Medicaid Eligibility Expansion Regardless of Immigration Status and Insurance Coverage Among Latinos Seen in Community Health Centers, 2018‒2023.

Medicaid Eligibility Expansion Regardless of Immigration Status and Insurance Coverage Among Latinos Seen in Community Health Centers, 2018‒2023 - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Am J Public Health . 2025 Jun;115(6):900–909. doi: 10.2105/AJPH.2025.308052 Medicaid Eligibility Expansion Regardless of Immigration Status and Insurance Coverage Among Latinos Seen in Community Health Centers, 2018‒2023 Nathalie Huguet 1, ✉ , Jorge Kaufmann 1 , Heather Holderness 1 , Jeremy Erroba 1 , Gretchen Mertes 1 , Anna Steeves-Reece 1 , Rachel Springer 1 , John Heintzman 1 , Miguel Marino 1 Author information Article notes Copyright and License information 1 Nathalie Huguet, Jorge Kaufmann, Heather Holderness, Jeremy Erroba, Rachel Springer, John Heintzman, and Miguel Marino are with the Department of Family Medicine, Oregon Health and Science University, Portland. Gretchen Mertes and Anna Steeves-Reece are with the Research Department at OCHIN Inc, Portland. ✉ Correspondence should be sent to Nathalie Huguet, PhD, Department of Family Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239-3098 (e-mail: huguetn@ohsu.edu ). Reprints can be ordered at https://www.ajph.org by clicking the “Reprints” link. CONTRIBUTORS N. Huguet conceptualized the study and drafted the first version of the article. G. Mertes provided the data. J. Kaufmann performed the data processing and analyses. R. Springer and M. Marino provided statistical expertise. All authors provided critically important intellectual content and approved the final version of the article. N. Huguet is the guarantor of this work and takes responsibility for the integrity of the data and the accuracy of the data analysis. ✉ Corresponding author. Accepted 2025 Jan 31; Issue date 2025 Jun. © American Public Health Association 2025 PMC Copyright notice PMCID: PMC12080449  PMID: 40179344 Abstract Objectives. To assess whether Latino patients receiving care in community-based health centers (CHCs) in US states that expanded Medicaid eligibility regardless of immigration status to adults 50 years and older had greater insurance coverage after the eligibility amendment compared with states that did not expand eligibility. Methods. We performed a retrospective cohort study, using electronic health record data from 40 602 nonpregnant CHC patients aged 50 to 64 years living in states that expanded eligibility (OR, CA) or that did not (AK, CT, IN, MN, MT, NC, NJ, OH, WA) with a visit in both 2018–2019 (before policy change) and 2021–2023 (after policy change). Results. Among Spanish-preferring Latinas, the overall Medicaid-insured difference-in-difference estimate across all 3 years after the amendment was positively moderate (average treatment effect on treated [ATT] = +7.04; 95% confidence interval [CI] = 0.10, 13.98); however, this effect was greatest in the third year after the amendment (ATT = +21.82; 95% CI = 14.04, 29.59), and this was accompanied by a substantial drop in third year uninsured visit rates (ATT = −15.45; 95% CI = −24.77, ‒6.13). We observed the same pattern for Spanish-preferring Latinos. Conclusions. The findings suggest that expanding Medicaid eligibility regardless of immigration status improved access to health insurance for some Latino communities. ( Am J Public Health . 2025;115(6):900–909. https://doi.org/10.2105/AJPH.2025.308052 ) The Latino community—the largest, youngest, and one of the most rapidly growing communities in the United States—persistently has the highest uninsured rate (4 times higher) of any racial or ethnic group, despite improvements in insurance coverage access after the Patient Protection and Affordable Care Act (ACA). 1 Latinos who are immigrants or part of a mixed-immigration-status household are especially at risk for being uninsured. 2 – 5 According to US Census data, in 2022, 20 million US residents were foreign-born Latinos. 6 A report from US Department of Homeland Security estimates that 30% of foreign-born Latinos are undocumented. 