This article was originally published by Stateline, an initiative of The Pew Charitable Trusts.
Not long ago, Graciela Camarena, a community health worker in the Rio Grande Valley, had a perplexing case. Over a two-year period, the U.S.-born daughter of a single, working mother kept getting turned down for Medicaid coverage even though her brother was enrolled in the public health plan.
The situation was fraught because the 12-year-old girl was ailing. She had developed breathing problems and was always fatigued, to the point that she couldn’t participate in gym class.
With the help of Camarena, who works for the Children’s Defense Fund-Texas, a child advocacy nonprofit, the mother again applied to the state’s Medicaid agency. Despite Camarena’s certainty that the girl met all the qualifications, the application was again denied.
“It made no sense that one child was in and one was out,” Camarena said in an interview.
This time Camarena pressed the agency for a review. After six weeks or so, the mystery was solved. The agency had miscoded the application, identifying the girl not as a child but an adult, which in Texas meant much more stringent income requirements.
The girl, a Latina, was finally enrolled. Two weeks later, Camarena said, the child underwent surgery to repair a faulty heart valve that could have cost her life.
“Having health insurance literally saved her life,” Camarena said.
But more than 1.8 million Latino children in the United States do not have health insurance, and the situation has grown more dire in recent years, advocates say. The share of all children without health insurance has risen since 2016, but the increase has been most pronounced for Latino children.
According to a recent analysis by the Center for Children and Families at Georgetown University, in 2016 the percentage of non-Latino children without insurance stood at 3.7%, compared with 7.7% for Latino children.
By 2019, the numbers had climbed to 4.4% for non-Latino children and to 9.3% for Latino kids.
The report blames the rising rates of uninsured Latino children on anti-immigrant federal policies and rhetoric during the Trump administration, including the targeting of immigrants who use public safety net programs and cutting of funds for outreach efforts to enroll people in health insurance. But it also highlights state actions, including decisions not to expand Medicaid eligibility under the Affordable Care Act and bureaucratic procedures that can make it difficult to maintain enrollment in Medicaid.
The report says some of the federal and state actions have reduced enrollment for all children, but Latino children have been particularly affected.
“Something that jumped out to me was how incredibly important state policy decisions are,” said Kelly Whitener, a public health coverage expert at Georgetown and co-author of the report, which analyzed U.S. Census Bureau data.
The citizenship status of the children has not been an obvious factor in the rising rates of Latino children without health insurance. Most Latino children living in the United States—95%, according to the Georgetown analysis of census data—are U.S. citizens. The report suggests, however, that the immigration status of parents and their proficiency in English both affect whether their children will be enrolled in health insurance.
In the case of the Texas child, for example, her mother was living in the United States without legal documentation and so did not qualify for Medicaid for herself.
The timing of the increased numbers of Latino kids without insurance, coming as the coronavirus pandemic hit the United States, was alarming, said Matthew Snider, a senior health policy analyst with UnidosUS, formerly known as the National Council of La Raza, the nation’s largest Latino civil rights and advocacy organization.
“It is very disturbing, not least of which because these trends were occurring as Latino kids were entering this tremendous health crisis, which put them in an even more vulnerable position,” he said.
Some experts, including Edmund Haislmaier, a senior health policy analyst at the conservative Heritage Foundation, were unmoved by the Georgetown report and its findings.
“It’s like looking at reservoirs in California,” he said. “Do you describe how full they are or how empty they are? Instead of saying the uninsurance rate among Latino kids has gone from 7.7% to 9.3%, you could say the insurance rate has gone from 92.3% to 90.7%. It’s still above 90%.”
And many people choose not to enroll in insurance, he said, and are able to take advantage of opportunities for free health care.
Federal and State Barriers
In 2017, the Trump administration slashed funding to help people enroll in ACA health insurance marketplaces. That program paid for public service announcements as well as community guides, called navigators, who could walk residents through the often confusing signup process for both ACA plans and Medicaid. The Biden administration has restored that funding.
In 2019, the Trump administration expanded the federal “public charge” rule, which sought to deny legal status to immigrants who used safety net programs such as Medicaid. Although the final rule exempted programs used by children, immigrant advocates said it deterred many Latinos.
“There was widespread fear in our communities, and you could see people going back into the shadows,” Camarena said. “We saw many families not applying or not renewing or literally pulling out of these services even though they were entitled to them.”
A federal court blocked the implementation of the expanded public charge rule last year and President Joe Biden this year rescinded it entirely. Even so, a recent report by the nonpartisan Urban Institute think tank suggests that the chilling effect is likely to persist as immigrants remain fearful of enrolling in safety net programs.
If federal actions contributed to the decline in health insurance among Latino kids, state policies and administrative hurdles deepened the problem, health policy experts and advocacy groups say.
