Medicaid extension during COVID-19 pandemic helped reduce immigrant insurance coverage inequity

Undocumented immigrants have limited insurance coverage after birthing. During the COVID-19 pandemic, New York City extended Medicaid coverage for residents, including immigrants, beyond the normal 60-day period. Now a study has found that this policy changes reduced inequities in health coverage in the postpartum period between immigrants and US-born residents in the city. The reduction in insurance coverage inequity among the Hispanic population was the least compared to other racial groups.

Immigrants in New York City who are undocumented and otherwise nonqualified for insurance often receive inadequate post-partum care. While undocumented immigrants are eligible for Medicaid, coverage typically ends 60 days after birth. In 2020, the United States passed a federal policy called the Medicaid Maintenance of Eligibility in Families First Coronavirus Response Act (FFCRA) that provided continuous Medicaid coverage to all residents, including immigrants, after birth.

In a recent study that was published in American Journal of Public Health, researchers examined the inequities in insurance coverage among immigrants in New York City, as compared to US-born residents between 2016 and 2021. They found that inequities in insurance coverage among US-born versus immigrant birthing people decreased after the FFCRA was passed. However, this reduction was the least among Hispanic people compared to other racial groups.

“Among immigrants, postpartum uninsurance decreased from 13.6% to 9.3%, whereas among the US-born, it changed from 1.2% to 0.7%. Postpartum uninsurance decreased among all immigrant groups, but least among Hispanic immigrants, from 23.5% to 17.7%. Overall, the immigrant versus US-born disparity in postpartum uninsurance decreased 3.7 percentage points,” explains Dr. Teresa Janevic of Columbia University Mailman School of Public Health.

The researchers analyzed self-reported insurance status of people using the New York City Pregnancy Risk Assessment Monitoring System (PRAMS) to arrive at their findings, assessing 2611 births before FFCRA and 1197 births after. They found that one in six Hispanic people reported they were insured during the post-FFCRA period, despite being Medicaid eligible. The finding indicates a significant lack of awareness about FFCRA implications among this racial group.

“Many Hispanic immigrants reported no health insurance despite being eligible for continuous Medicaid coverage during FFCRA, suggesting a lack of awareness of their coverage,” Dr. Janevic notes. “One explanation for our findings is the fear and misunderstanding about Medicaid eligibility related to immigration status and public charge criteria among immigrants, which was thought to influence the uptake of Medicaid and Supplemental Nutrition Assistance Program (SNAP) at the onset of the pandemic. Other explanations include poorer dissemination of information related to the continuous Medicaid provision in immigrant-serving health institutions or immigrant communities,” she observes.

While the FFCRA likely had a positive impact on maternal health in immigrant communities overall, the findings indicate lapses in implementation, especially in community outreach. With the continued anti-immigration sentiments across the country, the study calls for more community awareness initiatives for federally funded health programs like the Postpartum Medicaid extension to ensure they offer maximum benefits to vulnerable populations.

“Postpartum Medicaid extension policies have the potential to reduce inequities, but a targeted, community-integrated approach is needed to raise awareness of coverage and ensure optimal implementation to advance maternal health equity,” Dr. Janevic cautions.

Finally, the study was done in one of the 12 states in the United States that offered enrollment to FFCRA for residents regardless of immigration status. Therefore, it remains unknown whether other states where immigrants remained ineligible for continued Medicaid coverage through the COVID-19 period experienced similar health benefits.

“Our findings have national implications. To date, of 47 states that implemented postpartum Medicaid extensions, New York and 11 other states include enrollees regardless of immigration status. As such, the gains in equity we identified in our natural experiment estimate what to expect in these states,” observes Dr. Janevic. “However, states that exclude categories of immigrants may not see similar gains, thus reducing the effectiveness of the policy while leaving behind many immigrants,” she offers a crucial caveat.