Welfare reform and older immigrant adults' Medicaid and health insurance coverage: changes caused by chilling effects of welfare reform, protective citizenship, or distinct effects of labor market condition by citizenship?

Do state laws reduce uptake of Medicaid/CHIP by U.S. citizen children in immigrant families: evaluating evidence for a chilling effect

Background

Restrictive state laws aimed at immigrants can have unintended consequences for health insurance coverage of United States citizens in immigrant families due to both actual barriers created by the laws and perceived barriers among immigrants. Increasing numbers of children in the U.S. are part of immigrant families, and these children are more likely to be living in poverty than their counterparts in native families. Immigrant restrictive policies could lead to reduced access to Medicaid and CHIP even for citizen children in immigrant families.

Methods

Using data from the Current Population Survey's (CPS) March Supplement, linear probability models with difference-in-differences (DD) estimates compare probability of enrollment in Medicaid/CHIP among low-income U.S. citizen children in immigrant families and low-income children in native families and U.S. citizen children in immigrant families in states that did not adopt restrictive legislation, in order to estimate the impact of restrictive state laws aimed at immigrants. An additional model explores the effect of mother’s citizenship on enrollment among all immigrant families in states with and without restrictive legislation.

Results

Results suggest a significant chilling effect where the magnitude of the effect varies according to family demographics and by the types of laws being passed. Immigrant restrictive social welfare laws being adopted have a strong negative effect on U.S. citizen children in immigrant families’ enrollment in Medicaid/CHIP, a 5.5 percentage point reduction in coverage. Among the subsample of only immigrant families, results point toward a global chilling effect created by an overall restrictive policy environment. All immigrant restrictive related laws, including those aimed at education, job restriction, identification access, and social welfare restrictions have a significant and negative impact on access to public insurance for U.S. citizen children with non-citizen mothers.

Conclusions

This research shows that the unintended consequence of restrictive state legislation aimed at immigrants is the reduction in access to Medicaid and CHIP by low-income U.S. citizen children living in immigrant families. Reduced access to health insurance can increase unmet medical needs for an already vulnerable group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01651-2.

What the Group Threat Hypothesis Notes About States' Medicaid Spending

This secondary data analysis examined the relationship between state Medicaid spending in 2000-2014 and the perspective of the group threat hypothesis. The hypothesis posits that as any racial minority group grows in size, the increase is perceived by the racial majority group to threaten its dominant status. The employed data described states' Medicaid spending, racial makeup, and poverty and unemployment rates and came from reports compiled by several federal agencies. It was processed first in 2 discrete date-based groups. Results with 2000-2009 data showed states' per capita Medicaid spending to be associated negatively with their racial makeup. Specifically, states with proportionally larger Hispanic populations appeared to spend less on Medicaid versus states with fewer Hispanic residents, as did states with proportionally larger other non-African American minority populations (versus states with fewer such residents). Our findings with 2010-2014 data indicated no association between Hispanic population and states' per capita Medicaid spending. Combining data from both periods, we observed no significant association between state Medicaid spending and each of the following: proportion of African Americans in state population, poverty rate, and unemployment rate. In general, state Medicaid spending increased gradually throughout the years studied. Policy implications are discussed.

Impact of Medicare Age Eligibility on Health Spending among U.S. and Foreign-Born Adults

OBJECTIVE

Examine differences in health care expenditures between foreign-born and U.S.-born adults in late mid-life, and how these differences change after age 65, when Medicare is near-universal.

DATA

Medical Expenditures Panel Survey data (2000-2010) on adults ages 55-75 years (n = 46,132) to examine annual total and payer-specific expenditures.

STUDY DESIGN

We use (1) propensity score matching to generate quasi-experimental samples with equivalent health needs and health care preferences, (2) generalized linear modeling to estimate group differences in expenditures, and (3) bootstrapping methods to obtain variance estimates for significance testing.

