Getting Back on Track: A Detailed Look at Health Coverage Trends for Latino Children by Kelly Whitener and Alexandra Corcoran Introduction From 2008 to 2016, the Latino child uninsured rate CHIP out of fear of adverse immigration consequences, fell steadily, eventually achieving a historic low of 7.7 known as the “chilling effect.”4 Federal cuts to funding percent in 2016.1 Although this rate was still higher than for outreach efforts and health insurance navigators who that for non-Latino children, the decline signaled steady could help explain the nuances of the public charge rule progress towards narrowing health coverage disparities and remind families of the affordable coverage options between Latino children and their peers. However, as the available to them only exacerbated the problem.5 Moreover, overall child uninsured rate started going in the wrong repeated attempts to repeal the Affordable Care Act (ACA) direction between 2016 and 2019, Latino children were and ongoing court battles have left many families uncertain disproportionately affected.2 Erasing years of progress, about the availability of public coverage.6 Latino children’s uninsured rate reached 9.3 percent in At the state level, red tape barriers, such as frequent income 2019.3 This 1.6 percentage point increase was more than reviews between renewal periods, closure of applications twice as fast as the 0.7 percentage point increase for non- without screening eligibility for other assistance programs, Latino youth (from 3.7 percent in 2016 to 4.4 percent in and unreasonably quick turnaround deadlines for 2019). information requests made getting and keeping coverage At the national level, the Trump administration publicized harder for families.7 As of 2019, there were approximately and implemented the “public charge” rule, which 1.83 million uninsured Latino children in the nation, an penalized adults for using public programs prior to gaining increase of 354,400 children compared to 2016. This report citizenship. Even though 95 percent of Latino children are takes a closer look at who these children are. citizens and not subject to public charge, many Latino families avoided enrolling their children in Medicaid or Figure 1. Uninsured Rate for Latino and Non-Latino Children, 2016-2019 2016 2019 | | Latino 7.7% 9.3%* Non-Latino 3.7% 4.4%* 4.0% 5.0% 6.0% 7.0% 8.0% 9.0% 10.0% Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau 2016-2019 American Community Survey (ACS) data using Public Use Microdata Sample (PUMS). * Change is significant at the 90 percent confidence level relative to the prior year indicated. JUNE 2021 CCF.GEORGETOWN.EDU HEALTH COVERAGE TRENDS FOR LATINO CHILDREN 1 Understanding Diversity within the “Hispanic/Latino” Category Within the broad label “Hispanic/Latino” there are many Figure 2. Diversity of Ethnicity within the Latino different stories shaped by socioeconomic status, Child Population in 10 States with Largest Latino documentation status, state of residence, immigration Child Population history (or lack thereof for those whose families have lived Mexican Puerto​ Rican Salvadoran Dominican Guatemalan Cuban Honduran here since before the U.S. existed), and country of origin Colombian Spanish Ecuadoran Nicaraguan Peruvian Venezuelan Other (see Appendix A for an explanation of how the U.S. Census United States 65.6% 9.4% Bureau collects and compiles Latino data).8 Across the 50 Arizona 90.1% states and the District of Columbia (D.C.), 65.6 percent of California 85.2% Latino children are of Mexican descent and 9.4 percent are Colorado 77.7% 13.4% of Puerto Rican descent.9 Children whose families identify Florida 18.1% 24.0% 21.6% as Salvadoran, Dominican, Guatemalan, and Cuban each represent between two and four percent of the national Georgia 62.9% 9.1% Latino child population (see Figure 2).10 However, there are Illinois 79.9% 9.2% significant differences at the state level—in Arizona, for New Jersey 15.6% 24.9% 18.2% 9.4% example, 90 percent of Latino children are Mexican while in New York 15.1% 28.5% 21.8% 9.9% New York, Puerto Rican and Dominican children make up North Carolina 58.1% 11.2% more than half of the Latino child population. Texas 84.9% Which Latino Children are Losing Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau 2019 American Community Survey (ACS) data using Coverage? Public Use Microdata Sample (PUMS). Coverage losses were widespread across age groups and income levels between 2016 and 2019. School-age Latino Table 1. Uninsured Rate for Latino Children by Age, children saw a slightly sharper increase than young children, 2016-2019 jumping 1.8 percentage points from 8.7 percent in 2016 to 10.5 percent in 2019 (see Table 1). The lowest income Latino Age 2016 2019 children, those with family incomes at or below 137 percent Under 6 5.3% 6.6%* of poverty, lost the most ground with their uninsured rate rising more than two percentage points in the three-year 6-18 8.7% 10.5%* period (see Figure 3).11 Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau 2016-2019 American Community Survey (ACS) data using Public Use Microdata Sample (PUMS). * Change is significant at the 90 percent confidence level relative to the prior year indicated. Latinos, Immigration, and Citizenship Status Many Latinos have deep family roots in what is today the United States (U.S.), dating back to well before Europeans arrived on the East Coast and the U.S. expanded its territory to the west and south, annexing large parts of Mexico. Yet, assumptions that all Latinos are immigrants remain prevalent. In fact, the vast majority (80.3 percent) of Latinos in the U.S. are citizens, many of them with long histories that even predate the founding of the U.S. 2 HEALTH COVERAGE TRENDS FOR LATINO CHILDREN CCF.GEORGETOWN.EDU JUNE 2021 Figure 3. Uninsured Rate for Latino Children by Figure 4. National Child Uninsured Rate by Detailed Income, 2016-2019 Ethnicity, 2019 2016 2019 8.4% Honduran 24.4% 0-137% of poverty 10.5%* Guatemalan 17.9% 9.0% 138-250% of poverty Venezuelan 14.5% 10.6%* Salvadoran 13.1% 5.6% 251% of poverty or above 7.3%* Mexican 9.6% All Other Spanish/Hispanic/Latino 8.9% Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau 2016-2019 American Community Survey (ACS) data Nicaraguan 8.8% using Public Use Microdata Sample (PUMS). * Change is significant at the 90 percent confidence level relative to the prior Colombian 6.8% year indicated. Cuban 5.9% Ecuadoran 5.3% These trends illustrate how the systemic barriers to coverage that Latino children face have grown over the past three Dominican 4.8% years. But they do not tell the full story. Looking at the Peruvian 4.6% data through the lens of detailed demographics and state Non-Latino 4.4% residency helps illuminate the distinct challenges that Puerto Rican 4.2% families face in accessing health coverage. Disaggregating Spanish 3.3% the data in this manner can also serve as the first step towards targeted outreach and enrollment efforts to make sure that all children get the care they need to grow and Source: Georgetown University Center for Children and Families analysis of thrive. U.S. Census Bureau 2019 American Community Survey (ACS) data using Public Use Microdata Sample (PUMS). Note that the uninsured rate for Puerto Rican children reflects those who are living in one of the 50 states or When disaggregated, the national uninsured rate of 9.3 the District of Columbia. percent for Latino children reveals wide variation (see Figure 4). For example, while almost a quarter of children of Further, the child uninsured rate has not accelerated at an Honduran descent are uninsured, approximately 8.8 percent even pace for different communities of Latino children (see of Nicaraguan children are uninsured, and only 3.3 percent Figure 5). While the uninsured rate for Guatemalan children of children of Spanish descent are uninsured. The uninsured shot up more than seven percentage points during the past rate for Puerto Rican children is on par with the uninsured three years, the uninsured