Effects of Medicaid expansion and state inclusionary policies on immigrant health and healthcare use in the United States
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Abstract
The United States is home to an estimated 51.9 million immigrants, a growing population that experiences substantial disparities in health insurance coverage and access to care. These disparities are shaped and perpetuated, in part, by a complex and often exclusionary policy environment, exemplified by recurrent changes to the public charge rule and the recent enactment of the One Big Beautiful Bill Act (OBBBA). Among the most consequential policies reinforcing these barriers is the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, which bars legal immigrants from accessing public benefits including Medicaid, Children’s Health Insurance Program (CHIP), Temporary Assistance for Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), and Supplemental Security Income (SSI) during their first five years in the U.S., a restriction commonly known as the “five-year bar”. PRWORA also replaced the Aid to Families with Dependent Children (AFDC) entitlement program with the TANF block grant, and added complexity to the determination of benefit eligibility through the strict definition of “qualified alien”. The effects of PRWORA extend beyond immigrants themselves, impacting U.S.-born children in mixed-status households. Although the vast majority of children in mixed-status families are U.S. citizens (88%) and therefore eligible for public benefits, their access and experience is often undermined by the restrictive provisions of PRWORA and the chilling effects of related immigration policies. In response, there have been efforts to improve healthcare access for immigrants through the adoption of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA), as well as inclusionary state Medicaid policies providing coverage to otherwise ineligible immigrants by using state or local funds. Despite these efforts, the uptake of public benefits remains low among eligible immigrants and U.S.-born children in mixed-status households—often due to the fears of immigration-related consequences, especially in light of recent changes to the public charge rule and rising anti-immigrant sentiment. In 2023, an estimated 18 percent of lawfully present immigrant adults were uninsured compared to 8 percent of U.S.-born adults. Among U.S. citizen children, 4 percent were uninsured among those with U.S. citizen parents compared to 8 percent among those with noncitizen parents, demonstrating that disparities based on immigration status persist decades after PRWORA. Similarly, following changes to the public charge rule, participation in critical food and nutrition programs like SNAP and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) declined among households with immigrant parents as compared to those with U.S.-born parents. This dissertation evaluates the compounding impact of federal and state health insurance policies—specifically PRWORA, Medicaid expansion, and inclusionary state Medicaid policies—on healthcare utilization, total healthcare expenditures, health outcomes, and experiences of care among multigenerational immigrant families. Guided by the Social Determinants of Health Framework, this research leveraged multiple years of restricted-use data from the Agency for Healthcare Research and Quality (AHRQ), linking the Centers for Disease Control and Prevention’s National Health Interview Survey (NHIS) with AHRQ’s Medical Expenditure Panel Survey (MEPS), along with state policy data from the Urban Institute State Immigration Policy Resource (SIPR). The long-term goal of this research is to strengthen the evidence base on the impact of health and social policies on immigrants and their families in the United States. Chapter 1 provides a review of the literature motivating this work, including a historical overview of U.S. immigration policy with a particular focus on PRWORA and its implications for public benefit use across generations. Chapters 2 through 4 present the three specific aims of the dissertation. Chapter 2, To Quantify Differences in Immigrant Adult Healthcare Use and Expenditures Following Medicaid Expansion, examined changes in healthcare utilization and expenditures following Medicaid expansion among immigrant adults based on years of residence in the U.S. Chapter 3, To Identify the Effect of Inclusionary State Medicaid Policies on the Physical and Mental Health of Immigrant Adults, assessed changes in physical and mental health functioning associated with the adoption of inclusionary state Medicaid policies among immigrant adults based on years of residence in the U.S. Chapter 4, To Assess the Timely Receipt of and Experience of Care for Children of Immigrants Following Medicaid Expansion, evaluated differences in the quality of care for children following Medicaid expansion based on household immigration status. Chapter 5 provides concluding remarks on the findings of Chapters 2 through 4, as well as directions for future research.
Description
2026
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Attribution 4.0 International