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Medicaid Health Insurance Coverage Among the Foreign-Born Following ACA Implementation: Disparities by Migration Status

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Abstract

Estimating the impact of the Affordable Care Act’s (ACA) Medicaid expansion on health coverage in the foreign-born population is complicated by the inability of most national-level surveys to measure the migration status—and thus eligibility for public programs—of foreign-born residents, especially those who are not naturalized U.S. citizens. Using a combined-sample multiple imputation (CSMI) approach, we leverage the large sample of the American Community Survey (ACS) and impute migration status using the 2008 and 2014 panels of the Survey of Income and Program Participation (SIPP), the only nationally representative survey to include any proxies for migration status. Multivariate difference-in-differences models suggest that Medicaid expansion increased the odds of Medicaid coverage among eligible immigrants. Medicaid expansion, however, was not associated with changes in Medicaid coverage rates for non-Lawful Permanent Residents (non-LPRs, a group that consists overwhelmingly of unauthorized immigrants). Disparities in Medicaid coverage persist across migration status groups following the ACA, particularly as the unauthorized remain excluded from expansion, subsidies, and the ACA marketplace. The results have implications for health and immigration policy reform.

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Notes

  1. In the study period of 2008–2016, Washington, DC was the only state or locality with a public health insurance program accessible to everyone, irrespective of migration status. Six states (Alaska, California, Massachusetts, New Jersey, New Mexico, and New York) provided benefits to small segments of the foreign-born population classified as PRUCOL or permanently residing in the US under color of the law, for a variety of groups such as pregnant women, immigrant children, seniors or persons with a disability, those with a terminal illness, or victim of human trafficking. Other states provide Medicaid to pregnant women, but vary in who is eligible.

  2. States that expanded after January 2014 through the end of 2016 included Michigan, New Hampshire, Indiana, Pennsylvania, Alaska, Montana, and Louisiana. https://www.healthinsurance.org/medicaid/

  3. Medicaid, as a state-run social benefit, is sometimes referred to by state specific names such as Medical Assistance (MA). Despite different naming conventions, the state Medicaid programs are governed by Federal Medicaid laws and regulations (See https://www.benefits.gov/benefit/1000 for details.).

  4. Using the same logic, we also treat as missing the exclusion in the 2014 SIPP of the question asking non-LPR arriving noncitizens whether they have adjusted to LPR status since first arriving. CSMI is flexible in that it can integrate this missing data problem with others to be addressed in the same imputation models. In the case of the missing 2014 status adjustment question, this information was “filled in” using prediction models estimated from the 2008 SIPP. This model, then, assumes that the determinants of adjustment among non-LPR arriving migrants did not change meaningfully between 2008 and 2014.

  5. Comparisons (available upon request) of the foreign-born population estimated in the SIPP to that estimated using the ACS show remarkable similarities in characteristics across the two samples in both 2008 and 2014. The SIPP foreign-born population is, however, somewhat less likely than the ACS foreign-born population to be limited English proficient (LEP) and to be non-citizens (in other words, the SIPP overcounts naturalized citizens and proficient English speakers). Census surveys are known to include undocumented immigrants in their samples, but undocumented immigrants are far more likely to be undercounted. In general, comparisons between the SIPP and ACS foreign-born population estimates suggest that the undercount of the undocumented population is more pronounced in the SIPP than in the ACS. It is reasonable to anticipate that the uncounted portion of the unauthorized population is more disadvantaged than those unauthorized immigrants that are covered by the survey. Insofar as this is true, then our estimates of the scale of inequality in Medicaid coverage will be conservative, and thus biased downward.

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Authors and Affiliations

  1. Department of Health Sciences and Truman School of Government and Public Affairs, University of Missouri, Columbia, MO, 65211, USA

    Claire E. Altman

  2. Center on Poverty and Social Policy, School of Social Work, Columbia University, New York City, NY, 10027, USA

    Christal Hamilton

  3. Department of Sociology, Temple University, Philadelphia, PA, USA

    James D. Bachmeier

  4. U.S. Census Bureau, Washington, DC, 20233, USA

    Cody Spence

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  1. Claire E. Altman
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Author “Cody Spence” completed work on this article prior to current position at the U.S. Census Bureau. Views expressed in this paper are those of the authors, and do not represent those of the U.S. Census Bureau.

Appendix

Appendix

See Tables 5, 6, 7 and 8.

Table 5 Event Study Estimates of Medicaid Expansion on Medicaid Coverage for Low-Income Immigrant Adults
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Table 6 Difference-in-difference estimates of Medicaid eligibility expansion on Medicaid coverage among immigrant low-income adults by migration status group
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Table 7 Difference-in-difference estimates of Medicaid eligibility expansion on Medicaid coverage for low-income Hispanic immigrant adults
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Table 8 Difference-in-difference Estimates of Medicaid eligibility expansion on Medicaid coverage among immigrant Hispanic low-income adults by migration status group
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Altman, C.E., Hamilton, C., Bachmeier, J.D. et al. Medicaid Health Insurance Coverage Among the Foreign-Born Following ACA Implementation: Disparities by Migration Status. Popul Res Policy Rev 42, 68 (2023). https://doi.org/10.1007/s11113-023-09814-x

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