rate for Puerto Rican children rate for non-Latino children. residing in the states or D.C. rose just over a percentage point. Some groups, such as Dominican children, saw no statistically significant change in their uninsured rate over the three years (see Appendix B). Puerto Rico The Commonwealth of Puerto Rico is a territory of the U.S., and Puerto Ricans are U.S. citizens. The child uninsured rate for Latino children living in the Commonwealth is 3.5 percent.12 In this report, references to Puerto Rican children reflect those who are living in one of the 50 states or the District of Columbia. JUNE 2021 CCF.GEORGETOWN.EDU HEALTH COVERAGE TRENDS FOR LATINO CHILDREN 3 Factors Associated with Higher Uninsured Rates Figure 5. Changes in Child Uninsured Rate by Between 2016 and 2019, South Carolina saw the largest jump Detailed Ethnicity, 2016-2019 in the uninsured rate for Latino kids, rising 6.8 percentage points from 8.5 percent to 15.3 percent (see Appendix C). California and Texas are home to the largest numbers of 24.0% Honduran Latino children (4.89 million and 3.87 million, respectively) but Latino children in Texas are almost four times more likely 22.0% to be uninsured compared to their peers in California (see 20.0% Appendices D and E). 18.0% Importantly, some subgroups of Latinos are more likely to Guatemalan live in certain states — while a quarter of Mexican children 16.0% live in Texas, less than five percent of Puerto Rican children do. And, while Guatemalan children are most likely to live 14.0% in California, roughly one in five live in Florida, Texas, or Salvadoran Georgia (19.6 percent) (see Figure 7). As a result of this 12.0% geographic variation, state and local policies to make coverage more affordable and inclusive to Latino children 10.0% Mexican and families play an important role in reducing the uninsured 8.0% Other rate for specific subgroups. Hispanic/Latino The uninsured rate for Latino children in states that had not 6.0% implemented Medicaid expansion by 2019 is more than 4.0% Not 2.5 times higher than expansion states (14.9 percent to 5.8 Hispanic/Latino Puerto Rican percent respectively). For non-Latino children, the uninsured 2.0% rate in non-expansion states is only slightly more than 1.5 times the rate of expansion states (5.8 percent to 3.6 0.0% percent) (see Table 2). 2016 2019 Source: Georgetown University Center for Children and Families analysis of Table 2. Uninsured Rate for Latino and Non-Latino U.S. Census Bureau 2019 American Community Survey (ACS) data using Children by Expansion Status, 2019 Public Use Microdata Sample (PUMS). Graphic only shows those subgroups for whom there was a statistically significant change at a 90 percent ​​ Latino Non-Latino confidence interval relative to the prior year indicated. See Appendix B for full results. Note that the uninsured rate for Puerto Rican children reflects Expansion States 5.8% 3.6% those who are living in one of the 50 states or the District of Columbia. Non-Expansion States 14.9% 5.8% State Residency. There is considerable variation in the Source: Georgetown Center for Children and Families analysis of U.S. Latino child uninsured rate by state (see Figure 6). State- Census Bureau 2019 American Community Survey Public Use Microdata Sample (PUMS). Maine and Virginia, who expanded between 2016 and 2019, level policies play a key role in enhancing or limiting access are excluded from this analysis. to health coverage for Latino children. The Latino child uninsured rate ranges from 1.8 percent in Massachusetts to 19.2 percent in Mississippi. The five states with the highest rates of uninsured Latino children are: Mississippi (19.2 percent), Texas (17.7 percent), Tennessee (17.7 percent), Georgia (16.3 percent), and Arkansas (15.5 percent). 4 HEALTH COVERAGE TRENDS FOR LATINO CHILDREN CCF.GEORGETOWN.EDU JUNE 2021 1.8% 19.2% Figure 6. Uninsured Rate for Latino Children, 2019 WA MN WI MI NY MA 5.1% 6.7% 8.4% 5.1% 2.6% 1.8% ID IL IN OH PA NJ CT 9.1% 6.0% 12.3% 8.3% 4.6% 6.9% 4.8% OR NV CO NE MO KY VA MD 5.5% 12.3% 7.4% 10.0% 11.8% 8.7% 12.3% 7.5% CA UT NM KS AR TN NC SC 4.7% 14.6% 5.4% 11.8% 15.5% 17.7% 12.6% 15.3% AZ OK LA MS AL GA 10.2% 10.8% 13.4% 19.2% 10.9% 16.3% TX FL 17.7% 9.5% Source: Georgetown Center for Children and Families analysis of U.S. Census Bureau 2019 American Community Survey Public Use Microdata Sample (PUMS). To ensure accuracy and consistency, Georgetown CCF calculates the coefficient of variation (CV; also known as the relative standard error) for each estimate. Estimates with CVs greater than 25 percent are not presented in this analysis. See methodology section for full details. Figure 7. Top States of Residence for Latino Children from Different Backgrounds Mexican ​ Puerto Rican ​ Salvadoran ​ Dominican ​ Guatemalan ​ Children Children Children Children Children California 32.3% Florida 18.7% California 25.7% New York 37.5% California 23.5% Texas 25.5% New York 16.3% Texas 16.0% New Jersey 16.7% Florida 8.7% Arizona 5.4% Pennsylvania 9.7% Maryland 10.8% Florida 10.6% Texas 6.8% Illinois 4.6% New Jersey 7.6% Virginia 8.6% Pennsylvania 7.8% New York 6.5% Colorado 2.5% Massachusetts 6.2% New York 8.2% Massachusetts 7.8% Georgia 4.1% Washington 2.4% Connecticut 5.2% Massachusetts 3.5% Connecticut 2.9% Massachusetts 4.0% Florida 2.0% Texas 4.3% New Jersey 3.3% Rhode Island 2.4% New Jersey 3.7% Source: Georgetown Center for Children and Families analysis of U.S. Census Bureau 2019 American Community Survey Data Public Use Microdata Sample (PUMS). JUNE 2021 CCF.GEORGETOWN.EDU HEALTH COVERAGE TRENDS FOR LATINO CHILDREN 5 Due to sample size and reliability limitations, it is not children in the state, signaling that these communities face possible to disaggregate the Latino child uninsured rate by different barriers to coverage. subgroup for every state. However, a closer look at the five While Arizona has one of the highest numbers of Latino states with the highest number of uninsured Latino children children in the nation, over 90 percent are of Mexican illustrates how variable coverage rates are, both within and descent. Consequently, it is only possible to estimate the between states (see Figure 8). In Florida, Colombian and uninsured rate for children of Mexican descent with accuracy Puerto Rican children have the lowest uninsured rates (3.8 in Arizona: 10.4 percent. Children of Mexican descent in percent and 5.8 percent) overall and Cuban children have Arizona’s neighboring California are much less likely to be the same uninsured rate as non-Latino children (6.8 percent). uninsured. While Guatemalan children in California have Almost one out of every two Honduran children in Georgia the highest uninsured rate of the state’s reliable estimates is uninsured, compared to less than one in five Mexican for Latino subgroups at 7.5 percent, they are better off Figure 8. Latino Child Uninsured Rate by Detailed than their counterparts in Georgia where 32.2 percent of Ethnicity and State, 2019 Guatemalan children are uninsured. TEXAS Language. Federal regulations direct Medicaid agencies to Honduran 34.3% communicate available benefits and eligibility requirements Salvadoran 31.7% “in plain language” and in “a manner that is accessible and Mexican 17.1% timely” to English-language learners through the provision All Other Spanish/Hispanic/Latino 17.0% of oral interpretation and written translations at no cost Puerto Rican 10.1% to the individual. Federal regulations also require that the Not Hispanic/Latino 8.1% Medicaid application itself is accessible to English-language learners.13 FLORIDA Venezuelan 12.7% However, recent research indicates that more oversight of Mexican 12.5% these requirements is needed because language remains a Cuban 6.8% major barrier for many Latino families: Latino adolescents Not Hispanic/Latino 6.8% in Spanish-speaking households are more likely to be Puerto Rican 5.8% uninsured than Latino adolescents overall and over half of Colombian 3.8% uninsured school-age Latino children in Texas have at least CALIFORNIA one parent more comfortable with a language other than Guatemalan 7.5% English (LOE). 