When children of undocumented status have access to affordable and high-quality health care and their parents receive adequate support navigating the health care system, the children are more likely to receive preventive services, including vaccinations and well-child visits, as well as care to address chronic conditions like asthma, diabetes, and developmental disabilities. Covering all children, regardless of immigration status, increases health equity and leads to improved outcomes across the lifespan, from fewer emergency department visits for children to decreased incidence of chronic conditions in adults.

Yet, as many as 32 percent of children of undocumented status are uninsured, compared to only four percent of citizen children with citizen parents. Recognizing this disparity, policymakers in a growing number of states — including California, Connecticut, Illinois, New Jersey, New York, Oregon, and Washington State — have passed legislation to use state funds to extend health care coverage that mirrors Medicaid and CHIP coverage to income-eligible children of undocumented status.

Even with policy changes, however, mistrust and avoidance of public programs in immigrant families brought about by previous public charge rule changes, as well as increased economic hardship due in part to the COVID-19 pandemic, have led to declines in health care coverage in immigrant families. Misperceptions about affordability of public health insurance among Spanish-speaking families and families earning low-incomes, as well as difficulties accessing factual information through trusted resources, also discourage enrollment. This blog post highlights outreach, enrollment, and retention strategies that states offering coverage to children of undocumented status are implementing to help gain the trust of immigrant communities and increase health care coverage for their children.

Opportunities to Improve Take-Up of Health Care Coverage for Children with Undocumented Status

Following are five strategies states are using to improve health care coverage rates for children with undocumented status.

1. Develop Tailored Messaging and Comprehensive Outreach Materials

• Craft motivational messages. Messaging that emphasizes values-based statements can widen support and increase enrollment. In California, the Children’s Partnership’s Health4AllKids initiative uses a variety of messaging including “We’re all in this together. California is stronger when everyone is covered,” while Oregon Health Plan (OHP) uses “OHP Now Covers Me!” As suggested by the Centers for Medicare and Medicaid Services (CMS), states can also use broad motivational outreach messages like “Join the millions who are covered” and “Get enrolled, stay enrolled” to entice parents to enroll their children.
• Create outreach kits with stakeholder input. In Oregon, California, and New Jersey, state agencies or community organizations developed outreach toolkits with core messaging, talking points, downloadable posters, social media cards, and frequently asked questions in several languages to cater to specific populations. These toolkits are designed for an array of stakeholders, such as state agencies, community-based organizations (CBOs), schools, and health care providers. As part of New Jersey’s Cover All Kids legislation, the state created an Outreach, Enrollment, and Retention Working Group — composed of cabinet representatives, children’s advocacy and policy groups, and CBOs serving immigrant communities, among other stakeholders — to provide feedback on toolkit development, outreach, and implementation strategies.

2. Increase Language Accessibility and Target Diverse Media Outlets

• Improve language accessibility. Language accessibility helps ensure that diverse populations can understand eligibility rules and the application process. Washington State and New Jersey developed outreach materials in more than a dozen languages. Other states distribute multilingual printed cards that families can present to request translation services when applying for coverage in person. Connecticut developed a “Healthy Chat” online series in English and Spanish to share information on coverage options and enrollment.
• Target diverse media. To broaden and target outreach efforts, state agencies can engage media outlets like Telemundo and Univision or Latin radio stations to reach new audiences, share ready-made content that can easily be inserted in community newsletters or blog posts, track data analytics to identify platforms preferred by specific communities, and target ads by zip codes on social media for digital ad campaigns reaching specific communities.

3. Leverage Partnerships to Assist with Outreach and Enrollment

• Engage and contract with community partners. Building partnerships with CBOs that serve immigrant families can support more effective outreach to those populations. In 2007, the Oregon Health Authority created the Oregon Community Partner Outreach Program, which contracts with over 300 CBOs and 1,400 application assisters to provide culturally and linguistically responsive application and enrollment assistance for communities that face barriers to accessing health care. In 2019 and 2022, California passed legislation to initially fund and continue funding the Health Enrollment Navigators Project, which provides funding to counties and CBOs to conduct outreach, application assistance, and enrollment troubleshooting for hard-to-reach Medi-Cal eligible populations. States can partner with immigrant support groups, non-profit legal aid organizations, after-school programs, parks and recreation programs, food pantries, libraries, cultural centers, and faith-based institutions.
• Coordinate with other state agencies. Working with other agencies — including ones focused on education, public health, food and housing assistance, and employment assistance — can support coordinated outreach to immigrant populations. The New York Department of Labor hosted information-sharing events for individuals who are unemployed that included information on health care coverage, while Connecticut collaborated with multiple state agencies and chambers of commerce to train staff at job centers and food banks to help answer health care enrollment-related questions. States can also partner with schools to create links on school websites to provide parents with convenient access to the public health insurance application in English and Spanish. To increase insurance coverage rates for children, Oregon works closely with school health clinics and created a referral process with their department of education, schools, and summer camp programs.

4. Rely on Trusted Community Messengers to Connect with Immigrant Communities

• Reduce fear and misinformation. Strategies to reduce barriers and fear of health insurance enrollment in immigrant communities include working with trusted community partners to help provide clear multilingual information to families and to introduce the concept of public health care coverage, as needed. In Illinois, the Coalition for Immigrant and Refugee Rights created a health care assistance fact sheet in both English and Spanish that details health insurance programs available for immigrants and refugees. Advocacy and legal aid partners in Oregon developed written products to address public charge misinformation and helped pay for translation and dissemination of materials.
• Rely on trusted messengers. The Oregon Community Partner Outreach Program team piloted an ambassador program that collaborated with local CBOs and leaders from faith-based organizations to reach immigrant communities. Trust-building strategies included one-on-one discussions with trusted community gatekeepers. Oregon also moved away from using the term “undocumented immigrants” and is instead referring to “regardless of immigration status” to reduce stigma. California’s Health Enrollment Navigators Project found that partnering with faith-based institutions and other trusted community partners for enrollment assistance can help connect with families where they live, work, learn, play, and worship.

5. Focus on Coverage Retention and Health Care Utilization

• Maintain contact over time. Staying in contact with families is a strategy that state agencies, CBOs, and providers can use to ensure higher coverage retention and health care utilization rates. Catholic Charities, one of the contracted partners with California’s Health Enrollment Navigators Project, reminds families to renew their public health insurance benefits in time, to reduce churn. Illinois implemented a robust reporting system to track application status and follows up with individuals who still need to complete their application. Washington State Health Care Authority provides health plans with daily reports of enrollees who need to provide information to renew coverage so health plans can connect with beneficiaries to offer renewal assistance.
• Ensure usage of health care services. Enrolling children in public health insurance programs is not enough to positively impact health outcomes. Families have to know how to access preventive services and health care services when children get hurt or sick. Outreach staff and navigators can assist families with finding providers and scheduling doctor appointments. If other family members do not qualify for coverage assistance, outreach staff can also help them find clinics that offer sliding scale fees.

Looking Forward

Momentum continues to build among states to invest in the health of their communities by extending state-funded health care coverage to all income-eligible children, regardless of immigration status. Some states are increasing income eligibility levels, eliminating premiums, and working to reduce renewal coverage hurdles and corresponding churn. These are promising steps, and there are additional policy solutions, including ones via Medicaid and CHIP, that could further help all children in the U.S., including children of undocumented status, access quality, equitable, and affordable health care services.