Can Medicaid and Immigration Policies Help Close Perinatal Care Gaps among Latinx Families?

Barriers to Latinx Communities’ Access to Perinatal Health Care

Longstanding concern in the health research community over racial disparities in maternal health is growing stronger. Large gaps in access to and the quality of perinatal care - the crucial information and screenings recommended before, during, and after pregnancy - exist within the Latinx community. Prior studies have found that these gaps can be attributed to multiple factors, including those related to health insurance, language barriers, racism, and discrimination in healthcare settings. Materially, half of all immigrants to the U.S. have limited English proficiency. Additionally, various immigrant citizenship statuses leave many without access to health insurance. For example, one in four Latinx immigrants are uninsured, as are over half of all undocumented Latinx immigrants. Many of these barriers are, or can be, influenced by policymaking.

At the University of Minnesota School of Public Health, we conducted a study that examined the association between state immigration and Medicaid policies and perinatal care access and quality within Latinx communities. The study found that only 54% of Latinx people had healthcare visits in the year prior to becoming pregnant, and Spanish-speaking Latinx people (44%) were less likely to have access to high quality care (getting recommended information and screenings) compared to their English-speaking Latinx counterparts (62%). Additionally, Spanish-speaking Latinx people – on average - started prenatal care later in pregnancy, had fewer than the recommended number of prenatal visits, and were less likely to get the recommended information or care during prenatal and postpartum visits, when compared with English-speaking Latinx people.

Spillover Effects from State Immigration Policies May Contribute to Gaps in Perinatal Care for Latinx Communities

Our research also examined differences in perinatal care based on variations in state policies and found that disparities by language among Latinx people were smaller in states that waived the five-year Medicaid restriction imposed on documented immigrants and in states with expanded Medicaid income eligibility.

Using a technique developed by Pew Research, we included an indicator of whether Latinx people were a) likely citizens or b) likely non-citizens and found that:

• Latinx people who were likely non-citizens and who lived in states without the five-year Medicaid waiver on documented immigrants used prenatal care less often than those in waiver states, while there was no difference in this measure among likely citizens.

• In non-waiver states Latinx people, in general, had fewer postpartum visits and received less of the recommended care information or screenings before, during, and after pregnancy, regardless of their likely citizenship status.

These findings demonstrate that states’ immigration policy environment may lead to spillover effects onto other immigrant populations and to U.S. citizens, so that even Latinx U.S. citizens, who are not a policy’s target, may be negatively affected by immigration-related policies. The mechanism behind these findings has been previously established.  Specifically, many undocumented Latinx immigrants are concerned about themselves or a family member being arrested or deported over their citizenship, leading to disengagement with healthcare institutions. Additionally, these concerns over citizenship status have extended to naturalized citizens and permanent residents. Households with permanent residents and naturalized citizens have reportedly avoided applying to public programs due to concerns over citizenship status, especially in an uncertain federal immigration policy landscape. Furthermore, these spillover effects can be multi-generational, impacting both access to and quality of necessary healthcare, as well as the long-term health and well-being of non-citizen Latinx individuals residing in the U.S. and U.S. citizen children of foreign-born immigrant families.

Our study’s findings suggest that in Latinx communities, state policies that explicitly exclude non-citizens can, and do, also adversely affect health and healthcare access for U.S. citizens.

Disparities in Perinatal Care Access and Quality: Crafting Effective Policy in the Current Political Environment

While our study indicates that state-level Medicaid income-eligibility and immigrant coverage policies are associated with reductions in some disparities in perinatal care by language and citizenship status, the study’s findings of other persistent disparities suggest that state policies alone could not solve all perinatal healthcare access and quality barriers for the Latinx community.

It is worth pointing out in an election year that the current political climate, threats to immigrants’ stability in the U.S., and federal inaction on immigration reform have forced states to take on the job of creating immigrant-inclusive policies. Predictably, these policies vary across states, leaving a patchwork of state policies and an accumulation of disparities in perinatal health and care dependent on where people live in the U.S.

Without action from state and federal policymakers, anti-immigrant rhetoric from public officials and institutions, alongside policies excluding immigrants from healthcare coverage, are likely to continue keeping pregnant Latinx people from accessing the recommended perinatal health care before, during, and after pregnancy – the essential care that supports healthy parents, infants, and families. Attention to the health and well-being of all Latinx birthing people – regardless of language or citizenship status – requires a policy environment that facilitates health insurance coverage and access to care instead of restricting it.

Given the upcoming presidential election and the public’s focus on immigration and healthcare, it is crucial at this time to encourage state and federal policy decisions that could contribute to improved perinatal health outcomes in Latinx communities and thereby improve population health across the nation.

State Policies May Help Address Perinatal Health Disparities with Better Health Insurance Access

State policies may help improve care for all birthing people by improving health insurance access. Our study examined two alternative approaches toward this goal of reducing disparities in adverse outcomes. 

• Federal law permits Medicaid enrollment for lawfully residing immigrants, but typically only after a five-year waiting period. States have the option to waive this restriction for pregnant immigrants, which 30 states and the District of Columbia (DC) have adopted. (Additionally, 26 states (including DC) provide coverage for pregnant immigrants regardless of citizenship status using the Children’s Health Insurance Program funding or state-only funding.)

• The other policy we examined involves expanding Medicaid eligibility under the Affordable Care Act to people earning less than 138% of the Federal Poverty Level, a change that has improved healthcare coverage and access for Latinx people with lower income.

Yet, it is important to be aware that federal immigration policies dictate the citizenship status, social environment, and associated rights of immigrants, and often exclude immigrants from beneficial federal health insurance reforms or create barriers to obtaining health insurance coverage. These restrictions can lead to as previously explained spillover effects and disengagement with healthcare institutions that harm the health of both Latinx noncitizens and citizens long-term. Therefore, healthcare coverage disparities will continue to exist, at least in part, because of immigrants’ fears and concerns over citizenship status, which is a federal – not a state – issue.

As the presidential election approaches, we hope for a renewed focus on addressing perinatal health disparities in Latinx communities by reassessing current federal and state policies and encouraging future evidence-informed policy decisions that can improve maternal health in Latinx communities and nationwide.  

Our study can be found here.