The Shifting Federal and State Policy Landscapes for Health Insurance Coverage of Noncitizen Immigrants: Where Are We Thirty Years After PRWORA?

Since the 1996 passage of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), states have taken different approaches to noncitizen health coverage. California and Illinois expanded access using state funds, driven by policy innovation and advocacy coalitions, while Texas and Georgia maintained restrictive policies that reflected conservative politics and fiscal concerns. This study used the Policy Diffusion and Policy Contexts frameworks to analyze PRWORA influence on state decisions on immigrant health coverage. By examining the policy trajectories of California, Illinois, Texas, and Georgia, we highlighted the growing fragmentation in immigrant health coverage. The study reviewed trends in health insurance and Medicaid enrollment among noncitizens from 2008 to 2023 using data from the American Community Survey (ACS) and a RAND cost estimation tool. California and Illinois showed greater improvements in insurance coverage and Medicaid enrollment, while Texas and Georgia had lower gains. We found that restrictive policies led to higher uninsured rates and different tradeoffs in terms of cost and potential enrollment of noncitizens into Medicaid. Future policy developments will likely be influenced by federal policy changes, demographic shifts, and advocacy efforts. Understanding these dynamics is important for addressing disparities in immigrant health care access and informing policy debates.