14 Salvadoran 4.8% Mexican 4.6% Not Hispanic/Latino 2.7% More than Spanish Families from Latin America speak a wide variety of GEORGIA languages. For example, the Mexican government Honduran 46.7% recognizes 68 national languages, 63 of which are Guatemalan 32.2% indigenous.15 In the U.S., there are approximately Mexican 15.5% 32,000 Latino individuals who speak either an Uto- Not Hispanic/Latino 5.9% Aztecan language (such as Michoacán Nahuatl or El ARIZONA Nayar Cora) or another Central or South American Mexican 10.4% language (such as Mixtec or Quechua) at home and Not Hispanic/Latino 7.7% roughly 26,000 Latinos speak Portuguese in the house.16 Source: Georgetown Center for Children and Families analysis of U.S. Census Bureau 2019 American Community Survey Data Public Use Microdata Sample (PUMS). 6 HEALTH COVERAGE TRENDS FOR LATINO CHILDREN CCF.GEORGETOWN.EDU JUNE 2021 Disaggregated data shows the communities for whom Citizenship Status of Parents and Public Charge. Despite the language is a bigger barrier: less than four percent of Puerto fact that the overwhelming majority of Latino children are Rican children living in the states or D.C. have parents who citizens, almost half of Latino children who are citizens live in indicate that they do not speak English or have difficulty a mixed-status family, meaning they have at least one non- speaking English. In contrast, over one-third of Guatemalan citizen parent. A disproportionate share of uninsured Latino and Honduran children, and over a quarter of Salvadoran citizen children live in mixed-status families (see Figure 9). children, have parents who are English-language learners. In 2018, the Trump Administration introduced the “public For uninsured Latino children specifically, over half of charge” rule which would have allowed an immigrant’s Guatemalan and Honduran children without health coverage participation in public benefit programs to count against (60.9 percent and 66.6 percent, respectively) live with LOE them in their application for permanent residency. While the parents. final rule stipulated that children’s participation in programs like Medicaid and CHIP would not affect parents’ green Citizenship Status of Child. Overall, 95 percent of Latino card applications, the long, hostile messaging campaign children are U.S. citizens (see Figure 9). However, for those around the public charge rule left many immigrant families Latino children who are not citizens, accessing coverage is worried and confused. Almost four in five adults in immigrant more difficult. In 16 states, children without citizenship must families with children who indicated that they understood be lawfully-residing for five years before they can enroll in the Trump-era public charge rule did not understand that Medicaid or CHIP and in 43 states undocumented children children’s Medicaid enrollment would not affect their own are not eligible for comprehensive coverage. Children and public charge determination.18 The Trump Administration also youth with Deferred Action for Childhood Arrivals (DACA) worked hard to change immigration policies in other ways, status are also ineligible for federally-funded, comprehensive such as by limiting asylum, reducing refugee resettlement, coverage.17 As a result of this patchwork of eligibility, some trying to end DACA and Temporary Protected Status (TPS) Latino children are more likely to be eligible for public designations, and conducting high-profile workplace raids.19 coverage programs than others. For example, while nearly all Puerto Rican children are citizens and can enroll in The “chilling effect” of the public charge rule and other Medicaid, CHIP, or Marketplace coverage without worrying immigration rule changes was likely widespread across about the immigration-based restrictions, Venezuelan and Latino ethnicities. More than half of Honduran, Guatemalan, Honduran children are much less likely to be citizens, forcing Salvadoran, Venezuelan, Ecuadoran, Dominican, and a greater share of them to contend with these barriers. Mexican children living in the U.S. have at least one parent who is not a citizen. However, for a few subgroups, the Figure 9. Latino Child Population by Citizenship Status Citizenship Status Citizenship Status of Latino of Latino Children Familial Citizenship Status of Familial Citizenship Status of Children Non-Citizen Citizen Non-Citizen Citizen Familial Latino Citizenship StatusChildren FamilialUninsured of Citizen Latino Children Citizen Citizenship Status Latino of Uninsured Children Citizen Latino Children 5.0% Data Note: Who is included in the non-citizen category? The American Community Survey tracks citizenship status—not immigration Children Living in Families status. The “non-citizen” category Children Living in Children Living in where Parent(s) includes children and adults who are Families where Mixed-Status are Citizens 37.1% lawfully-residing permanent residents, Parent(s) are Families Children Living in Citizens 48.5% Mixed-Status lawfully-residing residents under 51.5% another protected class (for example, Families Citizen 62.9% temporary protected status, deferred 95% Citizen enforcement departure, and special 95.0% immigrant juveniles), and those without documentation. Source: Georgetown University Center for Children and Families analysis Source:​ ​Source: Georgetown ofUniversity U.S. Census Bureau Center for Children 2019 analysis and Families American Community of U.S. Census Bureau 2019Survey American Community Survey (ACS) data using Integrated Public Use Microdata Sample (IPUMS). For the (ACS) data using Integrated Public Use Microdata Sample (IPUMS). purposes For the of this analysis, purposes mixed-status families of this analysis, are defined mixed-status as families where families the child is a citizen are defined and at least one parent as families where the child is a citizen and at least one parent isisnot not a a citizen. ChildrenChildren citizen. living in families wherein living parent(s) familiesare citizens where include single-parent parent(s) are citizens households with a citizen parent and two-parent households where both parents are citizens. include single-parent households with a citizen parent and two-parent households where both parents are citizens. JUNE 2021 CCF.GEORGETOWN.EDU HEALTH COVERAGE TRENDS FOR LATINO CHILDREN 7 public charge rule was likely less of a concern. For example, coverage. The Biden Administration recently announced roughly 35 percent of Cuban children have at least one increased funding for community groups to provide in- non-citizen parent and only 7.1 percent of Puerto Rican person enrollment assistance during the Marketplace special children have at least one non-citizen parent (a share lower enrollment period created as a result of the COVID-19 than non-Latino children overall). Note that although the pandemic.26 Continuing these investments and ensuring Biden Administration withdrew the Trump-era public charge funds are available to assist with enrollment in Medicaid, rule in March 2021, the data presented here are from 2016- CHIP, and Marketplace plans could help regain lost ground 2019 when the Trump-era rule was proposed, finalized, and on Latino child insurance rates. implemented. Clear and consistent messaging around the reversal of the Trump-era Public Charge Rule: On March 9, 2021, Recommendations the Biden Administration rescinded the public charge rule.27 However, erasing the rule’s “chilling effect” will take As communities of color have disproportionately borne the time. While trusted community messengers will be critical brunt of the COVID-19 crisis, the number of Latino children in communicating the policy changes (see state/local without coverage has likely worsened. Survey results from recommendations below), immigrant families identify U.S. 2020 show that Latino households with school age children Citizenship and Immigration Services, legal