The blog of the Urban Institute
February 4, 2021

Reforms to Health Care Policy Can Help Support Children of Immigrants and Their Families’ Well-Being

The Biden administration has moved quickly to reverse many harmful immigration policies, putting forth a legislative proposal that includes a broad legalization effort and issuing a number of executive orders.

Biden’s actions signal that immigration reform will be a priority, but the current state of the COVID-19 pandemic also poses urgent risks for immigrant communities, who are less likely to have health insurance for many reasons, including immigrant eligibility restrictions for subsidized health insurance like Medicaid and the Children’s Health Insurance Program (CHIP).

A quarter of all children nationwide had an immigrant parent in 2019, with that share higher in many states and communities. Although these children face the same challenges accessing quality health care that many children do, they and their parents also encounter additional structural barriers to safety net programs and policies. Ensuring these children and their parents have access to quality health care is critical to our nation’s future.

We spoke with Jennifer M. Haley and Dulce Gonzalez from the Urban Institute’s Health Policy Center to understand how children of immigrants are currently served in health policy, how they’ve been affected by the COVID-19 pandemic, and how the Biden administration can help alleviate the barriers they face. Haley and Gonzalez offered three takeaways.

1. Uninsurance rates among children have risen in recent years

After more than two decades of sustained bipartisan effort to increase children’s health insurance coverage by expanding Medicaid/CHIP eligibility, supporting outreach, and simplifying enrollment and renewal processes, the uninsurance rate among children dropped to a historic low of 4.3 percent in 2016. The introduction of the Affordable Care Act (ACA) contributed to this decline, Haley said, despite being targeted mostly at increasing health care coverage for adults. Outreach and enrollment efforts, new avenues through the federal and state marketplaces, and spillover effects for children as parents sought coverage also helped. Through policy changes and investments in covering children in immigrant families, such as grants to local organizations to increase awareness and take-up of public health insurance, gaps in coverage and Medicaid/CHIP participation between citizen children with noncitizen parents and those with only citizen parents considerably narrowed but were not eliminated.

During the Trump administration, children’s uninsurance rates began to rise again as enrollment in Medicaid/CHIP dropped. A number of changes likely contributed to these reversals, Haley said, including the delayed reauthorization of CHIP funding, efforts to repeal the ACA, new work requirement restrictions on Medicaid for adults, administrative hurdles around Medicaid/CHIP renewal, and major cuts in outreach and enrollment funding, which may have led to confusion about the availability of coverage and made it harder for families to obtain and keep coverage. Of particular consequence to immigrant families was the proposed expansion of the public charge rule, which made it easier for immigration officials to deny green cards to adults who have participated in certain public programs like Medicaid.

“In 2019, before the rule was even finalized, as many as one in five adults in immigrant families with children reported someone in the family avoided a public program, such as SNAP [Supplemental Nutrition Assistance Program], Medicaid, CHIP, or housing subsidies for fear of risking their status,” Haley said. Even those who aren’t subject to the public charge rule have avoided public programs. These “chilling effects” have led some immigrant families to forgo medical care and nutrition supports. Data indicate larger coverage declines between 2017 and 2019 for Hispanic children—including many in immigrant families—than for other groups of children.

2. Public charge chilling effects could keep immigrant families from COVID-19 testing, treatment, and vaccination

With the COVID-19 pandemic continuing to spread, particularly impacting the Black, Latinx, and Indigenous communities, frequent testing and quickly distributed vaccinations are critical for stemming its advance. Although the federal government communicated that neither testing nor treatment would be considered in public charge determinations, many immigrant families may not have gotten this information or may not believe it. Newly released data show chilling effects continued in 2020. If an immigrant or their child were to contract COVID-19, they may be avoiding testing or treatment because of a lack of insurance, concerns about cost, language barriers, or immigration-related concerns, Gonzalez said.

To counteract these communication gaps and fears, policymakers can minimize the collection of sensitive personal data such as social security numbers or immigration status, communicate that immigration status will not be affected, use trusted immigrant serving organizations to disseminate accurate information, and support accessibility across all needed languages.

3. Policymakers can expand eligibility and streamline safety net enrollment processes to help children in immigrant families

The Biden administration has taken steps to direct agency review of the public charge rule. Even as the administration moves to undo the harms of the regulation, after so much misinformation and fear over the past few years, many immigrant families may still be reluctant to seek available resources, regardless of policy changes.

To help bolster the health of children of immigrants, Gonzalez and Haley suggest policymakers look to improve eligibility and enrollment processes for safety net programs. According to Haley, children are more likely to participate in Medicaid and CHIP if their families also participate in other programs like SNAP.

Other avenues Gonzalez and Haley suggested for boosting coverage rates could include expanding the upper income limit for marketplace coverage and increasing subsidies to make marketplace coverage more affordable, increasing enrollment assistance to help families navigate enrollment processes, and encouraging immigrant parents to enroll their eligible children in Medicaid/CHIP through intentional engagement, such as targeted, culturally relevant outreach. Policymakers can also open access to the safety net for immigrant children by eliminating the five-year bar for Medicaid or CHIP coverage for immigrants who have obtained qualified immigration status or by using state funds to cover all children regardless of immigration status, as several states already do, Gonzalez said.

Supporting insurance coverage for immigrant parents is also important, as parents’ own health needs must be met to support their children’s healthy development. Given that Medicaid eligibility rules based on immigration status are even more restrictive for adults than for children, including among those who are legally present, removing eligibility restrictions for parents would also help their children.

Supporting children of immigrants requires engagement and trust building

Increasing outreach to bridge misinformation and cultural gaps, improving language access, and modifying eligibility requirements are important tools to increase immigrant families’ access to and use of public health care services, Gonzalez said. For efforts to be successful, they need to demonstrate to immigrant families that seeking health care and participating in vaccinations are critical during the pandemic and that doing so will not threaten their immigration status.

Most children in immigrant families are US citizens. Policies affecting coverage and care for them and other family members can have long-lasting effects on society by shaping their future health, education, and prosperity. If we want communities to successfully weather and recover from the COVID-19 pandemic and to nurture the next generation, ensuring families have access to needed health care is more urgent than ever.

A nurse draws blood for a COVID-19 antibody test from Guatemalan immigrant, Junior, as his father, Marvin, looks on at a clinic on May 5, 2020 in Stamford, Connecticut. They were also re-tested for COVID-19 to find out whether they are now negative, a month after getting sick from coronavirus. (Photo by John Moore/Getty Images)

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