Policy Snapshot: Immigrant Children’s Program and DC Health Care Alliance

 

Policy Snapshot

Immigrant Children’s Program and DC Health Care Alliance

 

KEY FACTS

  • In order to provide health care to those in need regardless of immigration status, DC created and funds two programs: the Immigrant Children’s Program and DC Health Care Alliance.
  • Given that only about half of all enrollees successfully recertify for the DC Health Care Alliance program every six months, likely due to burdensome in-person recertification requirement, DC should re-extend its recertification period to 12 months and make the process more accessible. Reducing the “churn” in health care coverage would allow for better access to preventative care and could reduce long-term costs - both to DC residents’ physical health and to the city financially - by keeping conditions from getting severe enough to require more expensive treatment in the future. 

 

What are the Immigrant Children’s Health Program and DC Health Care Alliance, and why are they important?

With limited exceptions, undocumented residents such as recent green card holders are not eligible for federally-funded health insurance programs such as Medicaid and Medicare.1 However, in order to provide health care to those in need regardless of immigration status, the District of Columbia created two programs: the Immigrant Children’s Program and the DC Health Care Alliance. While both of these health insurance programs are locally funded, they provide coverage similar to Medicaid, including:2

 

Immigrant Children’s Program3

DC Health Care Alliance4

Doctor visits

Preventive care (checkups, diet, and nutrition)

Vision

 

Prenatal care 

 

Dental care

✔ (up to $1000)

Prescription drugs

Laboratory services

Medical supplies

 

Who are the Immigrant Children’s Program and DC Health Care Alliance intended to help?

The Immigrant Children’s Program is available to District residents who5:

  1. Are 20 years old or younger
  2. Are not eligible for Medicaid
  3. Have income at or below 200% of the Federal Poverty Line 

Similarly, DC Health Care Alliance is available to District residents that meet the following requirements:6

  1. Are 21 years old or older
  2. Have no other health insurance and are not eligible for Medicare or Medicaid
  3. Have resources (a bank account, for example) at or below $4,000 for a single applicant and at or below $6,000 for couples and families
  4. Have income at or below 200% of the federal poverty level

Unfortunately, DC Health Care Finance hasn’t started reporting program demographical data. So, for example, we know that there are more Latino and Asian American people in DC’s foreign-born non-citizen population compared to its native population (43 vs 7% for Latino, and 15 vs. 2% for Asian American).7 But because different immigration statuses (e.g. green card holders, asylees, those with temporary protected status, H-1B visa holders) qualify for Medicaid and the Alliance in different ways, and, of course, many immigrants have incomes beyond the level that allows for enrollment in the Alliance (or, as is the case for most H1B visa holders, have private health insurance), getting an exact picture of the eligible population is quite challenging. 

Similarly for the Immigrant Children’s Program, we can say that about four percent of DC children are foreign-born8, but some of those children have immigration statuses that allow them to be eligible for CHIP (and therefore ineligible for the Alliance), and some are in families with income above the eligibility criteria, making it hard to get an exact picture of the eligible population. Regarding income, we know that for married couples with children, poverty rates are higher for foreign-born than for native-born couples (7.6 vs. 2.5%). When looking at all families, however, not just those with married couples, poverty rates are actually lower for foreign-born than for native families, and also many foreign-born parents have children born in the U.S..9 So, while we know (see below) how many people these programs are serving, we cannot say how many eligible DC residents are still not being served.

How do the Immigrant Children’s Program and DC Health Care Alliance Operate?

How to apply for these Programs 

DC residents can apply to the DC Health Care Alliance by completing the application10 by mail, fax, or at an in-person service center.11 The application is a part of the Combined Application for Benefits in DC. Additionally a face-to-face interview is required at application and the application must be renewed every six months thereafter.12

DC residents can apply to the Immigrant Children’s Program online13 or in person.14

How much do these programs cost participants?

There are no monthly premiums, copayments, or other charges for covered services for DC Health Care Alliance and the Immigrant Children’s Program.15

Who benefits from the Immigrant Children’s Program and DC Health Care Alliance?

The most recent monthly enrollment report indicates there are 15,569 DC residents participating in the  DC Health Care Alliance and 3,651 children in the Immigrant Children’s Program.16 After a nearly one-third drop in enrollment when the DC Health Care Alliance switched from annual to six-month recertification,17 enrollment numbers in both programs have remained relatively stable over the past several years: 

Immigrant Children’s Program and the DC Health Care Alliance Enrollment

Source: Monthly Medicaid and Alliance Enrollment Reports, https://dhcf.dc.gov/page/monthly-medicaid-and-alliance-enrollment-reports

 

While DC Health Care Alliance enrollment has been stable for the past several years, enrollees’ use of health care services increased between 2013 and 2017 due to a combination of the average age of enrollees increasing (which tends to come with more medical issues) and somewhat increased coverage.18

Opportunities to Improve the DC Health Care Alliance and Immigrant Children’s Program

Continue Investments in Community-Based Services

DC Health Care Alliance and the Immigrant Children’s Program serve as model examples of public insurance programs for immigrants. As one of only seven jurisdictions that offer such programs, Washington DC is a national leader in immigrant health.19 In addition, DC has invested in community health centers with wraparound services that can help make both traditional health care and connections to resources that impact health (e.g. WIC, SNAP) more accessible for residents. DC should continue this investment in the health of all its residents.

