Immigrant Children’s Program and DC Health Care Alliance 01-07-2021

January 7, 2021
Policy Snapshot

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

As of fiscal year 2018 roughly half of the DC residents enrolled in the Alliance were Latinx and a quarter were Black, with most of the rest being identified as “other” race (49%, 25%, and 21%, respectively) and just 1 percent each white and Asian/Pacific Islander.7a Unfortunately, DC Health Care Finance has not reported coverage rates for eligible DC residents. So, for example, we know that there are more Latinx and Asian American people in DC’s foreign-born non-citizen population compared to its native population (38 vs 8% for Latinx, and 17 vs. 2% for Asian American).7b 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 2% of DC children are not U.S. citizens8, but some of those children have immigration statuses that allow them to be eligible for CHIP (and therefore ineligible for ICP), 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 vs. 2%). 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

Prior to the COVID-19 pandemic, District residents applied 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. Additionally a face-to-face interview was required at application (could be conducted by phone only for a narrow subsection of residents with disabilities, etc.) and the application had to be renewed every six months thereafter.12 

During the public health emergency DC has allowed for online applications and telephone interviews for new applicants and has waived the recertification requirement. In addition, in 2020, looking beyond the public health emergency, DC Council passed funding for FY21 to allow one of the two twice-yearly recertification appointments to be done by phone rather than in person.  District 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 last recent monthly enrollment report before the pandemic indicates that in February 2020 there were 15,683 residents participating in the DC Health Care Alliance and 4,206 children in the Immigrant Children’s Program. Enrollment in the Alliance increased somewhat during the pandemic: the most recent monthly enrollment report indicates that in December 2020 there were 18,568 people in the Alliance (ICP enrollment has remained stable).16 The pre-pandemic enrollment numbers in both programs had been relatively stable for several years after a nearly one-third drop in enrollment when the DC Health Care Alliance switched from annual to six-month recertification17:

Immigrant Children's Program and DC Health Care Alliance Enrollment

 

While DC Health Care Alliance enrollment had 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

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.

During the COVID-19 pandemic this requirement (which at the time was exclusively in person for all but a handful of participants) was suspended in the short term, but there’s no indication that the change will continue after the pandemic is over.20

Extending recertification and eliminating the in person requirement 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 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 the District, where 41% of residents who don’t have U.S. citizenship are Latinx, 18% are Black, and 13% are Asian American, churn in health care access for immigrants is likely to disproportionately impact people of color.24 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.25 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 took a helpful step to make recertification less of a barrier by allowing it to be done by phone once a year in addition to in person once a year. An even more helpful step, however, would be to fund Bill 23-890, passed in December of 2020, which would make recertification annual.and eliminate the in-person requirement altogether.26

 

In the Financial Impact Statement for that legislation the Office of Revenue Analysis estimated that DHCF can absorb the cost of this change in fiscal year 2021 but will need an additional $34.85 million over the 2021-2024 financial plan to implement the bill27 though given that enrollment has not skyrocketed during the period during the pandemic in which re-certification is waived it may be possible to absorb more of the cost than forecasted.  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 lingering chilling effect of the Trump administration’s expansion of the public charge rule, even with the Biden administration reversing that expansion,28 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.

Break Down Program Data by Race

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

7a.  https://dccouncil.us/wp-content/uploads/2019/04/dhcf.pdf

7b. American Community Survey Table S0501 2019 2-year estimates

8.  ibid. However, due to the small sample size there’s a big margin of error. In 2018 data from this same source the percentage was 4% rather than 2%.

9.  ibid

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. 6 month recertification for the Alliance was implemented in October 2011. For more details see 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.  American Community Survey Table S0501 2019 1-year estimates

25. 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

26. https://lims.dccouncil.us/downloads/LIMS/45633/Meeting2/Enrollment/B23-0890-Enrollment1.pdf

27. https://lims.dccouncil.us/downloads/LIMS/45633/Other/B23-0890-FIS_-_PDMP_Query_Omnibus_Amendment_Act.pdf

28.  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 On Feb. 2, 2021 the Biden administration reversed this broadening, however many families may still be still confused or afraid.

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 recertification requirements, the District of Columbia 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.