6 , 7 Half of likely undocumented immigrant adults report being uninsured compared with less than 1 in 10 naturalized citizen (6%) and US-born citizen (8%) adults. 8 Federal and state policies restricting or prohibiting coverage based on documentation status directly contribute to higher uninsured rates among undocumented populations. Recognizing that immigration status is a critical factor in the willingness and ability of Latino community members to seek health insurance and access health care services, 9 several US states and the District of Columbia (DC) have expanded access to health insurance (via Medicaid eligibility, marketplace eligibility, specific local program) to provide coverage for children (12 states and DC) and adults (6 states and DC) regardless of immigration status. 10 Considering the importance of health insurance for prevention and disease management, these eligibility amendments could significantly mitigate care-access barriers and health disparities for many Latinos and their families in these states. For example, studies have shown that Latinos who gained insurance showed the greatest improvement in diabetes control, one of the most costly diseases. 11 , 12 Furthermore, health care utilization and total expenditures for low-income immigrants is less than one half of US-born adults. 13 Therefore, increasing access to health insurance for all Latinos could be cost-saving. In 2021, California and Oregon both expanded Medicaid eligibility to adults aged 50 years and older, regardless of immigration status. 14 , 15 We evaluated the association of this eligibility expansion on insurance coverage among Latino patients receiving care in community-based health centers (CHCs). These clinics provide care regardless of insurance to a large proportion of socioeconomically disadvantaged patients. We compared changes in insured and uninsured visit rates before and after eligibility amendments in California and Oregon relative to states without this eligibility expansion. We did so by comparing changes in insured and uninsured visits among Latino patients by language preference (Spanish or English) and sex (male or female). We chose to disaggregate Latinos by language preference as preferred language has been shown to be a proxy for acculturation and cultural status and has been shown to be associated with differing health care utilization. 16 , 17 Lastly, evidence shows that Latino men are less likely to seek care than Latinas; therefore, we evaluated changes in Medicaid coverage separately for men and women. 18 , 19 We hypothesized that the rate of Medicaid-insured visits among Spanish-speaking Latino and Latina patients will have a greater increase than English-speaking Latino and Latina patients in states that expanded eligibility regardless of immigration status related to their peers in states that did not expand eligibility. METHODS This retrospective cohort study centers on California and Oregon because they are the only states to expand their Medicaid eligibility to adults aged 50 years and older regardless of immigration status in 2021. As a comparison, we included states that did not expand Medicaid eligibility regardless of immigration. These included states that expanded Medicaid to low-income adults in accordance with the ACA Medicaid expansion and that had clinics with more than 30 Latino patients on panel, did not have other insurance program (e.g., local program or marketplace) to assist undocumented immigrants, and participated in the OCHIN network in the pre- and postperiod. These states were Alaska, Connecticut, Indiana, Minnesota, Montana, North Carolina, New Jersey, Ohio, and Washington. Data Source We sourced patient-level data from the OCHIN Epic electronic health record (EHR) system. OCHIN provides a fully hosted and shared EHR platform across a nationwide network of health centers. OCHIN is part of the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) Clinical Research Network of PCORnet. 