professionals, were three times more likely to report food insecurity and state government agencies as among the most trusted than non-Latino white families, signaling widespread sources of information.28 The Administration must use the economic distress.20 Further, the importance of accessing power of their office to ensure families that they can sign up comprehensive and affordable health coverage is pressing. for coverage without fear. Latino adults participate in the workforce at a higher rate than the national average,21 but they are less likely to have Remove all citizenship-based eligibility criteria from jobs with employer-sponsored health insurance.22 Latino Medicaid and CHIP: As of 2021, 34 states and the District workers are also more likely than their white counterparts of Columbia already allow lawfully-residing immigrant to be in frontline jobs where they are exposed to the virus, children to enroll in Medicaid or CHIP without a five-year leading to higher rates of infection and stress for families.23 waiting period under section 1903(v)(4) of the Social Security And, 31 percent of children affected by the serious COVID- Act.29 A total of six states (California, Illinois, Massachusetts, related multisystem inflammatory syndrome have been New York, Oregon, and Washington) and the District of Latino.24 It will take a concerted, and strategic, effort on Columbia leverage state funds to cover undocumented the part of national and state policymakers to help Latino children.30 Though only five percent of Latino children are children get the health coverage they need both now and not citizens (and an even smaller share are undocumented), into the future. eliminating citizenship and immigration-based eligibility restrictions would help reach more children by creating an Federal recommendations: inclusive public coverage system. Making income eligibility the sole criteria for Medicaid and CHIP across all states Conduct robust outreach and enrollment campaigns to would also simplify and strengthen outreach and enrollment reach eligible but uninsured Latino children: The majority messaging and streamline program administration and of uninsured children are eligible for Medicaid or CHIP but financing.31 unenrolled. The Medicaid/CHIP participation rate for Latino children is on par with children overall, but increases in State/local recommendations: Medicaid/CHIP enrollment are correlated with decreases in the uninsured rate.25 Robust outreach programs would Expand Medicaid: Currently, there are 12 states still refusing help inform Latino families about their coverage options and to accept federal funds to expand Medicaid eligibility for culturally and linguistically competent enrollment assistance adults up to 138 percent of the federal poverty level. Years would help eligible children access free or low-cost of research show that expanding Medicaid coverage to 8 HEALTH COVERAGE TRENDS FOR LATINO CHILDREN CCF.GEORGETOWN.EDU JUNE 2021 more adults lowers the child uninsured rate as newly-eligible at the state and local level can turn to Census Bureau data parents enroll their whole family.32 to identify groups of Latino children that may benefit from more targeted outreach and enrollment efforts and build Simplify and tailor enrollment and renewal processes: partnerships with community health workers to reach them The data presented above show that children in the poorest in culturally and linguistically appropriate ways. Over the households and in LOE households are more likely to be long term, the Biden Administration can work to improve uninsured. Burdens such as 10-day turnaround times for Census Bureau data to address issues with the sample size state requests for information likely disproportionately and how the questions are phrased to better capture lived affect these families. States should adopt streamlined experiences. Leaders at the federal and state levels can also enrollment and renewal processes that lessen the burden begin to rebuild trust among Latino communities by sharing on families and tailor their instructions to meet the linguistic clear and reliable information as they work toward more preferences of beneficiaries’ families. Disaggregated data inclusive health coverage policies. shows that that language is much more likely to be a barrier for Guatemalan and Honduran families, highlighting an opportunity for agencies to craft accessible materials for these communities. Work with a range of community groups to target outreach and enrollment efforts: Given the diversity within the Latino community, state agencies must ensure that they are working with a variety of groups and community leaders. For example, community leaders reaching out to mixed-status Venezuelan families in Florida may need to This report was written by Kelly Whitener and use different messages than those working with the Cuban Alexandra Corcoran. The authors thank Steven community. Lopez and Matthew Snider of UnidosUS for Fund Promotora programs: Promotoras, or community their thoughtful comments on an earlier version health workers who share a background with those they of this paper. The authors also thank Allexa are serving, can play an important role in connecting Latino Gardner for diligent research assistance and communities to coverage.33 Given the disparities highlighted Cathy Hope for editing assistance. Design and by the disaggregated data, it will be important for state and layout provided by Oyinade Koyi. local governments to partner with Promotoras who have The Georgetown University Center for Children connections in the appropriate community. and Families (CCF) is an independent, nonpartisan policy and research center founded Conclusion in 2005 with a mission to expand and improve high-quality, affordable health coverage for Overall, Latino children are more likely to be uninsured than America’s children and families. CCF is based their peers, even though nearly all Latino children are U.S. in the McCourt School of Public Policy’s Health citizens. Research has shown that having health coverage Policy Institute. as a child has life-long, positive impacts such as improved health, improved educational outcomes, and higher paying jobs in adulthood. Efforts to cover more Latino children will require developing a deeper understanding of the characteristics of subgroups of uninsured Latino children such as by age, income level, state residency, and country of origin. As a starting place, policymakers and stakeholders JUNE 2021 CCF.GEORGETOWN.EDU HEALTH COVERAGE TRENDS FOR LATINO CHILDREN 9 Appendix A. How the Census Bureau Collects Questions about Race and Ethnicity on the American Community Survey and Compiles Hispanic/Latino Data The American Community Survey (ACS), fielded by the U.S. Census Bureau, collects questionnaires from approximately 3.5 million households every year and extrapolates estimates from these responses.35 The ACS provides the most reliable annual estimates of health insurance coverage for geographic areas of over 65,000 individuals. The data is used by various agencies at multiple levels of government to plan outreach and enrollment efforts.36 However, post-survey quality checks and measures of accuracy conducted by the Census Bureau indicate that the Latino population is consistently under-sampled in the ACS.37 Exacerbating this challenge, young children ages 0-4, especially young Latino children, have historically been undercounted in ACS and Census Bureau data.38 The Census Bureau follows guidelines set by the Office of Management and Budget (OMB) that define race and ethnicity as two separate facets of a person’s identity.39 The ACS definition of Hispanic/Latino is: “Hispanics or Latinos who identify with the terms ‘Hispanic,’ ‘Latino,’ or ‘Spanish’ are those who classify themselves in one or more of the specific Hispanic, Latino, or Spanish categories listed on the questionnaire (‘Mexican,’ ‘Puerto Rican,’ or ‘Cuban’) as well as those who indicate that they are ‘another Hispanic, Latino, or Spanish origin.’ People who do not identify with any of the specific origins listed on the questionnaire but indicate that they are ‘another Hispanic, Latino, or Spanish origin” are those who identify as Argentinian, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, or other Spanish cultures or origins […] Origin can be viewed as the heritage, nationality group, lineage, or country of birth of the person or the person’s parents or ancestors before their arrival in the United States. People who identify their origin as Hispanic, Latino, or Spanish may be of any race.” When tallying responses, the Census Bureau constructs the “Hispanic/Latino” category by adding together all those who indicate that they were of Mexican, Puerto Rican, Cuban, or another Hispanic/Latino origin, regardless of race (see Data Note). While the Census Bureau does not specifically list Brazilian as an option for Latino ethnicity, if a Brazilian individual self-identifies as Hispanic/Latino and indicates “another Hispanic, Latino, or Spanish origin” on their survey, they are counted as Latino. A very small share of individuals who indicate that they are of Brazilian descent also indicate that they are Hispanic/ Latino on the Census.40 Data Note: Concerns about the ACS Definition of Hispanic/Latino Separating ethnic and racial identity is not a universally accepted standard for collecting demographic data.41 Asked to choose a race, but not identifying as white, a large share of Latino survey respondents select “Some other race” or skip the race question altogether.42 The Census Bureau itself has conducted research showing that combining the questions on race and Hispanic/Latino question into a single “race/ ethnicity” question would reduce item nonresponse rates and yield more accurate results.43 In a 2017 report to OMB, the Census Bureau concluded that, “By combining the race and Hispanic origin questions into one question on race/ethnicity, the research has shown that Hispanics can better find themselves among the race and ethnicity categories.”44 10 HEALTH COVERAGE TRENDS FOR LATINO CHILDREN CCF.GEORGETOWN.EDU JUNE 2021 Appendix B. National Latino Child Uninsured Rate by Detailed Ethnicity, 2016-2019 Ethnicity 2016 2019 Colombian 6.1 6.8 Cuban 4.8 5.9 Dominican 5.1 4.8 Ecuadoran 6.2 5.3 Guatemalan 10.3 17.9* Honduran 18.2 24.4* Mexican 8.2 9.6* Nicaraguan 7.6 8.8 Not Latino 3.7 4.4* Other Hispanic/Latino 6.3 8.9* Peruvian 5.7 4.6 Puerto Rican 3.1 4.2* Salvadoran 10.0 13.1* Spanish 3.5 3.3 Venezuelan 13.4 14.5 Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau 2016-2019 American Community Survey (ACS) data using Public Use Microdata Sample (PUMS). * Change is significant at the 90 percent confidence level relative to the prior year indicated. JUNE 2021 CCF.GEORGETOWN.EDU HEALTH COVERAGE TRENDS FOR LATINO CHILDREN 11 Appendix C. Latino Child Uninsured Rate by State, 2016-2019 Uninsured Rate Uninsured Rate Percentage Point Change in State 2016 2019 Uninsured Rate United States 7.7 9.3 1.6* Alabama 7.3 10.9 3.7 Arizona 11.1 10.2 -0.9 Arkansas 9.4 15.5 6.1* California 4.1 4.7 0.5* Colorado 7.4 7.4 0.0 Connecticut 3.6 4.8 1.2 Florida 8.6 9.5 0.9 Georgia 13.2 16.3 3.1* Idaho 10.3 9.1 -1.1 Illinois 3.3 6.0 2.7* Indiana 8.1 12.3 4.2* Source: Georgetown University Center for Children and Families analysis Kansas 7.7 11.8 4.1* of U.S. Census Bureau 2016-2019 Kentucky American Community Survey (ACS) data 9.7 8.7 -1.0 using Public Use Microdata Sample Louisiana 11.6 13.4 1.8 (PUMS). * Change is significant at the 90 percent Maryland 7.2 7.5 0.3 confidence level relative to the prior year Massachusetts indicated. -- 1.8 -- Michigan 4.9 5.1 0.3 To ensure accuracy and consistency, Minnesota 9.0 6.7 -2.3 Georgetown CCF calculates the coefficient of variation (CV; also known Mississippi -- 19.2 -- as the relative standard error) for each estimate. Estimates with CVs greater Missouri 9.0 11.8 2.8 than 25 percent are not presented in Nebraska 12.1 10.0 -2.0 this analysis. As a consequence, some states are excluded entirely from the Nevada 9.8 12.3 2.5 above table and others include only one estimate. For more information on New Jersey 6.5 6.9 0.4 suppression rules, see the methodology New Mexico 4.7 5.4 0.7 section. New York 2.7 2.6 0.0 North Carolina 11.2 12.6 1.4 Ohio 5.9 8.3 2.4 Oklahoma 9.3 10.8 1.5 Oregon 5.6 5.5 -0.1 Pennsylvania 6.2 4.6 -1.6 South Carolina 8.5 15.3 6.8* Tennessee 11.7 17.7 6.0* Texas 13.5 17.7 4.3* Utah 11.1 14.6 3.5 Virginia 13.3 12.3 -1.0 Washington 3.8 5.1 1.3 Wisconsin 6.4 8.4 2.0 12 HEALTH COVERAGE TRENDS FOR LATINO CHILDREN CCF.GEORGETOWN.EDU JUNE 2021 Appendix D. Number of Uninsured Latino Children by State, 2016-2019 State Uninsured Children Uninsured Children Change in Number of 2016 2019 Uninsured Latino Children United States 1,476,200 1,830,600 354,400* Alabama 5,900 10,200 4,300* Arizona 83,800 78,400 -5,400 Arkansas 8,400 14,300 5,900* California 204,800 227,700 22,900* Colorado 30,300 30,800 500 Connecticut 6,700 9,300 2,600 Florida 114,200 136,900 22,700* Georgia 49,100 64,300 15,200* Idaho 8,500 7,800 -700 Illinois 24,700 44,500 19,800* Indiana 14,500 23,500 9,000* Kansas 10,400 16,200 5,800* Kentucky 6,100 -- -- Louisiana 8,500 11,300 2,800 Maryland 14,600 17,100 2,500 Massachusetts -- 4,900 -- Michigan 9,300 9,900 600 Minnesota 10,100 8,400 -1,700 Mississippi -- 6,500 -- Missouri 8,700 11,600 2,900 Nebraska 10,300 9,100 -1,200 Nevada 28,500 36,700 8,200* New Jersey 36,000 38,900 2,900 New Mexico 14,700 16,400 1,700 New York 29,000 27,800 -1,200 North Carolina 42,600 51,000 8,400 Ohio 9,300 14,400 5,100* Oklahoma 15,800 18,800 3,000 Oregon 11,300 11,200 -100 Pennsylvania 20,400 16,000 -4,400 South Carolina 8,900 16,800 7,900* Tennessee 17,000 28,700 11,700* Texas 510,400 686,800 176,400* Utah 18,900 26,300 7,400* Virginia 34,300 34,200 -100 Washington 13,700 19,200 5,500 Wisconsin 9,800 13,100 3,300 Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau 2016-2019 American Community Survey (ACS) data using Public Use Microdata (PUMS). Estimates rounded to the nearest hundred. These numbers are estimates, not direct counts, and should be interpreted as such. * Change is significant at the 90 percent confidence level relative to the prior year indicated. To ensure accuracy and consistency, Georgetown CCF calculates the coefficient of variation (CV; also known as the relative standard error) for each estimate. Estimates with CVs greater than 25 percent are not presented in this analysis. As a consequence, some states are excluded entirely from the above table and others have only one estimate present. For more information on suppression rules, see the methodology section. JUNE 2021 CCF.GEORGETOWN.EDU HEALTH COVERAGE TRENDS FOR LATINO CHILDREN 13 Appendix E. Comparing the Rate of Uninsured Latino Children to Uninsured Non-Latino Children Uninsured Rate: Uninsured Rate: Latino Children are X Times as Likely to be   Latino Children Non-Latino Children Uninsured as Non-Latino Children United States 9.3 4.4 More than 2x Alabama 10.9 2.8 Almost 4x Arizona 10.2 7.7 Almost 1.5x Arkansas 15.5 4.2 More than 3.5x California 4.7 2.7 More than 1.5x Colorado 7.4 4.2 Almost 2x Connecticut 4.8 3.1 More than 1.5x Florida 9.5 6.8 Almost 1.5x Georgia 16.3 5.9 Almost 3x Idaho 9.1 3.9 Almost 2.5x Illinois 6.0 3.6 More than 1.5x Indiana 12.3 6.5 Almost 2x Kansas 11.8 4.6 More than 2.5x Kentucky 8.7 4.0 More than 2x Louisiana 13.4 3.8 More than 3.5x Maryland 7.5 2.3 More than 3x Massachusetts 1.8 1.4 Almost 1.5x Michigan 5.1 3.1 More than 1.5x Minnesota 6.7 3.0 More than 2x Mississippi 19.2 5.4 More than 3.5x Missouri 11.8 6.3 Almost 2x Nebraska 10.0s 4.3 Almost 2.5x Nevada 12.3 4.7 More than 2.5x New Jersey 6.9 3.4 2x North Carolina 12.6 4.4 Almost 3x Ohio 8.3 4.6 Almost 2x Oklahoma 10.8 7.8 Almost 1.5x Oregon 5.5 3.8 Almost 1.5x South Carolina 15.3 4.9 More than 3x Tennessee 17.7 3.9 More than 4.5x Texas 17.7 8.1 More than 2x Utah 14.6 6.6 More than 2x Virginia 12.3 3.7 Almost 3.5x Washington 5.1 2.6 Almost 2x Wisconsin 8.4 3.1 More than 2.5x Source: Georgetown University Center for Children and Families analysis of U.S. Census Bureau 2016-2019 American Community Survey (ACS) data using Public Use Microdata Sample (PUMS). There are many ways to measure barriers to comprehensive coverage and high-quality care. This table compares Latino children’s uninsured rates to non- Latino children’s uninsured rates based on ethnicity without regard to race. The purpose of the chart is to illustrate disparities and show that it is possible for states to achieve lower uninsured rates, not to distinguish non-Latino children as models or an ultimate baseline. Multipliers are rounded to the nearest 0.5. For example, the US disparity of 2.11 (Non- Latino Child Uninsured Rate x 2.11 = Latino Child Uninsured Rate) is reported as “more than 2x.” Disparities less than 1.25x (seen in New Mexico, New York, and Pennsylvania) are not presented. To ensure accuracy and consistency, Georgetown CCF calculates the coefficient of variation (CV; also known as the relative standard error) for each estimate. Estimates with CVs greater than 25 percent are not presented in this analysis. As a consequence, some states are excluded from the above table. For more information on suppression rules, see the methodology section. 14 HEALTH COVERAGE TRENDS FOR LATINO CHILDREN CCF.GEORGETOWN.EDU JUNE 2021 Methodology interval of 90 percent. In other words, when the difference between two values is marked as significant, there is a 90 Data Sources percent likelihood that the difference is not due to chance or sampling error. Margins of error are a critical part of Georgetown University Center for Children and Families determining statistical significance. Two estimates with high (CCF) uses the U.S. Census Bureau American Community levels of uncertainty, or high margins of error, indicate that Survey (ACS), an annual survey of approximately 3.5 million the difference could be due to chance or sampling error. individuals, to analyze national, state, and local trends in Consequently, they are less likely to “pass” the significance health insurance coverage. The data in this report come from test. three sources: To ensure accuracy and consistency, CCF calculates the 1. 2016-2019 Public Use Microdata Sample coefficient of variation (CV; also known as the relative (PUMS), a two-thirds sample of the full ACS standard error) for each estimate. CCF follows the data file. This sample allows for disaggregation instructions included in the Census Bureau’s publication, by detailed Latino ethnicity. Files are “Understanding and Using American Community Survey downloaded from census.gov FTP platform. Data: What All Data Users Need to Know” (September 2. 2019 Integrated Public Use Microdata Sample 2020). CVs produce a comparable indicator of how large (IPUMS), a recoded and enhanced version of the error is by dividing the standard error of an estimate by PUMS which enables the analysis of parental the estimate itself. The lower the CV, the more reliable the characteristics (such as comfort level with estimate. Estimates with CVs greater than 25 percent are English). not presented in this analysis. Applying this rule results in the suppression of several estimates for Latino subgroups 3. 2019 Puerto Rico Community Survey Public (for example, the uninsured rate for Puerto Rican children in Use Microdata Sample (PUMS), a sample of the Arizona) and of several states in figure 7 and the appendix full PRCS data file. tables (Alaska, Delaware, District of Columbia, Hawaii, Iowa, Maine, Montana, New Hampshire, North Dakota, Rhode Other analyses and reports from CCF, including Island, South Dakota, West Virginia, and Wyoming). kidshealthcarereport.ccf.georgetown.edu and “Children’s Uninsured Rate Rises by Largest Annual Jump in More than Demographic Characteristics a Decade” (October 2020) use the American Community Children refers to individuals under age 19 (0 to 18 years Survey detailed tables, published on data.census.gov. The of age). In 2017, the Census Bureau changed the upper detailed tables are based on the full sample of ACS results, bound for children from 18 (0 to 17 years of age) to 19 (0 but do not allow for detailed disaggregation. Consequently, to 18 years of age) on the detailed health insurance tables estimates may vary between CCF’s analyses. published on data.census.gov, thus making comparisons Margin of Error, Statistical Significance, and Data between earlier years difficult. Because this report uses Suppression microdata from PUMS and IPUMS, it is possible to compare trends from 2016 to 2019. Following the instructions given in the “Calculating Margins of Error the ACS Way Using Replicate Methodology to As noted in Appendix A, the Census Bureau distinguishes Calculate Uncertainty” webinar (February 2020), standard between race and Hispanic origin/Latino ethnicity. For error and coefficients of variation are computed using the purposes of this analysis, “Latino” refers to all those successive differences replication (SDR) in STATA statistical who indicated that they were of Hispanic or Latino origin software. Margin of error calculations are not published in on question five of the ACS. “Latinx” can also be used to this report but are available upon request. respect various gender identities and expressions. “Non- Latino” refers to all those who indicated that they were not Statistical significance is determined using the U.S. of Hispanic or Latino origin on question five of the ACS. Census Bureau “Statistical Testing Tool” with a confidence JUNE 2021 CCF.GEORGETOWN.EDU HEALTH COVERAGE TRENDS FOR LATINO CHILDREN 15 Latino and Non-Latino individuals may be of any race. computing income that state Medicaid and CHIP programs use when determining income-based eligibility. English Proficiency Question 14c of the ACS asks respondents “How well does Medicaid Expansion Analysis this person speak English?” and provides them with the This report relies on ACS data collected in 2019. For following options: Very well, Well, Not well, Not at all. For this reason, expansion status is determined based on the purposes of this paper, individuals who indicate “Not if a state had implemented expansion for the majority well” or “Not at all” are categorized as “Language Other than of 2019. The expansion states include: Alaska, Arizona, English (LOE).” CCF linked parental language proficiency to Arkansas, California, Colorado, Connecticut, Delaware, children using the Integrated Public Use Microdata Sample’s District of Columbia, Hawaii, Illinois, Indiana, Iowa, (IPUMS’) “attach characteristic” feature. Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, Health Coverage New Mexico, New York, North Dakota, Ohio, Oregon, ACS data is collected over the course of a year and Pennsylvania, Rhode Island, Washington, West Virginia, represents a “point-in-time” estimate of a person’s insurance and Vermont. The following states are categorized as non- status. That is, the survey collects information on whether expansion: Alabama, Florida, Georgia, Idaho (implemented the respondent is insured at the moment they complete the in November 2019), Kansas, Mississippi, Missouri (plans form, not if they have been insured/uninsured at any point to implement in 2021), Nebraska (implemented in 2020), during the year. The US Census Bureau does not consider North Carolina, Oklahoma (plans to implement in 2021), Indian Health Service (IHS) access a comprehensive form of South Carolina, South Dakota, Tennessee, Texas, Utah coverage. Consequently, those who indicate that IHS is their (implemented in 2020), Wisconsin, and Wyoming. Maine and only source of coverage are designated as uninsured. Virginia were excluded from this analysis given that these Citizenship Status of Child and Parent estimates were also used to calculate change over time. Unlike the decennial Census, the ACS collects data on respondents’ citizenship status. Citizenship status is not the same as immigration status; a respondent classified as non- citizen can be lawfully-residing or undocumented. For