One of the main factors affecting the enrollment of Latino children in health insurance is whether they live in states that have expanded Medicaid under the Affordable Care Act.
The law, widely known as Obamacare, provided states with a higher federal match to extend Medicaid benefits to all adults with incomes up to 138% of the federal poverty line. Thirty-eight states and Washington, D.C., signed on.
Of the five states with the largest percentages of Latino children without health insurance—Mississippi (19.2%), Texas (17.7%), Tennessee (17.7%), Georgia (16.3%) and Arkansas (15.5%)—only Arkansas has expanded Medicaid.
While children of noneligible adults still can qualify for Medicaid depending on the family’s income, studies show children are less likely to be enrolled in Medicaid if their parents aren’t either.
According to the Georgetown analysis, the rate of Latino children without health insurance in states that had not expanded Medicaid by 2019 was more than 2.5 times higher than that in states that had expanded—14.9% compared with 5.8%.
A number of states with high rates of uninsured Latino children also impose five-year waiting periods for legally residing immigrants before they can qualify for Medicaid benefits. Among those states are Arizona, Georgia, Indiana, Mississippi, Missouri and Oklahoma, all of which have a 10.8% or higher uninsured rate for Latino children.
Critics point to other state bureaucratic hurdles to Medicaid enrollment for children in general and for Latino children in particular.
According to a 2020 review of Medicaid policies by the Kaiser Family Foundation, only about half the states allow beneficiaries to stay in Medicaid for a full year without having to reaffirm their income or provide other documentation.
But many of the states with high rates of uninsured children do not have such policies and require enrollees to provide documentation multiple times a year. Families often receive requests for such submissions with very short response windows, and face disenrollment of their children. That is particularly burdensome on Latino parents, who may have poor English language skills.
Bureaucratic mistakes, from coding errors to late mailings, also can trip up immigrants. Documents often are generated automatically and might be prompted by inaccurate information about, for example, a parent’s employment situation or income, said Patrick Bresette, executive director of the Children’s Defense Fund-Texas.
Camarena said it is common for letters asking for documentation to arrive after the response deadline has passed. Even when the letters do arrive on time, it is often impossible for parents to secure the necessary documents from employers on such a tight turnaround.
Camarena said she’s seen parents confused about the repeated requests for information they think they have already submitted. Whitener said that families with multiple children can receive requests at different times for different children, making it a nightmare to keep track of what has to be submitted and for whom.
“Parents and families that we see locally, some of them are just overwhelmed and busy just trying to provide a roof over their head and food for their families,” Camarena said. “Health is important, but sometimes they don’t think about it until it’s needed.”
Earlier this year, the Texas legislature passed a measure to extend the deadline for responding to documentation requests from 10 to 30 days and also to limit the number of times in the course of the year the Medicaid agency can review beneficiaries’ eligibility. Gov. Greg Abbott, a Republican, signed the bill earlier this month.
The state of Texas once invested in community outreach workers to help Latino residents and others enroll in public programs such as Medicaid, but that assistance has been severely reduced, Bresette said, and organizations like his cannot fully fill the gap. Instead, community groups employ health workers like Camarena, who are called “promotoras,” a term indicating that they share a background with those whom they serve.
Although promotoras often are Spanish speakers and federal regulations require states to offer oral interpretation and written translations to applicants, the Georgetown report concluded that English proficiency remains a barrier in Medicaid enrollment.
In response to questions from Stateline, Kelli Weldon, a spokesperson for the Texas Health and Human Services Commission, which runs the state’s Medicaid agency, wrote, “Our dedicated team of employees works hard every day to help people who are interested in Medicaid and CHIP to access the information they need, learn how to enroll, and manage their benefits.”
Asked about allegations of frequent errors occurring in the handling of Medicaid applications, Weldon wrote that the commission “utilizes a variety of quality assurance and quality control techniques to monitor and ensure accuracy in case work. We regularly provide training to our team members to ensure they have the most accurate information possible to provide to the public about benefits enrollment.”
The Georgetown report may be the first to examine differences in health insurance enrollment among Latino children of different national backgrounds. It reveals, for example, that nearly a quarter of children whose families came from Honduras lacked health insurance, compared with 9.6% of those with roots in Mexico and 4.6% of people with origins in Peru.
Those differences, Whitener said, likely can be attributed to how long families have lived in the United States. The most recent arrivals are likely less able to navigate American bureaucracy.
Even more, she said, the differences among Latino groups reflect the policies in the states where they end up settling.
In Texas, where 85% of Latino children have Mexican lineage, their uninsured rate is 17.7%, reflecting that state’s more stringent policies, Whitener said.
California, a Medicaid expansion state with fewer barriers and more assistance for immigrants, has about the same proportion of Latino children with a Mexican background as Texas.
But California’s uninsured rate among Latino kids is 4.7%.