20 ADVANCE clinical data are routinely assessed for completeness and quality following PCORnet’s standard analytic queries and data quality check process and have low missingness on relevant variables. All study data, including patient self-reported ethnicity and preferred language, are collected in the routine course of clinical care in structured, preexisting fields in the OCHIN Epic EHR system. We use the label “Latino” because it is often preferred in our study population; however, the actual ethnicity information collected by the clinics is most often “Hispanic or non-Hispanic.” Population The study population consisted of English- and Spanish-preferring Latino adults aged 50 to 64 years; we only used data from participants within this age range in analyses. Patients’ age was restricted to align with the eligibility amendment in Oregon and California during the study period. We included all patients with at least 1 primary care visit (ambulatory visit) within the OCHIN network both before (2018–2019) and after (2021–2023) the eligibility amendment. Primary care visits were identified as those occurring with a physician (allopath, osteopath, or naturopath), physician assistant, or nurse practitioner in combination with encounters utilizing any the following Current Procedural Terminology codes 99201–99205, 99212–99215, 99241–99245, 99386–99387, and 99396–99397 ( https://www.ama-assn.org/practice-management/cpt ). We excluded patients seen in clinics located in both states that did and did not expand eligibility (n = 134), patients who were ever pregnant during the study (n = 360), and those who were dually eligible (n = 11 801; Medicaid plus Medicare), because pregnant individuals and those who are dually eligible have different eligibility criteria for Medicaid than other adults. We also excluded the year 2020 because of the pandemic and its impact on primary care delivery. The year 2020 had different visit trends with significant reductions in March to June. 21 The final study sample consisted of 40 602 Latino and Latina patients aged 50 to 64 years in Oregon, California, Alaska, Connecticut, Indiana, Minnesota, Montana, North Carolina, New Jersey, Ohio, and Washington. Dependent Variables Our 3 outcome measures included monthly clinic rates of (1) Medicaid-insured, (2) privately insured, and (3) uninsured visits for each ethnicity‒ language group. Rates were measured as the count of the insured-type visit over the total visits for each group in each month. Independent Variables Our primary exposure variable was a binary variable indicating location in states that expanded eligibility (California and Oregon) or states that did not expand eligibility (Alaska, Connecticut, Indiana, Minnesota, Montana, North Carolina, New Jersey, Ohio, and Washington). Our main independent variable differentiated patient’s preferred language (Spanish or English preference), and we stratified analyses by sex (male or female). Covariates To describe the study groups, we extracted the following EHR-derived variables: year of first visit, distinct number of years with clinic visits, age at first study visit, total study visits over the time period, an indicator if the patient was a single clinic user (vs visiting multiple clinics), and last known income. In regression-based analyses that were clinic-level analyses, we included clinic’s urban or rural status and percentage of clinic’s patient population being at or below 138% of the US federal poverty level (FPL; as determined by the Department of Health and Human Services) as covariates. Statistical Analysis We first described characteristics of the full sample and by preferred language study groups. Next, we estimated and reported unadjusted sex- and language-stratified insured-type visit rates for Latinos before and after the amendment by eligibility expansion groups. We also produced profile plots that visually describe these rates over the study period. Then, to evaluate changes in insurance rates over time by eligibility expansion status, our primary analytic approach was done at the clinic level where insurance-type visit data and patient-level data were rolled up to the clinic‒month level. We evaluated all 3 outcome measures (Medicaid, private, and uninsured visits) at the clinic‒month level, where each insured-type visit was operationalized to reflect a percentage of the total visits within the clinic in the month of study by language preference. Specifically, all 3 outcome rates were estimated at the clinic‒month level for Latinos who prefer English and Latinos who prefer Spanish. To evaluate the association of this eligibility expansion on insurance coverage, we used a doubly robust covariate-adjusted difference-in-difference approach proposed by Sant’Anna and Zhao. 22 In short, this approach uses an outcome regression model and a propensity score model to address concerns about model misspecification, heterogeneity of treatment effects across patients, and lack of efficiency. Our outcome regression model was the standard difference-in-difference estimator that uses ordinary least squares with an indicator for expansion group start period, categorical time variable denoting month of study, and their interaction. The propensity score model was a logistic regression model that modeled the outcome of expansion group as a function of the pre-expansion clinic-level covariates listed previously (including the patient-level covariates that were rolled up to the clinic level). We used these propensity scores to produce stabilized inverse probability weighting with additional standard error adjustment for clustering of patients within clinics. This method combines the outcome and propensity score models by weighting the outcome regression with the propensity scores, ensuring that the treatment effect estimates remain consistent even if 1 of the models (either the outcome regression or propensity score) is misspecified. Stratified by sex, we report the average treatment effect on the treated (ATT) with 95% confidence intervals (CIs) for each study group (English-preferring and Spanish-preferring Latinos) along with linear combinations of dynamic treatment effects showing separate effects for each of the 3 years (2021, 2022, and 2023) following initiation of the Medicaid eligibility expansion. The reported ATTs describe the difference-in-difference in insured-type visit rates before to after the amendment (difference 1) between states that did or did not expand eligibility (difference 2). The reported values reflect differences in percentage-point change of insured-type visit rates. We visually inspected parallel trends between the eligibility expansion groups using adjusted event study plots and interaction tests using preperiod data. Sensitivity Analysis Lastly, while our primary analysis used patients and clinics that were not exposed to this 2021 eligibility expansion as a comparison group, it is possible to conceptualize an alternative comparison group. Specifically, we could compare patients aged 50 to 64 years (who were eligible for the expansion) with those aged 30 to 49 years (who were not eligible) within California and Oregon. As such, we performed this sensitivity analysis by replacing our original comparison group to Latino patients in California or Oregon who were aged 30 to 49 years (n = 53 975). We then redid our difference-in-difference approach replacing our primary exposure to age group (50‒64 vs 30–49 years). Of note, in July of 2023, Oregon expanded eligibility to all ages regardless of immigration status, and, thus, we further break out policy effects in the last year (2023) into January to June 2023 and July to December 2023. We created the analytic data set using R version 4.3.0 (R Foundation for Statistical Computing, Vienna, Austria) and conducted analyses with the CSDID package in Stata version 15.1 (StataCorp LP, College Station, TX) using 2-sided testing and type I error set to 5%. RESULTS The full sample aged 50 to 64 years consisted of 40 602 Spanish-preferring Latino (81%) and English-preferring Latino (19%) adults with a median age of 55 years. A higher proportion of Spanish-preferring Latinos were female (62%), lived at or below 138% of the FPL (72%), and utilized eligibility expansion-state clinics (92%) than English-preferring Latinos ( Table 1 ). TABLE 