Covering Uninsured Children: State Solutions for Immigrant Children 

As of 2023, nearly 3 million children in the United States remained uninsured, largely due to immigration-related exclusions in public insurance programs like Medicaid and the Children’s Health Insurance Program (CHIP). In response, state policymakers have sought ways to close the gap on children’s coverage. Fourteen states and the District of Columbia have used only state funds to provide health insurance coverage to income-eligible children without legal immigration status. While HR1/OBBBA originally proposed withholding billions in funds from states with benefits for immigrants without legal status, this provision was stricken following senate parliamentarian review. Still, given the political climate, it is unlikely OBBBA will be the last word on threats to states with generous health care policies. In this post, we examine the policies of these 15 jurisdictions to provide an overview for states considering similar legislation. 

State solutions to the children’s insurance gap 

Collectively, these state approaches reflect a growing recognition that immigration status should not be a barrier to children’s health care. Further, it demonstrates an awareness that without expansive state policies, pediatric providers bear the brunt of providing charity care to all who walk through their doors. Illinois was the first state to build on its existing “All Kids” program to include comprehensive coverage for undocumented children under 19 in 2006. Nearly 50,000 children gained coverage in the first year, with families purchasing coverage under a sliding scale model. Washington quickly followed suit with “Apple Health for Kids” in 2007, initially a five-year initiative, since extended well beyond the first five years, that provided coverage for immigrant children under 19 with increasingly generous income eligibility limits. 

Minnesota and New York were next, passing laws in 2010 and 2014, respectively, and Oregon’s Cover All Kids launched in 2018. Meanwhile, California’s “Health4All Kids” initiative extended full-scope Medi-Cal coverage to all low-income children regardless of immigration status in 2016. 

There is considerable variation in the design and scope of the policies. A handful of jurisdictions (DC, Illinois, Massachusetts) implemented broad income eligibility and many covered youth up to 21 years old (California, DC, Maine, Minnesota), while others limited covered services to low-income children under age 19 (Massachusetts, Minnesota, Utah). California and New Jersey eliminated premiums and waiting periods for undocumented children, while others, like Illinois, implemented a waiting period of one year of uninsurance, a requirement they have since eliminated from their policy. Program structure also varies: California’s program is integrated into Medi-Cal, whereas New Jersey relies more heavily on its CHIP infrastructure. States like Washington and Oregon prioritized outreach, investing in culturally and linguistically tailored enrollment support, often through community-based organizations. 

Table 1. Medicaid policies using state-only funds to address gaps in children’s insurance coverage based on immigration status 

^{Notes: The 15 jurisdictions detailed in Table 1 represent those using state funds to provide health insurance for children, regardless of immigration status.} 

Not just children 

As of July 2025, seven jurisdictions (California, Colorado, DC, Illinois, New York, Oregon, Washington) expanded their children’s coverage policies to include undocumented adults and/or older populations. California’s phased expansion included undocumented young adults under 26 (2019), adults 50 and over (2022), and ultimately, all income-eligible adults regardless of immigration status by 2024. Its incremental expansions allowed administrators to build the necessary infrastructure and community trust over time, aligning policy rollouts with fiscal planning along the way. Washington also expanded to all income-eligible adults in 2024, but capped enrollment at 13,000 people in light of budget limitations in the enabling legislation. 

Illinois and New York’s policies focused more directly on adults 65 and older. Illinois further expanded in 2025, introducing a program that included adults 42 and older. However, states like Illinois and Minnesota have faced operational and budgetary challenges in scaling expansions. After announcing an expansion to all income-eligible adults regardless of immigration status in January 2025, Minnesota has since restricted coverage to those under 18.  

Barriers to coverage remain 

Despite the promise of more expansive health insurance policies, barriers to successful expansion and implementation remain. Budgetary restrictions, administrative complexity, lack of political will, and state policymakers’ fear of retaliation from the federal government create a chilling effect for states considering implementing similar policies. And in states with coverage for immigrant children and adults, language barriers, lack of awareness, erosion of public trust in government entities, and fear of immigration enforcement discourage eligible families from enrolling their children. Moreover, in states that cover children only, undocumented parents’ lack of eligibility negatively affects enrollment and access for the family as a whole.  

Medicaid’s unwinding of provisions implemented during COVID to create coverage stability led states to resume eligibility checks, jeopardizing coverage for millions of adults and children due to procedural or administrative issues often unrelated to eligibility status. While cover-all-kids initiatives were well-positioned to help fill coverage gaps during this period, they had to compete with the high volume of disenrollment, eligibility confusion, and overburdened enrollment systems. 

Despite challenges, state-level innovations have insured nearly 2 million immigrants without legal status. While federal Medicaid and CHIP programs continue to exclude undocumented individuals (with few exceptions for emergency services or pregnancy coverage in some states), state-funded initiatives have responded to longstanding evidence that insuring children, regardless of immigration status, improves access to preventive care, reduces uncompensated care costs, and enhances long-term health outcomes. These policies signal a broader trend toward expansive coverage models that close eligibility gaps left by federal limitations. Understanding how well different strategies provide coverage to uninsured children (and others) will be important as these and other states use state-funds to expand health insurance to underinsured groups.