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July 28, 2023
Early View Perspective Health Insurance Child Health
Ana C. Monterrey
J. Raul Gutierrez
Julie M. Linton
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The United States is home to 44.9 million immigrants who contribute unique assets, economic stability, and rich lived experiences to communities across the nation.1-4 Immigrant children, or those who are born outside of the United States, reside in all 50 states and the District of Columbia.5 As the immigrant population in the United States reaches historic highs,6, 7 all communities benefit by ensuring immigrant children can fully participate in programs that support health, development, and well-being.
Health care coverage, i.e., health insurance, is associated with improved health care access and child health outcomes.8-10 The long-term effects of improved health care coverage for children, assessed during Medicaid expansions, include lower adult mortality rates, increased college enrollment, lower teenage pregnancy rates, and increased wages especially for adult women.11-13 Despite these benefits, 21% of documented and 34% of undocumented immigrant children remain uninsured.14 Some populations of noncitizen children, including refugees and children of active duty military, are eligible for Medicaid in all states without a waiting period.15 However, many states continue to impose a five-year waiting period on Medicaid access for children with other types of immigration status. These waiting periods were introduced through the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) in 1996.15-18 Because the passage of the Affordable Care Act (ACA), the percent of immigrants who are uninsured fell from 32% in 2013 to 20% in 2017.4 However, the approximately 11 million immigrants of all ages with undocumented status4 remain excluded from state and federal programs, including enrollment in the ACA, in most states.19, 20 Only 11 states (California, Connecticut, Illinois, Massachusetts, Maine, New Jersey, New York, Oregon, Rhode Island, Vermont, and Washington) and the District of Columbia offer state-funded, comprehensive Medicaid-level coverage to children (with some state-based differences in ages covered) regardless of immigration status.15, 16 Additional states expand coverage to pregnant people regardless of their immigration status,15, 16 recognizing that their US-born children would constitutionally be US citizens and thus eligible for federal coverage.
Even among eligible immigrants, the chilling effect of restrictive immigration policies and xenophobic rhetoric is a pervasive deterrent for those attempting to access health care coverage.21, 22 Additional barriers to health care access that immigrant families may experience include inadequate language services, low health literacy, limited transportation, fear and uncertainty regarding immigration status, and health care’s rising cost.21-24 These social drivers of health significantly exacerbate insurance coverage barriers.
In the absence of universal coverage for children and recognizing the heterogeneity of health care delivery, it is imperative to understand existing models that improve access to and delivery of consistent care for immigrant children. In this paper, we categorize and describe models of funding and care delivery for uninsured immigrant children based on existing evidence and relevant operational experiences, highlighting opportunities to incrementally and meaningfully increase access to care. Although this characterization into models of funding and delivery is imperfect in that it cannot claim to be exhaustive, it offers a framework through which to explore policy-level and practical components that can support better access for this population. Recognizing that access alone does not equate with improved outcomes, we also seek to identify successful models and gaps in current understanding that would inform policy and practice.
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