PRINCIPAL FINDINGS

Among adults ages 55-64, the foreign-born spend $3,314 (p < .001) less on health care, even when they have equivalent health needs and health care preferences. This difference is due mainly to lower spending through private insurance. After age 65, differences in total spending disappear but not differences in payer-specific spending. The foreign-born continue to spend significantly less through private insurance and begin to spend significantly more through Medicare and Medicaid.

CONCLUSION

Foreign-born adults in late mid-life spend significantly less on health care than U.S.-born adults. After age 65, with near-universal Medicare coverage, differences in total spending disappear between the groups, although differences in spending by payer persist.

Policy Implications of a Literature Review of Cardiovascular Disease in Uninsured Immigrant Older Adults

The number of older adults emigrating to the United States is expected to quadruple by 2050. The health of immigrant older adults is complicated by the limited options for low-cost health insurance available to this population. Welfare reform has limited new immigrants' access to public assistance programs, such as Medicaid; and low-cost private insurance options rarely exist for individuals older than 65, even with the passage of the Patient Protection and Affordable Care Act (PPACA). Uninsured immigrant older adults have been found to forgo preventive care due to cost and are among the leading users of emergency departments for preventable complications of chronic disease, primarily cardiovascular disease (CVD). A review of the literature found that insurance coverage has a significant impact on CVD risk among immigrant older adults. The current article discusses the implications of welfare reform initiatives and the shortcomings of the PPACA in addressing the health care needs of immigrant older adults.

Age at immigration and the incomes of older immigrants, 1994-2010

OBJECTIVES

Seniors comprise a growing proportion of new U.S. immigrants. We investigate whether late-age immigrants are disadvantaged in older age relative to those arriving earlier in life, based on income, reliance on public benefits, and access to public medical insurance. We test whether the 1996 welfare reform law altered the relationships between age at immigration and these outcomes.

METHOD

Immigrants aged 65 and older in the 1994-2010 Current Population Surveys were classified by age at immigration. Median and logistic regressions are used to estimate the association between age at immigration and several outcomes and to test whether these associations differ for arrivals before and after welfare reform.

RESULTS

Late-age immigration is strongly associated with lower personal income, lower rates of Medicare and Social Security receipt, and higher participation in Supplemental Security Income (SSI) and Medicaid. Arrival after 1996 is associated with lower rates of SSI, Medicaid, and Medicare receipt. The association between late-age immigration and income is stronger for post-1996 arrivals relative to earlier arrivals, whereas that between late-age immigration and Medicaid is weaker, suggesting that the penalty conferred by late-age immigration grew after reform.

DISCUSSION

Late-age immigrants face formidable economic disadvantages exacerbated by exclusion from public benefits, with implications for immigration, health care, and welfare policy.

Crossing the chasm of mistrust: collaborating with immigrant populations through community organizations and academic partners

As a community partner and an academic researcher, we experienced the direct and extended benefits of a relatively small-scale, community-engaged informed consent process that developed in an immigrant occupational health study, Assessing and Controlling Occupational Health Risks for Immigrant Populations in Somerville, Massachusetts. The practice of human participants research played a positive role in the community, and both community partners and researchers, as well as the larger academic community, reaped unexpected benefits during the five-year project (2005-2010), which continue into the present. Lessons learned from our experience may be helpful for wider application.

Family Sponsorship and Late-Age Immigration in Aging America: Revised and Expanded Estimates of Chained Migration

We use the Immigrants Admitted to the United States (micro-data) supplemented with special tabulations from the Department of Homeland Security to examine how family reunification impacts the age composition of new immigrant cohorts since 1980. We develop a family migration multiplier measure for the period 1981 to 2009 that improves on prior studies by including immigrants granted legal status under the 1986 Immigration Reform and Control Act and relaxing unrealistic assumptions required by synthetic cohort measures. Results show that every 100 initiating immigrants admitted between 1981-85 sponsored an average of 260 family members; the comparable figure for initiating immigrants for the 1996-2000 cohort is 345 family members. Furthermore, the number of family migrants ages 50 and over rose from 44 to 74 per 100 initiating migrants. The discussion considers the health and welfare implications of late-age immigration in a climate of growing fiscal restraint and an aging native population.