the purposes of this analysis, “citizen” includes any person born in the U.S., any person born abroad to American parents, and any naturalized citizen. Citizenship status of children’s parents was computed using the Integrated Public Use Microdata Sample (IPUMs) “attach characteristic” feature. More information on how the University of Minnesota codes the survey responses to create these enhanced variables, please see “Frequently Asked Questions (FAQ) Extract Option: Attach Characteristics.” Poverty Status The Census Bureau determines an individual’s poverty status by comparing their estimated income to the Census Poverty Thresholds. Though the overall Census Poverty Thresholds are similar to the Department of Health and Human Services Federal Poverty Level Guidelines, there are significant differences for Alaska and Hawaii. Further, the Census does not adhere to the same MAGI formula for 16 HEALTH COVERAGE TRENDS FOR LATINO CHILDREN CCF.GEORGETOWN.EDU JUNE 2021 Endnotes label “Hispanic/Latino.” While the label is a social construct that masks the complexities of individuals’ lives, some contend that the unification of various identities lends political clout to otherwise marginalized 1 We report the U.S. Census Bureau’s categorization of “Hispanic or groups. See: González op. cit. and Rubin, V., “Counting a Diverse Latino,” as “Latino.” “Latinx” may also be used to respect various Nation: Disaggregating Data on Race and Ethnicity to Advance a Culture gender identities and expressions. Whitener, K. et al., “Decade of of Health” (Oakland, CA: Policy Link, 2018), available at: https://www. Success for Latino Children’s Health Now in Jeopardy,” (Washington, policylink.org/sites/default/files/Counting_a_Diverse_Nation_08_15_18. D.C.: Georgetown Center for Children and Families and UnidosUS, pdf. March 2020), available at https://ccf.georgetown.edu/wp-content/ 9 Note that the uninsured rate for Puerto Rican children reflects those uploads/2020/03/Latino-Childrens-Health-Care-Coverage.pdf. who are living in one of the 50 states or the District of Columbia. In 2 Alker, J. and Corcoran, A., “Children’s Uninsured Rate rises by Largest addition to the American Community Survey, the U.S. Census Bureau Annual Jump in More than a Decade,” (Washington D.C.: Georgetown fields a Puerto Rico Community Survey annually. Center for Children and Families, October 2020), available at https://ccf. 10 There is significant evidence that these socially-constructed georgetown.edu/2020/10/08/childrens-uninsured-rate-rises-by-largest- groupings shape the way that people encounter the healthcare system annual-jump-in-more-than-a-decade-2/. and can have meaningful impacts on individuals’ access and health 3 Unless otherwise noted, all data in this factsheet come from outcomes. For example, recent research found that while foreign-born Georgetown University CCF’s analysis of the U.S. Census Bureau Cuban women ages 25-64 experienced lower mortality rates than American Community Survey’s (ACS) Public Use Microdata Sample, non-Hispanic white women, Mexican and Puerto Rican women both or PUMS. Because PUMS is a slightly smaller sample of the data had higher mortality rates. Fenelon, A., Chinn, J., and Anderson, R., presented in the Census Bureau’s ACS Detailed Tables, estimates may “A Comprehensive Analysis of the Mortality Experience of Hispanic vary slightly from what is reported in other CCF reports or analyses. Subgroups in the United States: Variation by Age, Country of Origin, 4 Haley, J. et al., “One in Five Adults in Immigrant Families with and Nativity,” SMM- Population Health 3 (December 2017, pg. 245- Children Reported Chilling Effects on Public Benefit,” (Washington, 254), available at https://www.sciencedirect.com/science/article/pii/ D.C.: The Urban Institute, June 2020), available at https://www. S2352827316300763. urban.org/research/publication/one-five-adults-immigrant-families- CCF uses the Census Poverty Threshold as a proxy for the Federal 11 children-reported-chilling-effects-public-benefit-receipt-2019; C. Poverty Level (FPL) which is used to determine Medicaid eligibility. See Anderson, “Public Charge and Private Dilemmas: Key Challenges and methodology section for more detail. Best Practices for Fighting the Chilling Effect in Texas, 2017-2019,” 12 Georgetown University Center for Children and Families analysis (Children’s Defense Fund Texas, November 2020), available at: https:// of U.S. Census Bureau 2019 Puerto Rico Community Survey (PCRS) cdftexas.org/wp-content/uploads/sites/8/2021/01/Public-Charge-and- data using Public Use Microdata Sample (PUMS). The Puerto Rico Private-Dilemmas_report_020.pdf. Community Survey, while similar to the American Community Survey, 5 The Trump administration reduced funding for Navigator programs differs slightly on several questions. For more information on the from $63 million in 2016 to $10 million in 2018. Additionally, the funds PCRS, see U.S. Census Bureau, “Understanding and Using Puerto set aside for outreach and advertising efforts during open enrollment Rico Community Survey Data: What All Data Users Need to Know,” periods suffered a 90 percent reduction. Hispanic/Latino individuals (Washington, D.C.: U.S. Census Bureau, April 2020), available at https:// use consumer assistance at a higher rate than non-Hispanic white www.census.gov/content/dam/Census/library/publications/2020/acs/ individuals. See Pollitz, K., Tolbert, J., and Diaz, M., “Data Note: Limited acs_prcs_handbook_2020.pdf. Navigator Funding for Federal Marketplace States,” Kaiser Family 13 42 C.F.R. 435.905 (2016) and 42 C.F.R. 435.907 (2013). Foundation, November 2019, available at https://www.kff.org/health- 14 LOE is used in place of limited English proficiency (LEP), to stress reform/issue-brief/data-notefurther-reductions-in-navigator-funding- the assets and abilities, rather than the deficiencies, of individuals. for-federal-marketplace-states/; Pollitz, K., Tolbert, J., Hamel, L., and Knipper, S., Rivers, W., and Goodman, J., “Effects of Citizenship Kearney, A., “Consumer Assistance in Health Insurance: Evidence of Status, Latino Ethnicity, and Household Language on Health Insurance Impact and Unmet Need,” Kaiser Family Foundation, August 2020, Coverage for U.S. Adolescents, 2007-2016,” Health Services Research available at https://www.kff.org/reportsection/consumer-assistance- 54, no. 6 (2019): 1166-1173, available at https://pubmed.ncbi.nlm.nih. in-health-insurance-evidence-of-impactand-unmet-need-issue-brief/; gov/31385302/; and Alvarez Caraveo et al., “Barriers to Medicaid and and Hoppe, O., “Affordable Care Act Navigators: Lack of Funding CHIP Coverage for Eligible but Uninsured Latinx Children: A Texas Case Leads to Consumer Confusion, Decreased Enrollment,” Georgetown Study,” (Washington D.C.: Urban Institute, February 2021), available at University Center for Health Insurance Reform, CHIRblog, January 18, https://www.urban.org/sites/default/files/publication/103471/barriers-to- 2019, available at http://chirblog.org/lack-of-navigator-funding-leads- medicaid-and-chip-coverage-for-eligible-but-uninsured-latinx-children- confusion-decreased-enrollment/. a-texas-case-study_1.pdf. 6 Kirzinger, A., Muñana, C., and Brodie, M., “KFF Health Tracking Poll 15 Cirjack, A., “How Many Native Languages are Spoken in Mexico?” – January 2019: The Public on Next Steps for the ACA and Proposals World Atlas, June 16, 2020, available at https://www.worldatlas.com/ to Expand Coverage,” (Washington, D.C.: Kaiser Family Foundation, how-many-native-languages-are-spoken-in-mexico.html. January 2019), available at https://www.kff.org/health-reform/poll- finding/kff-health-tracking-poll-january-2019/. 