Administrative Barriers and the Medicaid Unwinding: Parental Nativity and Medicaid Coverage Among Citizen Children

• In Event: Administrative Burdens in Healthcare: Evidence for Multiple Disciplines

Abstract

One in four U.S. children live with at least one foreign-born parent yet face disparate access to the safety net compared to peers of native-born parents. Prior research finds immigration enforcement and restrictive policies reduce Medicaid and CHIP enrollment among citizen children of immigrant parents—not because children lack eligibility, but because immigrant parents may avoid government contact due to immigration-related fear (i.e., chilling effects) or because administrative barriers hinder their enrollment and recertification. No prior research has examined how these children’s coverage has been shaped by more burdensome recertification requirements during the Medicaid unwinding period, when pandemic-era enrollment protections expired.

The Consolidated Appropriations Act of 2023 ended the federal continuous enrollment requirement, effective March 31, 2023, requiring states to redetermine eligibility for all Medicaid enrollees. States implemented unwinding throughout 2023 and into 2024, with wide variation in renewal policies adopted. Some states employed SNAP and TANF data for automated renewals, zero-income ex parte strategies, and/or pre-populated renewal forms to limit procedural disenrollment among eligible individuals. Despite these measures, studies document large-scale disenrollment, with nearly seven in ten due to procedural reasons, and cases of child disenrollment based on household-level rather than individual-level recertification. For citizen children in immigrant families, the renewal process itself may have amplified existing barriers: Immigrant parents receiving government renewal notices may not have completed them due to administrative burden (e.g., documentation and language barriers) and chilling effects, resulting in disenrollment of their eligible children for procedural rather than eligibility reasons.

This study draws microdata from the 2022, 2023, 2024 American Community Survey 1-year data files to examine changes in Medicaid/CHIP among citizen children across the pre-unwinding, unwinding, and post-unwinding periods. This analysis differentiates children by household parental nativity composition – two foreign-born parents, one foreign-born and one native-born parent, and single foreign-born parent households – relative to children in native-born parent households – to examine whether the presence of a U.S.-born parent limits the procedural barrier to continuous enrollment. State recertification policies are merged onto child records to examine whether streamlined renewal policies moderated enrollment disparities by parental nativity. In addition, the federal requirement for all states to provide 12-month continuous eligibility for children, in effect in January 2024, allows examination of whether this protection reversed enrollment disparities for children of immigrants. Beyond Medicaid/CHIP enrollment, this study also examines whether coverage loss is offset by employer-sponsored insurance, testing whether enrollment policies translate into uninsurance differentially by parental nativity. Findings will identify which state policy levers most effectively ensured continuous enrollment for citizen children of immigrant parents during the unwinding period, informing renewal policy design and immigrant family outreach strategies.

Authors

• Yiyu Chen, Independent
  Presenting Author

• Christopher Wodicka, University of Pennsylvania
  Non-Presenting Co-Author