Protecting Immigrant Families: Lessons from the Medicaid Unwinding 

State Medicaid agencies may soon face significant state and federal budget cuts and policy changes. As the policy and fiscal environment changes, the “unwinding” of Medicaid’s pandemic-era continuous coverage requirement offers lessons for maintaining coverage for eligible people in immigrant families.  

In early 2023, the Protecting Immigrant Families (PIF) coalition convened a Medicaid Unwinding Task Force composed of PIF member advocates who shared our concern about the threat unwinding posed to immigrant families. We released an overview of distinct barriers facing immigrant families and common-sense state policy responses that could mitigate these concerns (see Table). 

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In mid-2023, we surveyed advocates about states’ adoption of these best practices and received responses from organizations in 28 states and found that, in many states, these policy responses were not in place. More details are available in a PIF brief on the disparate impact of the unwinding on immigrant families. In late 2023, we partnered with the information and media organization Noticias Para Inmigrantes to survey 2,000 Spanish-speakers in immigrant families about their knowledge of and experience with Medicaid unwinding. The survey found: 

• Awareness and understanding of the eligibility change was extremely low, with two-thirds of people responding to the survey reporting little or no knowledge about Medicaid re-enrollment
• Misinformation was commonplace, with most respondents having heard at least one common piece of misinformation – most commonly, that only U.S. citizens can qualify – about Medicaid 
• Many respondents cited persistent fears about public charge and immigration consequences if they used Medicaid 

A new analysis, completed for PIF by the non-profit behavioral science research firm ideas42, found that in counties with large immigrant shares of county population, Medicaid unwinding resulted in 1.37 million additional people losing Medicaid compared to counties with fewer immigrants. That number is almost certainly low, because the analysis only included the 10 states for which data was available. 

In general, the analysis finds that excess disenrollments were larger in some states than others. For example, Texas disenrolled an additional 461,644 people in counties with large immigrant shares of county population. That’s 9.4% of Texas’ immigrant population. In contrast, California disenrolled an additional 316,993 people, which is just 3% of the state’s immigrant population. This impact reflects differences in state approaches and policies as it relates to addressing the needs of immigrants in re-enrollment processes. 

Taken together, our research demonstrates the need to better serve immigrants and the spouses, children, and other family members of immigrants. Progress will require a real commitment of resources. States agencies, governors, and legislators played a leadership role in developing common-sense reforms like ex parte renewals, whereby the state uses information like wage data already in its possession to determine the person’s continued eligibility. State officials should adopt and expand the reach of such reforms to help ensure all families covered by Medicaid maintain access to health care. In addition, state policymakers should: 

• Ensure that their states’ eligibility systems offer language access on par with the access offered in English for residents who speak and read non-English languages common in the state 
• Eliminate any unnecessary information requests that could deter immigrant families from applying or renewing as required by CMS 
• Employ research-backed messages about public charge and immigration concerns in Medicaid communications 
• Intensify outreach to immigrant families directly and through funded partnerships with nonprofits that have built trusting relationships with immigrant families 
• Use each hiring opportunity to build a culturally and linguistically competent workforce 

Maintaining coverage for eligible people in immigrant families should be an ongoing priority for health leaders. Improving outreach, enrollment, and eligibility determination system responsiveness, and retention efforts will help improve outcomes and equity, ultimately benefitting all participants in our health system, particularly when changes are on the horizon.