Momentum is building in state capitals to expand access to health coverage for people left out by the current system, including people excluded from federal coverage options due to immigration status and Marketplace affordability rules known as the family glitch. But before getting into plans for 2022, let’s recap progress made in 2021.
As my colleague Kyrstin Racine wrote in May, there was significant progress in moving legislation to cover all children regardless of immigration status in 2021. We closed out state legislative sessions with expanded Medicaid coverage for kids otherwise ineligible due to immigration status in Vermont and Maine, plus a buy-in program for kids regardless of status in New Jersey and coverage for kids under age nine regardless of status in Connecticut. These coverage programs are slated to go into effect in 2022-2023 and are in addition to programs already in effect in California, Illinois, Massachusetts, New York, Oregon, Washington, and the District of Columbia.
Coverage expansions didn’t stop with children either. California already covers children and youth under age 26 regardless of citizenship status, but will expand coverage in 2022 to immigrants over age 50. Similarly, Illinois has long covered children regardless of status, but this year the state expanded coverage to seniors over age 65 who are otherwise ineligible for Medicaid based on their immigration status. Those over age 55 will become eligible next year. In Oregon, the Cover All Kids program has been renamed the Cover All People program and will cover adults regardless of citizenship status. This new pilot program may initially focus on reaching parents of children currently covered by the Cover All Kids program and youth aging out of Cover All Kids.
So what’s in store for 2022? States are taking a few different paths as they explore options to cover more children and adults with a mixture of state, federal, and private funding.
Taking up existing federal options. Some states are exploring taking up existing federal options, such as covering lawfully residing pregnant people and children without a five-year waiting period. Known as CHIPRA §214 or ICHIA, 35 state Medicaid programs and 24 of 35 CHIP programs have already opted to cover lawfully residing children without a 5-year waiting period, while 25 state Medicaid programs and 4 of 6 CHIP programs have done so for pregnant people. Perhaps spurred on by broader momentum to improve maternal health outcomes, more states are exploring adopting coverage expansions for pregnant people in particular (see Virginia adopting the CHIP “unborn” option; Illinois and California extending postpartum coverage for pregnancies covered by the “unborn” option and related CMS guidance, Nevada making progress toward adopting CHIPRA §214, etc.).
Covering all kids. Looking ahead to 2022, we expect to see continued momentum to cover all kids regardless of citizenship status in several states, including in Utah and Virginia where there has been support in the state legislature to make more children eligible for Medicaid/CHIP. There are also strong advocacy campaigns building in Pennsylvania and Idaho to expand Medicaid/CHIP coverage to include children not currently ineligible due to citizenship status.
Creating new, broader coverage options. Other states are working on more comprehensive coverage options that would fill multiple gaps in the current system, such as those for immigrant communities (e.g., people without documentation, people who do not meet the strict citizenship requirements set by Medicaid/CHIP, DACA grantees, etc.) and people unable to access subsidized Marketplace coverage due to the “family glitch.” Under current Marketplace rules, employees who are offered “affordable” employer-sponsored insurance (ESI) cannot access subsidized Marketplace plans, but the regulatory definition of “affordable” only refers to the cost of insuring the employee, not their dependents. Even if the cost of coverage for the employee’s family would exceed the affordability threshold, the employee’s family in not eligible for Marketplace subsidies.
Colorado is setting up a Health Insurance Affordability Enterprise (SB20-215) that will use fees levied on insurance companies operating in the private market to provide reinsurance, reduce the cost of Marketplace plans, and provide affordable coverage options to “qualified individuals,” including immigrants and those caught in the family glitch. The state is still in the process of setting up the new program, with coverage expected to begin in 2023. New Mexico is setting up a similar program, the Health Care Affordability Fund (SB 317), also using fees levied on insurance companies to reduce the cost of coverage and provide new coverage options to groups excluded today. Minnesota is expanding access to their Basic Health Program for those with incomes 133-200 percent FPL caught up in the family glitch. Several states are also exploring ways to expand coverage to inmates pre-release to make sure people have coverage and continuity of care as they transition back to the community.
The message from these states is clear – gaps in the system must be filled in order for everyone to have access to affordable health coverage. States are most likely to move forward when there is federal funding available in addition to state funds, but even absent significant federal funding, states are trying to solve these access issues creatively. It would help if the federal government showed more leadership in this area – passing laws to make Medicaid, CHIP and Marketplace coverage accessible to immigrant communities and promoting existing options and best practices to enroll as many eligible people as possible. There are some hopeful signs. Just last week CMS issued a brief outlining outreach, enrollment and retention strategies and earlier this year CMS issued a fact sheet with important eligibility and enrollment information specifically for immigrant families. Let’s hope there is more to come.