1— Patient Characteristics Among Latinos Aged 50 to 64 Years by Language Preference in States With and Without Medicaid Eligibility Expansion: United States, 2018–2023 Patient Characteristics Total (n = 40 602), No. (%) or Median (Range) Latino, No. (%) or Median (Range) Prefers Spanish (n = 32 844) Prefers English (n = 7758) Sex Female 24 442 (60.2) 20 431 (62.2) 4 011 (51.7) Male 16 160 (39.8) 12 413 (37.8) 3 747 (48.3) First visit year 2018 20 678 (50.9) 17 192 (52.3) 3 486 (44.9) 2019 19 924 (49.1) 15 652 (47.7) 4 272 (55.1) Distinct years of contact 2 4 998 (12.3) 3 757 (11.4) 1 241 (16.0) 3 8 522 (21.0) 6 804 (20.7) 1 718 (22.1) 4 15 827 (39.0) 12 816 (39.0) 3 011 (38.8) 5 11 255 (27.7) 9 467 (28.8) 1 788 (23.0) Age at first study visit, y 55 (50‒63) 54 (50‒63) 55 (50‒63) Total study visits 12 (2‒222) 13 (2‒112) 12 (2‒141) Single clinic users 23 010 (56.7) 18 945 (57.7) 4 065 (52.4) Last known income ≤ 138% FPL 28 923 (71.2) 23 785 (72.4) 5 138 (66.2) > 138% FPL 5 826 (14.3) 4 726 (14.4) 1 100 (14.2) No information 5 853 (14.4) 4 333 (13.2) 1 520 (19.6) Eligibility expansion state 36 850 (90.8) 30 212 (92.0) 6 638 (85.6) Open in a new tab Note. FPL = federal poverty level, as determined by the Department of Health and Human Services. Data from 594 clinics in eligibility expansion states = CA, OR and eligibility nonexpansion states = AK, CT, IN, MN, MT, NC, NJ, OH, WA. Preamendment (2018, 2019) and postamendment (2021, 2022, 2023), among persons aged 50 to 64 years utilizing primary care in both periods. Amendment refers to expansion of Medicaid eligibility regardless of immigration status. Average unadjusted insured-type visit rates for the pre- and postamendment periods are shown in Table 2 by eligibility expansion status. In general, eligibility expansion states had higher rates of Medicaid visits and lower rates of private and uninsured visits compared with states that did not expand eligibility. These patterns did not differ by language preference, and, overall, rates between Latinas and Latinos were comparable. The average preamendment rate of Medicaid visits for Latinas was 30.7% (SD = 36.7%) in states that did not expand and 43.0% (SD = 29.5%) in eligibility expansion states. The average preamendment rate of Medicaid visits for Latinos was 25.0% (SD = 33.6%) in states that did not expand and 36.4% (SD = 28.4%) in eligibility expansion states. TABLE 2— Primary Care Insurance Visit Rates by Payment Type and Language Preference, Stratified by Sex, Among Patients Aged 50 to 64 Years in States With and Without Medicaid Eligibility Expansion: United States, 2018–2023 Payment Type States Without Eligibility Expansion, Visit Rate a (SD) Eligibility Expansion States, Visit Rate a (SD) Preamendment Postamendment Preamendment Postamendment Latinas Medicaid insured Prefers Spanish 30.7 (36.7) 31.9 (35.9) 43.0 (29.5) 59.5 (31.5) Prefers English 43.3 (41.3) 44.8 (40.9) 61.8 (35.4) 63.9 (34.8) Uninsured Prefers Spanish 49.5 (40.2) 42.2 (37.5) 27.3 (29.7) 16.8 (25.0) Prefers English 17.8 (32.6) 13.0 (30.3) 7.8 (20.8) 4.6 (15.5) Privately insured Prefers Spanish 13.9 (24.7) 19.1 (27.0) 18.5 (25.5) 16.3 (24.3) Prefers English 21.7 (33.8) 24.1 (34.5) 16.7 (29.6) 15.3 (27.6) Latinos Medicaid insured Prefers Spanish 25.0 (33.6) 27.5 (35.4) 36.4 (28.4) 52.4 (32.4) Prefers English 39.1 (40.6) 43.2 (42.4) 62.3 (35.3) 63.7 (35.8) Uninsured Prefers Spanish 49.0 (40.3) 42.5 (39.5) 28.5 (31.2) 17.8 (25.7) Prefers English 23.6 (36.5) 13.6 (30.4) 9.2 (21.8) 5.1 (16.3) Privately insured Prefers Spanish 16.4 (26.8) 20.1 (29.0) 18.6 (26.4) 17.1 (25.3) Prefers English 25.1 (35.5) 28.4 (38.7) 14.1 (27.8) 14.9 (28.0) Open in a new tab Note. Data from 594 clinics in eligibility expansion states = CA, OR and eligibility nonexpansion states = AK, CT, IN, MN, MT, NC, NJ, OH, WA. Preamendment (2018, 2019) and postamendment (2021, 2022, 2023), among persons aged 50 to 64 years utilizing primary care in both periods. Amendment refers to expansion of Medicaid eligibility regardless of immigration status. a Unadjusted rates measured as the number of monthly insured-type visits per 100 visits. Figure 