Research Question How would policy options aimed at expanding Medicaid and individual marketplace subsidy eligibility to undocumented and legally present recent immigrants in Connecticut affect enrollment, premiums, state spending, and hospital spending on uncompensated care relative to current law?

       Policymakers in Connecticut are considering various state-funded policy options to improve insurance coverage among undocumented and legally present recent immigrants in the state — almost 60 percent of whom lack health insurance. In particular, they are removing immigration status requirements from Medicaid eligibility. They are also considering whether to provide state-funded subsidies to undocumented immigrants enrolled in individual market plans.

       A key challenge for this analysis was determining what share of undocumented immigrants would be likely to take up insurance coverage if it were available to them. Because few states have expanded coverage to their undocumented populations and because the denominator is uncertain, estimates of take-up rates are highly uncertain. There is similar uncertainty in estimating how much health care undocumented populations will use once they become insured. To address these uncertainties, the authors conducted sensitivity analyses that varied both the take-up and utilization rates.

       Using the RAND Corporation's COMPARE microsimulation model, the authors estimate the impacts of each policy scenario on enrollment, premiums, state spending, and hospital spending on uncompensated care. Their analysis suggests that removing immigration status requirements for Medicaid and individual market subsidy eligibility would decrease uninsurance among the undocumented and legally present recent immigrant populations by 32 to 37 percent and could improve insurance coverage and affordability in Connecticut for these populations while not substantially impacting other Connecticut residents.

       Key Findings Enabling undocumented and legally present recent immigrant populations to enroll in Medicaid will increase total insurance enrollment among this population by approximately 21,400 individuals, or 43 percent, relative to current law Direct costs to the state to expand Medicaid eligibility for 2023 are $83 million. Expanding marketplace subsidies to undocumented immigrants would have a relatively small effect on coverage while having a larger effect on costs, which increase by 31 to 45 percent over the Medicaid-only scenario. These policies to expand Medicaid eligibility would have minimal effects on enrollment and premiums for Connecticut residents who are U.S. citizens or legally present immigrants who have lived in the United States for five or more years. State cost estimates do not include three potential sources of savings Savings to hospitals from reduced spending on uncompensated care could amount to roughly $63 million to $72 million. Connecticut currently has an emergency Medicaid program that covers emergency care to individuals who qualify based on income, regardless of immigration status. The costs for this program (approximately $15 million in 2021) would presumably be substantially reduced by the decrease in uninsurance among undocumented and legally present recent immigrants. By offering Medicaid to legally present recent immigrants, the state would forego federal advance premium tax credit funding for the portion of this population that would have otherwise enrolled in marketplace coverage and been eligible for subsidies; these costs could be recouped via a Section 1115 waiver.

       Table of Contents Chapter One

       Introduction

       Chapter Two

       Policy Landscape

       Chapter Three

       Methodology

       Chapter Four

       Results

       Chapter Five

       Discussion

       Appendix A

       Overview of the COMPARE Microsimulation Model

       Appendix B

       Results with ARP Subsidy Enhancements

       Research conducted by RAND Health Care

       This research was funded by the Robert Wood Johnson Foundation and was carried out within the Payment, Cost, and Coverage Program in RAND Health Care.

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