This month’s issue of Health Affairs is about borders, immigrants, and health, and there are several pieces focused on health of immigrant children and children in immigrant families. Mariellen Jewers and Leighton Ku’s article, “Noncitizen Children Face Higher Health Harms Compared With Their Siblings Who Have US Citizen Status,” looks at differences in access to routine medical care between noncitizen and citizen children generally, and then takes a closer look at differences between noncitizen and citizen siblings. This study design allows the authors to identify some of the causal factors impacting access to care because siblings are similarly situated with respect to potentially confounding factors such as family income, parental education, or differences in state Medicaid policies. Here are some of the findings about citizen versus noncitizen siblings:

• A higher share of noncitizen children were uninsured (42% versus 12%)
• More noncitizen children experienced delays in needed care (7% versus 3%)
• Significantly fewer noncitizens were covered by public insurance (39% versus 73%)

This last finding is especially important for Medicaid/CHIP policymakers.

“Most of the difference in insurance coverage is because citizen children had a 26-percentage-point higher probability of having Medicaid or CHIP than their noncitizen siblings. There was no significant difference in private insurance coverage, indicating that parents provide private insurance equally to their citizen and noncitizen children. Private insurance does not require citizenship, unlike public insurance.”

The authors go on to point out that the great majority of noncitizen children who remain in the US grow up to become citizens, and eligibility restrictions that prevent noncitizen children from being publicly insured contribute to their experiencing poorer health and higher medical costs in their adult lives. This informs one of the authors’ recommendations: eliminate restrictions on Medicaid/CHIP eligibility for noncitizens.

A majority of states (35 of 51 in Medicaid and 24 of 35 in separate CHIP) have taken advantage of the state option to waive the 5-year waiting period for lawfully residing immigrant children (known as ICHIA, the Immigrant Children’s Health Improvement Act option). For the remaining states that have yet to adopt ICHIA, the Migration Policy Institute has a very helpful spreadsheet with estimates by state of the number of low-income, uninsured children who are legal permanent residents with less than 5 years in the United States. These estimates can help inform state legislation and fiscal notes. In all of the remaining states and under all of the unemployment scenarios MPI modeled, the total number of children is relatively small. ICHIA coverage for children is also matched at the higher, CHIP match rate. Adopting ICHIA is low-hanging fruit to help address the problems with access to care identified by the authors.

Another important step, absent federal action, is for states to cover all children regardless of citizenship status (including undocumented children), using state-only funds. Seven states (CA, IL, MA, NY, OR, WA, and as of 2022, VT) and DC have opted to cover all children regardless of citizenship status.

This month’s issue of Health Affairs also includes an article on state experience covering all kids regardless of citizenship status, “California’s Health4All Kids Expansion and Health Insurance Coverage Among Low-Income Noncitizen Children,” by Brandy J. Lipton, Jefferson Nguyen, and Melody K. Schiaffino. The authors looked at coverage rates in California before and after the 2016 expansion to cover all kids and compared these trends to 11 other states.

The authors found that the California expansion translated to a 34% decline in the uninsurance rate among noncitizen children (from about 26% uninsured to about 17% uninsured). The coverage expansion to all children regardless of citizenship status made an even bigger dent in coverage disparities between citizen and noncitizen children – reducing coverage disparities by roughly 56%. When looking at California and the 11 control states, the authors found that in states that did not provide comprehensive public coverage to all kids, the gap between citizens and noncitizens was about 23 percentage points compared to a gap of about 6 percentage points in those states that cover all kids.

State policymakers that are interested in covering all children regardless of citizenship status can also turn to MPI for help estimating the total size of the uninsured, low-income child population. After determining the approximate size of the eligible population, it is important to account for a gradual ramp-up in enrollment, which can be quite slow without automated enrollment processes and robust outreach campaigns. Another factor to consider is that immigrant children are often healthier than citizen children, so states may need to discount the typical per child costs accordingly.

So far in 2021, Vermont is the only new state to pass legislation to cover all children regardless of status, but as my colleague Kyrstin Racine has noted, proposals to cover all kids are gaining momentum. Federal policymakers should take note and do their part to help narrow coverage disparities by making all children regardless of citizenship status eligible for Medicaid/CHIP.