16 Georgetown University Center for Children and Families analysis of U.S. Census Bureau 2019 American Community Survey (ACS) data 7 Brooks, T., Park, E., and Roygardner, L., “Medicaid and CHIP using Public Use Microdata Sample (PUMS). Enrollment Decline Suggests the Child Uninsured Rate May Rise Again,” (Washington, D.C.: Georgetown University Center for Children Brooks, T. et al., “Medicaid and CHIP Eligibility and Enrollment Policies 17 and Families, May 2019), available at https://ccf.georgetown.edu/wp- as of January 2021: Findings from a 50-State Survey,” (Washington content/uploads/2019/06/Enrollment-Decline.pdf. D.C.: Georgetown University Center for Children and Families and Kaiser Family Foundation, March 2021), 8 Indeed, there is considerable debate around the use of the pan-ethnic JUNE 2021 CCF.GEORGETOWN.EDU HEALTH COVERAGE TRENDS FOR LATINO CHILDREN 17 available at https://www.kff.org/report-section/medicaid-and-chip- 31 Whitener, K. and Alker, J., “Covering All Children,” (Washington eligibility-and-enrollment-policies-as-of-january-2021-findings-from-a- D.C.: Georgetown University Center for Children and Families, 50-state-survey-report/. February 2020), available at https://ccf.georgetown.edu/wp-content/ 18 Haley, J., “One in Five Adults in Immigrant Families,” op. cit. uploads/2020/02/CoverAllKidsFinal.pdf. 19 Pierce, S. and Bolter, J., “Dismantling and Reconstructing the 32 Searing, A., Corcoran, A., and Alker, J., “Children Are Left Behind U.S. Immigration System: A Catalog of Changes under the Trump When States Fail to Expand Medicaid,” (Washington D.C.: Georgetown Presidency,” (Washington D.C.: Migration Policy Institute, July 2020), Center for Children and Families, February 2020), available at https:// available at https://www.migrationpolicy.org/research/us-immigration- ccf.georgetown.edu/2021/02/17/report-finds-medicaid-expansion- system-changes-trump-presidency. associated-with-lower-child-uninsured-rates/; Hudson, J. and Moriya, A., “Medicaid Expansion for Adults Had Measurable ‘Welcome 20 Gupta, P., Gonzalez, D., and Waxman, E., “Forty Percent of Black Mat’ Effects on Their Children,” Health Affairs 36, no. 9 (September and Hispanic Parents of School-Age Children are Food Insecure,” 2017), available at https://www.healthaffairs.org/doi/ full/10.1377/ (Washington D.C.: Urban Institute, December 2020), available at https:// hlthaff.2017.0347. www.urban.org/research/publication/forty-percent-black-and-hispanic- parents-school-age-children-are-food-insecure. 33 Capitman, J. “The Effectiveness of a Promotora Health Education Model for Improving Latino Health Care Access in California’s Central 21 “Latino Unemployment Rate Drops Slightly to 8.6%,” (Washington Valley,” (Central Valley Health Policy Institute), available at http://www. D.C.: UnidosUS, February 2021), available at http://publications. fresnostate.edu/chhs/cvhpi/documents/cms-final-report.pdf. unidosus.org/bitstream/handle/123456789/2119/unidosus_ latinojobsreport_2521.pdf?sequence=1&isAllowed=y. 34 Park, E., Alker, J., and Corcoran, A., “Jeopardizing a Sound Investment: Why a Short-Term Cuts to Medicaid Coverage During 22 “Employer-Sponsored Coverage Rates for the Nonelderly by Race/ Pregnancy and Childhood Could Result in Long-Term Harm,” Ethnicity,” (Washington D.C.: Kaiser Family Foundation, 2019), available (Washington D.C.: The Commonwealth Foundation, December 2020), at https://www.kff.org/other/state-indicator/nonelderly-employer- available at https://www.commonwealthfund.org/publications/issue- coverage-rate-by-raceethnicity/?currentTimeframe=0&sortModel=%7B briefs/2020/dec/short-term-cuts-medicaid-long-term-harm. %22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. “American Community Survey Information Guide” (Washington D.C.: 35 23 Dubay, L., “How Risk of Exposure to the Coronavirus at Work Varies United States Census Bureau, December 2017), available at https:// by Race and Ethnicity and How to Protect the Health and Well-Being www.census.gov/programs-surveys/acs/about/information-guide.html. of Workers and Their Families,” (Washington D.C.: Urban Institute, December 2020), available at https://www.urban.org/research/ United States Census Bureau, “Why We Ask Questions About… 36 publication/how-risk-exposure-coronavirus-work-varies-race-and- Health Insurance Coverage,” available at https://www.census.gov/acs/ ethnicity-and-how-protect-health-and-well-being-workers-and-their- www/about/why-we-ask-each-question/health/. families. 37 United States Census Bureau, 2019 American Community Survey, 24 “Health Department-Reported Cases of Multisystem Inflammatory Table B98013, “Total Population Coverage Rate by Weighting Race and Syndrome in Children (MIS-C) in the United States,” U.S. Centers Hispanic or Latino Groups,” available at data.census.gov. for Disease Control and Prevention, May 3, 2021, available at 38 Jensen, E., “Investigating the 2010 Undercount of Young Children— https://www.cdc.gov/mis-c/cases/index.html#:~:text=Cases%20 Examining Coverage in Demographic Surveys,” (Washington D.C.: have%20occurred%20in%20children,virus%20that%20causes%20 United States Census Bureau, January 2019), available at https://www2. COVID%2D19.; and Fernandes, D. et al., “Severe Acute Respiratory census.gov/programs-surveys/decennial/2020/program-management/ Syndrome Coronavirus 2 Clinical Syndromes and Predictors of Disease final-analysis-reports/2020-report-2010-undercount-children- Severity in Hospitalized Children and Youth,” The Journal of Pediatrics, examining_coverage_demo.pdf. November 13, 2020, available at https://www.jpeds.com/article/S0022- 39 United States Census Bureau, “American Community Survey: Why 3476(20)31393-7/fulltext#tbl4. We Ask Questions About… Race,” available at https://www.census.gov/ 25 Haley, J., et al., “Progress in Children’s Coverage Continued to acs/www/about/why-we-ask-each-question/race/. Stall Out in 2018: Trends in Children’s Uninsurance and Medicaid/ 40 Hugo Lopez, M. Manuel Krogstad, J., and Passel, J., “Who is CHIP Participation,” (Washington D.C.: Urban Institute, October Hispanic?” (Washington D.C.: Pew Research Center, September 2020), 2020), available at https://www.urban.org/sites/default/files/ available at https://www.pewresearch.org/fact-tank/2020/09/15/who-is- publication/102983/progress-in-childrens-coverage-continued-to-stall- hispanic/. out-in-2018.pdf. 41 González, J. and Santos, R., “Separating Race from Ethnicity in 26 U.S. Department of Health and Human Services, HHS Announces Surveys Risks an Inaccurate Picture of the Latinx Community,” Urban the Largest Ever Funding Allocation for Navigators and Releases Final Wire Blog, The Urban Institute (October 15, 2019), available at https:// Numbers for 2021 Marketplace Open Enrollment, Press Release (April www.urban.org/urban-wire/separating-race-ethnicity-surveys-risks- 21, 2021), available at https://www.cms.gov/newsroom/press-releases/ inaccurate-picture-latinx-community. hhs-announces-largest-ever-funding-allocation-navigators-and- 42 “Research to Improve Data on Race and Ethnicity,” (Washington D.C.: releases-final-numbers-2021-marketplace. United States Census Bureau, March 2017), available at https://www. 27 “Inadmissibility on Public Charge Grounds; Implementation of census.gov/about/our-research/race-ethnicity.html. Vacatur,” 86 Federal Register: 14221-14229 (March 9, 2021), available 43 Ibid. at https://www.federalregister.gov/documents/2021/03/15/2021-05357/ inadmissibility-on-public-charge-grounds-implementation-of-vacatur. 44 Mathews, K. et al., “2015 National Content Test Race and Ethnicity Analysis Report: A New Design for the 21st Century,” (Washington D.C.: 28 Haley, J., “One in Five Adults in Immigrant Families,” op. cit. United States Census Bureau, February 2017), available at https:// 29 Brooks, T. op. cit. apps.npr.org/documents/document.html?id=4316468-2015nct-Race- 30 Ibid.; H.B. 130, 2021 General Assembly (Vermont, 2021). Ethnicity-Analysis. 18 HEALTH COVERAGE TRENDS FOR LATINO CHILDREN CCF.GEORGETOWN.EDU JUNE 2021 Georgetown University Center for Children and Families McCourt School of Public Policy 600 New Jersey Avenue, NW Washington, DC 20001 Phone: (202) 687-0880 Email: childhealth@georgetown.edu ccf.georgetown.edu/blog/ facebook.com/georgetownccf twitter.com/georgetownccf JUNE 2021 CCF.GEORGETOWN.EDU HEALTH COVERAGE TRENDS FOR LATINO CHILDREN 19