1 , which depicts average monthly unadjusted Medicaid-insured rates, shows Medicaid rates for Spanish-preferring Latinas ( Figure 1a ) and Latinos ( Figure 1b ) in eligibility expansion states began rising in the second-year after the amendment and then leveled out in the third year. In contrast, rates appear steady throughout the study period for both English-preferring Latino groups in eligibility expansion states and for all Latino groups in states that did not expand eligibility. FIGURE 1— Open in a new tab Monthly Unadjusted Rates of Medicaid-Insured Visits per 100 Total Visits for (a) Latinas and (b) Latinos Aged 50 to 64 Years by Language Preference and Eligibility Expansion Status: United States, 2018–2023 (Excluding 2020) Note. Data from 594 clinics in eligibility expansion states = CA, OR; eligibility nonexpansion states = AK, CT, IN, MN, MT, NC, NJ, OH, WA. Preamendment (2018, 2019) and postamendment (2021, 2022, 2023), among persons aged 50 to 64 years utilizing primary care in both periods. Amendment refers to expansion of Medicaid eligibility regardless of immigration status. Difference-in-difference analyses ( Table 3 ) show a statistically significant association between eligibility expansion and insured rates exclusively for the Spanish-preferring Latino and Latina groups aged 50 to 64 years. Among Spanish-preferring Latinas, the overall Medicaid-insured difference-in-difference estimate across all 3 years after the amendment was moderate (ATT = +7.04; 95% CI = 0.10, 13.98); however, this effect was greatest in the third year after the amendment (ATT = +21.82; 95% CI = 14.04, 29.59), and this was accompanied by a substantial drop in third year uninsured visit rates (ATT = −15.45; 95% CI = −24.77, ‒6.13). The same pattern was observed for Spanish-preferring Latinos (Medicaid rate overall across the 3-year follow-up: ATT = 16.08 [95% CI = 7.32, 24.84]; Medicaid third year: ATT = 26.56 [95% CI = 16.75, 36.37]; uninsured third year: ATT = −11.44 [95% CI = −21.63, −1.26]). TABLE 3— Average Treatment Effect on Treated (ATT) of the 2021 Medicaid Eligibility Expansion on Primary Care Visit Rates by Payment Type and Language Preference, Stratified by Sex, Among Patients Aged 50 to 64 Years in States With and Without Eligibility Expansion: United States, 2018–2023 Payment Type Postamendment Period, ATT, Percentage Points (95% CI) First Year (2021) Second Year (2022) Third Year (2023) All 3 Years Combined Latinas Medicaid insured Prefers Spanish −5.30 (−12.09, 1.49) 4.19 (−3.56, 11.93) 21.82 (14.04, 29.59) 7.04 (0.10, 13.98) Prefers English −5.73 (−14.32, 2.86) −1.00 (−11.00, 9.00) 4.84 (−5.10, 14.78) −0.70 (−9.66, 8.26) Uninsured Prefers Spanish −2.44 (−11.74, 6.86) −5.42 (−14.66, 3.82) −15.45 (−24.77, −6.13) −7.84 (−16.73, 1.06) Prefers English 3.05 (−4.33, 10.43) 0.15 (−7.25, 7.54) −0.72 (−8.34, 6.89) 0.86 (−6.27, 7.98) Private insured Prefers Spanish 8.71 (−0.11, 17.53) 4.59 (−3.40, 12.58) −1.57 (−9.60, 6.45) 3.86 (−4.07, 11.79) Prefers English 5.49 (−3.41, 14.39) 2.60 (−6.83, 12.03) −1.11 (−10.91, 8.70) 2.34 (−6.64, 11.31) Latinos Medicaid insured Prefers Spanish 5.83 (−2.97, 14.64) 15.44 (6.62, 24.26) 26.56 (16.75, 36.37) 16.08 (7.32, 24.84) Prefers English −4.22 (−15.21, 6.76) −3.69 (−15.82, 8.43) 0.27 (−11.82, 12.36) −2.58 (−13.72, 8.57) Uninsured Prefers Spanish −0.81 (−9.93, 8.31) −7.97 (−18.08, 2.14) −11.44 (−21.63, −1.26) −6.81 (−16.26, 2.63) Prefers English 1.12 (−8.43, 10.67) −0.38 (−9.66, 8.89) −0.26 (−10.17, 9.65) 0.17 (−9.13, 9.48) Private insured Prefers Spanish 0.87 (−6.87, 8.60) 0.84 (−7.23, 8.90) −4.58 (−13.28, 4.12) −0.98 (−8.72, 6.75) Prefers English 1.05 (−10.16, 12.26) 2.87 (−8.19, 13.93) 1.11 (−10.01, 12.24) 1.72 (−8.88, 12.31) Open in a new tab Note. CI = confidence interval. ATTs describe the difference-in-difference in insured-type visit rates before to after eligibility expansion (difference 1) between states that did or did not expand eligibility to Medicaid regardless of immigration status (difference 2). Rates were evaluated as the number of monthly insured-type visits per 100 visits and the reported ATT values reflect