parental Medicaid coverage helps families get by and reduces stress

As parents with Medicaid coverage experience improvements in health and reductions in medical costs, these benefits can spill over to improve the entire family’s financial security and well-being. Financially, Medicaid has been found to reduce out-of-pocket medical spending, increase financial stability, and reduce problems paying medical bills.

Medicaid has also been found to reduce severe psychological distress among parents and improve material well-being for low-income families. By reducing financial stress and worry, Medicaid coverage can help parents provide a positive and supportive environment for their children. The reverse is also true—losses in Medicaid coverage would likely lead to worsening psychological distress and material hardship and more challenging home environments for children.

Parental Medicaid coverage affects kids’ Medicaid and CHIP coverage and health care

Analyses of parental Medicaid expansions consistently find that low-income children are more likely to be insured and stay insured if their parents have continuous Medicaid coverage. And when parents lose Medicaid, children are less likely to enroll in Medicaid and CHIP.

Thus, if parents disenroll from Medicaid because of concerns about public charge and consequences for their immigration status, their children may be more likely to disenroll from public coverage, as well, leaving their families burdened with numerous challenges accessing health care.

Although benefits received by US-born children are not supposed to be factored into a parent’s public charge determination, confusion around the application of public charge may also lead to unintended consequences. For example, citizen children whose parents are not enrolled in Medicaid would also be at risk of coverage losses if their noncitizen parents fear that their children’s receipt of benefits could jeopardize their own path to legal residency.

Children’s coverage losses would not only affect uninsurance, access to care, and use of health services in the short run but would have long-term consequences, as childhood Medicaid or CHIP coverage has also been linked to improved adult outcomes, such as reduced mortality, improved adult health, better educational attainment, and less reliance on government support.

Even children who remain enrolled in Medicaid and CHIP may experience worse health outcomes if their parents disenroll from Medicaid. Evidence has shown that Medicaid expansions for parents increased the probability that low-income children received an annual well-child visit. Descriptive work has also found positive relationships between parental insurance and children’s access to health care—children whose parents are insured are more likely to use preventive services and less likely to report an unmet need for care.

If immigrant parents disenroll from Medicaid, disenroll their children, or fail to enroll in the first place because of concerns about public charge, their children are likely to lose out on the improved physical health, mental health, financial stability, and overall well-being benefits that Medicaid coverage provides to the entire family, which, in turn, will impede the contributions they make to society when they reach adulthood.

Photo via El Chiko/Shutterstock.

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