Extend Recertification Period to 12-Months

There is a major opportunity to further strengthen the Health Care Alliance by extending its recertification period to 12 months. Currently, District policy is that Health Care Alliance enrollees have to recertify their benefits every six months, in person. During the COVID-19 pandemic this requirement was suspended in the short term, but there’s no indication that the change will continue after the pandemic is over.20 

Extending recertification is important because only about half of all enrollees successfully recertify.21 This high churn rate (the rate at which individuals transition between different types of insurance and/or lose insurance coverage) is likely the result of the burdensome in-person recertification requirement as opposed to a loss of eligibility due to a change in income or residency status.22 Such churn has been shown to lead to numerous adverse effects for individuals, including delayed health care access, reduced medication adherence, and increased emergency room visits. 23 In DC, where 43 percent of residents who don't have U.S. citizenship are Latinx, 18 percent are Black, and 15 percent are Asian American, churn in health care access for immigrants is likely to disproportionately impact people of color. Extending the recertification period to 12 months would not only reduce this harmful churn but also align the program with Medicaid’s 12-month certification period.24 Similar to Medicaid’s shift from fee-to-service to managed care, in the long run better continuity of coverage has the potential to save the city money if residents access preventative care, which alleviates the need for more expensive treatments in the future. DC could consider other steps to make recertification less of a barrier, such as allowing it to be done by phone or at health centers rather than at city service centers.

In addition, the District must also review Alliance and Immigrant Children’s Program application language to make sure that the language does not deter eligible families from applying. With the recent changes to the Public Charge rule,25 immigrant families may be less likely to apply for benefits. DC Health Care Finance must be aware of this concern and make sure to provide clear and consistent information around eligibility rules for the program. 

Disaggregate Program Data

Last but not least, to better understand the impact of decisions such as switching the recertification period for the Alliance and how well the Alliance and the Immigrant Children’s Program are working, DC should report re-enrollment, utilization, and outcome data disaggregated by race. If racial disparities exist in the percentage of enrollees who do not recertify, or in the percentage of Alliance enrollees who get preventative care on a consistent basis, there may be systemic barriers to doing so. Similarly, by publicly reporting data on outcomes (similar to Medicaid’s State Health System performance measures), and disaggregating those data by race, the District can better understand where it’s doing well and where there may be areas for improvement.

Endnotes

1.  https://dchealthlink.com/node/1689; https://www.healthcare.gov/immigrants/lawfully-present-immigrants/ 

2.  https://dhs.dc.gov/service/medical-assistance

3.  https://dhcf.dc.gov/service/immigrant-childrens-program

4.  https://dhcf.dc.gov/service/health-care-alliance

5.  https://dhcf.dc.gov/service/immigrant-childrens-program 

6.  https://dchealthlink.com/node/2478#que1

7.  American Community Survey Table S0501 2018 5-year estimates

8.  https://www.migrationpolicy.org/data/state-profiles/state/demographics/DC

9.  American Community Survey Table S0501 2018 5-year estimate

10.  https://dhs.dc.gov/publication/combined-application-benefits

11.  https://dhcf.dc.gov/service/how-apply-medical-coverage

12.  https://dhs.dc.gov/service/find-service-center-near-you

13.  https://enroll.dchealthlink.com/users/sign_up

14.  https://dhs.dc.gov/service/find-service-center-near-you See also https://www.myamerigroup.com/dc/benefits/enroll.html

15.  https://dchealthlink.com/node/2478#que1

16.  https://dhcf.dc.gov/page/monthly-medicaid-and-alliance-enrollment-reports

17.  https://dccouncil.us/wp-content/uploads/2019/04/dhcf.pdf

18. https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/DC%20Health%20Care%20Alliance%20Demographics%20and%20Cost%20Drivers%20FY%2013-17%20101018%20KT%20Approved.pdf

19.  https://www.kff.org/disparities-policy/issue-brief/health-coverage-and-care-of-undocumented-immigrants/

20.  https://dhcf.dc.gov/service/how-renew-your-medical-coverage; https://coronavirus.dc.gov/release/during-modified-dc-government-operations-many-services-still-operating

21.  https://www.dcfpi.org/all/no-way-to-run-a-healthcare-program-dcs-access-barriers-for-immigrants-contribute-to-poor-outcomes-and-higher-costs/#_edn1

22.  See e.g. https://www.popville.com/2019/05/the-dc-health-care-alliance-is-a-model-public-insurance-program-but-its-burdensome-requirements-cause-many-eligible-residents-and-their-health-to-lose-out/

23.  https://www.cbpp.org/research/health/locking-people-out-of-medicaid-coverage-will-increase-uninsured-harm-beneficiaries and https://www.healthaffairs.org/doi/10.1377/hlthaff.2019.00378

24. https://dhs.dc.gov/sites/default/files/dc/sites/dhs/service_content/attachments/FAQs_About_Medicaid_Renewals_12_10_2014.pdf and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4664196/ 

25.  Historically, the “public charge” inadmissibility test was designed to identify people who may depend on the government as their primary source of support. If the government determines that a person is “likely at any time to become a public charge” in the future, it can deny a person admission to the U.S. or lawful permanent residence (or “green card” status). (Immigration and Naturalization Act section 212(a)(4), 8 USC 1182(a)(4)) Revised public charge regulations published by the Department of Homeland Security (DHS) and the U.S. State Department that went into effect on February 24, 2020, redefine a “public charge” as a non-citizen who receives or is likely to receive one or more of the specified public benefits for more than 12 months in the aggregate within any 36-month period (such that, for instance, receipt of two benefits in one month counts as two months). The benefits considered are cash assistance for income maintenance from any level of government, SNAP (formerly Food Stamps), public housing, Section 8 housing assistance, and Medicaid (with exceptions for persons under age 21, women during pregnancy and for 60 days after the pregnancy ends and emergency services). This is much broader than the original test for public charge. For more information see: https://protectingimmigrantfamilies.org/analysis-research/