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 funded two programs: the Immigrant Children’s Program and DC Health Care Alliance.

After a decade in which only about half of all enrollees successfully recertified for the DC Health Care Alliance program every six months, the District’s fiscal year 2023 budget funded a shift so that people only have to recertify once a year. There is still work to be done, however, to make the process more accessible. Reducing lapses 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 and 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:

Are 20 years old or younger
Are not eligible for Medicaid
Have income at or below 319% of the Federal Poverty Line (for children up to age 18) or up to 216% of the Federal Poverty Line (for ages 19-20)

As of fiscal year 2020, 59% of participants are Latinx and 8% are Black, with 28% identified as “other.”

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

Are 21 years old or older
Have no other health insurance and are not eligible for Medicare or Medicaid
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
Have income at or below 200% of the federal poverty level

As of fiscal year 2020 roughly half of participants are Latinx and just under one-fifth are Black, with most of the rest being identified as “other” (50%, 20%, and 24%, respectively) and just 2 and 1 percent each white and Asian/Pacific Islander.^7a

Unfortunately, DC Health Care Finance has not reported coverage rates for eligible DC residents, which makes it difficult to determine whether or not there are significant access gaps. 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-born population (43 vs 7% for Latinx, and 15 vs. 2% for Asian American).^7b But because people with some immigration statuses are eligible for Medicaid and not the Alliance, and, of course, many immigrants have incomes beyond the level that allows for enrollment in public health insurance programs or 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 3% of DC children are not US 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 with children, however, not just those with married couples, poverty rates are actually lower for foreign-born than for native-born families, and many foreign-born parents have children born in the U.S.⁹ So, while we know how many people these programs are serving (see below), we cannot determine 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 (which 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 allowed online applications and telephone interviews for the Alliance. As the emergency provisions ended, DC Council passed funding to allow 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.¹

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 during the pandemic: the most recent monthly enrollment report indicates that in January 2022 there were 22,974 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 recertification (see chart on next page).¹⁷

While DC Health Care Alliance enrollment had been stable for the past several pre-pandemic 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

The District took a vital step to strengthen the Health Care Alliance by extending its recertification period to 12 months. However, many of the hurdles that made twice-a-year recertification a problem still remain even with the less frequent requirement. If eligible District residents cycle in and out of the Alliance or ICP due to procedural issues hindering their recertification process, they lose access to important medical care. 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 43% of residents who don’t have US citizenship are Latinx, 18% are Black, and 15% are Asian American, lapses in health care access for immigrants is likely to disproportionately impact people of color.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. To minimize hurdles, we have several recommendations.

Improve Language Accessibility for the Recertification Process

We recommend several steps for the District to improve the language accessibility of Alliance recertification:

Consistently send participants notifications in their primary language.
Make the online application and recertification tool available in multiple languages.
Work to make linked documents available in Amharic and other languages commonly spoken by District residents (though we appreciate the work to make more of them available in Spanish).

Provide Applicants Information on Their Application/Recertification Status

Many residents seek out support from community-based organizations when they don’t hear back from the Department of Human Services, only to discover that a document did not upload correctly or that there are other issues that would be fixable with clear communication.

Break Down Program Data by Race

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 regularly 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

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%.

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.

2022 Policy Snapshot: Immigrant Children’s Program and DC Health Care Alliance