Estimating the Effects of Further Expanding Health Insurance Coverage to Noncitizen Populations in Connecticut

Noncitizen immigrants represent roughly 8 percent of the U.S. population but represent more than 30 percent of the uninsured population (Buettgens and Ramchandani, 2023). Undocumented immigrants are generally ineligible for all forms of federally funded health insurance, including Medicaid, Medicare, and coverage on the Health Insurance Marketplace. Legally present immigrants who have held “qualified immigrant” status for fewer than five years are generally ineligible for Medicaid and Medicare coverage, although they are permitted to enroll in Health Insurance Marketplace coverage and receive subsidies (U.S. Department of Health and Human Services, undated).¹

Several states have used state funding to extend health insurance coverage to immigrants who are ineligible for federally funded coverage, whom we refer to as ineligible immigrants in this study. Connecticut is one such state and has extended coverage for HUSKY, the state's Medicaid program, to a subset of immigrants. There are four HUSKY programs that serve different populations:

1. HUSKY A: Medicaid for children ages 0–18, parents or caregivers, and pregnant people
2. HUSKY B: Children's Health Insurance Program (CHIP) for children ages 0–18
3. HUSKY C: Medicaid for adults who are ages 65 and older, blind, or disabled
4. HUSKY D: Medicaid for adults ages 19–64 without minor children

Connecticut policymakers first extended HUSKY coverage to ineligible immigrants in 2021 by allowing income-eligible children ages 8 and younger to enroll in HUSKY A or HUSKY B, regardless of immigration status. The age threshold was extended to age 12 in January 2023 and then to age 15 in July 2024 (Hirshman, 2024). Ineligible immigrants who are pregnant are also permitted to enroll in coverage via HUSKY B and can maintain that coverage for 12 months postpartum.

Policymakers are considering further extending eligibility for HUSKY A and B to the remaining ineligible immigrant population of children through age 18. Policymakers are also considering expanding HUSKY A, B, and D to the adult population, with or without the additional expansion of HUSKY C. Furthermore, policymakers are considering options for covering the population of adults ages 65 and older; under existing eligibility requirements, only adults ages 19–64 qualify for HUSKY D because individuals ages 65 and older are assumed to be eligible for Medicare. However, covering seniors through HUSKY C could be much more expensive than covering them through HUSKY D because HUSKY C has more generous coverage of long-term care. Therefore, we consider a scenario in which HUSKY D eligibility is extended to seniors. Other than this exception, in the scenarios we model, these programs would retain all existing age- and income-based eligibility requirements but would no longer have any requirements related to immigration status.

Table 1 summarizes the details of these policy scenarios. In this study, we use microsimulation modeling to understand the effects of such expansions on insurance enrollment and state spending in Connecticut.

Methods

COMPARE is a nationally representative microsimulation model in which individuals and households make choices about health insurance. We make several updates to the COMPARE microsimulation model so that it represents Connecticut and allows for analyses of the scenarios under consideration, including

• reweighting the data underlying the model to represent the population size and key demographics (e.g., age, sex, income, insurance status, race, ethnicity) of Connecticut
• imputing undocumented immigrant status using an algorithm informed by the literature that identifies potential undocumented immigrants by ruling out citizens and individuals who report receiving benefits unavailable to undocumented immigrants (e.g., Medicaid, Supplemental Security Income) or who report having occupations that are not available to undocumented immigrants, such as police officer (Passel and Cohn, 2018; Van Hook et al., 2021)
• using data from the Migration Policy Institute about the total number of undocumented adults and children in Connecticut
• imputing pregnancy status by using data specific to Connecticut by age, race, and ethnicity for women ages 15–45
• imputing disability status in the undocumented immigrant population by age, income, gender, race, ethnicity, and health status.

There are uncertainties related to health insurance take-up and medical spending among undocumented immigrants. As a default, we assume both take-up and medical spending are similar to those of the general population in Connecticut by demographic characteristics, but we conduct sensitivity analyses using higher and lower take-up.²

Results

Expanding eligibility for HUSKY by removing immigration status as an eligibility requirement would result in increased rates of insurance and increased costs to the state, although findings varied according to which age groups and HUSKY programs were included in the proposed expansions (Table 1). In particular, we note the following results (summarized in Table 2):

• Total insurance enrollment would increase by 6,400 individuals when extending HUSKY A, B, and D to those ages 16–25. The addition of HUSKY C for this age group would have little effect.
• Enrollment would increase by 22,600 to 24,400 individuals when HUSKY eligibility is expanded to all people who would otherwise qualify, depending on whether HUSKY C is also expanded or whether seniors are made eligible for HUSKY D.
• The total number of individuals covered by HUSKY would increase by more than the change in total insurance coverage across all scenarios because a small number of immigrants previously covered by other insurance types (e.g., employer-sponsored coverage, off-marketplace individual market coverage) would switch to HUSKY.
• Costs to the state would be approximately $39 to $40 million when extending coverage to those ages 16–25 only.
• Costs would increase substantially when extending coverage to all ages (subject to the existing age requirements in each HUSKY program). Expanding HUSKY A, B, and D to all eligible ages (Scenario 3) would result in the smallest increase in costs relative to existing law at $186 million. The addition of HUSKY C for this group would lead to spending $252 million relative to existing law because of the cost of long-term care under HUSKY C. Additionally expanding access to HUSKY D for seniors (a departure from existing age-based eligibility requirements), rather than expanding HUSKY C, would cost the state $203 million relative to existing law.

Discussion

Our analyses suggest that policymakers in Connecticut should consider the following findings from our models when evaluating the options for expanding HUSKY coverage:

• Removing immigration status requirements from Medicaid and CHIP eligibility to children and young adults ages 16–25 would substantially reduce uninsurance among this population and comes at a relatively low cost to Connecticut. The addition of HUSKY C would make little difference to this population because of the low rate of disability.
• Further expanding Medicaid coverage to the remaining adult population via HUSKY A, B, and D (Scenario 3) would increase insurance coverage by a greater proportion among adults through age 64 but to a much lesser extent to adults ages 65 and older because seniors do not qualify for HUSKY D and would gain coverage in this scenario only if they were parents or caregivers to a minor child.
• Including HUSKY C in the expansion would result in an almost 40-percentage point reduction in uninsurance among seniors but would substantially increase costs to Connecticut because of the coverage of long-term care under HUSKY C.
• Allowing seniors to enroll in HUSKY D would result in almost as large of an increase in insurance coverage among adults ages 65 and older as the HUSKY C expansion but at a lower cost to Connecticut. However, this policy scenario would involve a difference in eligibility requirements relative to the federally funded HUSKY D program.