Medicaid Enrollment Affected by Household Immigration Status in Some States

A new study from the Yale School of Public Health finds that states that did not expand Medicaid appeared to have a chilling effect on the participation of eligible adults who could have enrolled in the program, but did not, because of undocumented immigrants living in the same household.

The study explores why approximately 1 in 4 of the eligible uninsured in the United States did not enroll in the Medicaid program in 2016, 2 years after expansion of Medicaid eligibility under the Affordable Care Act (ACA). The study was published in the March issue of Health Affairs.

The researchers used 2009-2015 data from the US Census Bureau to identify Medicaid-eligible individuals in households that likely included at least 1 undocumented immigrant. It examined trends in Medicaid coverage over time.

In states that expanded Medicaid eligibility, the rate of enrollment was statistically indistinguishable between Medicaid-eligible individuals living in households with mixed-immigration status and those in households with non-mixed-immigration status.

Both populations saw Medicaid enrollment increase the same amount following implementation of Medicaid expansion.

However, in non-expansion states, enrollment was depressed for eligible individuals living in mixed-status households. Medicaid enrollment increased for individuals in non-mixed-status households in those states.

Governments in non-expansion states were more likely to take legislative actions that enhanced enforcement of immigration laws, restricted immigrants’ access to public services, or placed additional administrative burdens on immigrants applying for public benefits, the study noted.

The researchers wrote their findings for non-expansion states may be partially due to those actions, amid concerns by mixed-status households to sharing information with government entities. Lowering take-up of public health insurance among a subset of otherwise eligible people may introduce disparities in health outcomes and hurt labor-market productivity, they wrote.

“Our findings suggest that living in a mixed-status household may have dampened the so-called ‘woodwork effect,’ in which the ACA improved knowledge about Medicaid availability and increased enrollment in the program, even in non-expansion states,” Michael Cohen, a PhD candidate in health policy and management and a study co-author, said in a statement.

Evidence of reduced Medicaid enrollment among eligible individuals in mixed-status households could be partially attributed to fear in some states that applying for public benefits may expose household members to scrutiny from immigration law enforcement agencies, the researchers noted. Other studies have shown that immigration enforcement activities reduced Medicaid enrollment among eligible children of non-citizens.

“Our findings may also suggest that certain states are particularly effective at making relevant enrollment information available and at helping eligible individuals enroll in the Medicaid program,” said William Schpero, a PhD candidate in health policy and management and the study’s co-author. “It is possible that differences across states in immigration enforcement or in information availability may underlie our results.”

Applicants must provide detailed data on household composition and income in order to apply for Medicaid. When using the HealthCare.gov website, for example, people may be asked to give the Social Security numbers and incomes of non-applicant household members. But if a non-applicant family member does not have a Social Security number, an applicant may be worried that leaving the field blank, even when the number is not required, could hint that the person is undocumented.

Also, otherwise eligible applicants could be hesitant to continue with the application process if they are aware that they are providing questionable personal information for a family member. While many of the undocumented people do have a Social Security number, nearly 2 million numbers may be fake or stolen, the study said.

States can improve Medicaid enrollment among eligible individuals in mixed-status households by explicitly clarifying that insurance application information will not be shared with immigration law enforcement agencies, the authors suggest.

Increased availability of bilingual enrollment materials and assisters, as well as outreach to community organizations, may also increase Medicaid enrollment within this eligible sub-population, they add.

The study was supported by funding from the Agency for Healthcare Research and Quality and the National Institute on Aging.

Reference

Cohen MS, Schpero WL. Household immigration status had differential impact on Medicaid enrollment in expansion and nonexpansion states [published online March 5, 2018]. Health Aff. doi: 10.1377/hlthaff.2017.0978