differences in percentage-point change of insured-type visit rates. ATTs were derived using stabilized inverse probability weighting and ordinary least squares linear regression, adjusted for covariates, and standard error estimates clustered on clinics. Data from 594 clinics in eligibility expansion states = CA, OR and eligibility nonexpansion states = AK, CT, IN, MN, MT, NC, NJ, OH, WA. Preamendment (2018, 2019) and postamendment (2021, 2022, 2023), among persons aged 50 to 64 years utilizing primary care in both periods. Amendment refers to expansion of Medicaid eligibility regardless of immigration status. In our evaluation of the parallel trends assumption (Appendices A and B, available as supplements to the online version of this article at https://ajph.org ), we found that the parallel trends assumption holds for 10 of the 12 comparisons. For 2 groups (private female English-speaking and Medicaid male English-speaking), those P values were significant, suggesting a potential violation of the parallel trends assumption. Furthermore, in sensitivity analyses that compared different eligible age groups within Oregon and California, Appendix C (available as a supplement to the online version of this article at https://ajph.org ) shows that the increases in Medicaid rates among Spanish-preferring Latinas (panel a) and Latinos (panel b) aged 50 to 64 years were not observed among their younger age group counterparts until July of 2023, when Oregon expanded eligibility to all adults regardless of age). Difference-in-difference analyses utilizing the younger age groups within expansion states as the controls shows similar differences as the original analysis between English- and Spanish-preferring Latinos. However, the difference-in-difference estimates in Medicaid rates were greater overall, and, additionally, statistically significant declines in uninsured and privately insured visit rates were also observed beginning in the second-year after the amendment. Lastly, in these analyses, the difference estimates for the first 6 months of the third-year after the amendment were twice those than in the last 6 months, evidence that the differences between the older and younger groups decreased when the amended eligibility was expanded to the younger age group (Appendix D, available as a supplement to the online version of this article at https://ajph.org ). DISCUSSION In this early evaluation of 2021 Medicaid eligibility expansion regardless of immigration status, we observed significant increases in Medicaid-insured visits among Spanish-speaking Latina and Latino patients receiving care in CHCs in eligibility expansion states relative to their counterparts in states that did not expand; this was also observed when we compared age groups within Medicaid eligibility expansion states. These results suggest an increase in Medicaid enrollment in these states, which aligns with California enrollment reports. 23 These early findings are promising, especially as both California and Oregon have further expanded eligibility to adults aged 19 to 64 years. In 2024, other states, Washington and Colorado, have expanded eligibility for Marketplace insurance to all adults regardless of immigration status. This study could inform expected increases in Medicaid-insured rates as evaluations of these policies for these newly expanded states are being performed and assist other states in their decisions to expand their health insurance options regardless of immigration. Evidence shows that if all Latinos were eligible for and enrolled in health insurance, insurance premiums overall would be lower, because Latino communities including immigrants are healthier. Thus, promoting insurance for all would be cost-saving. 24 , 25 Findings from the difference-in-difference analyses suggest that the majority of the association between increased Medicaid insurance visit rates and eligibility expansion status among Spanish-preferring Latinos occurs on the third year after the policy expansion. Delays in implementation and dissemination of this policy change and barriers to enrollment likely explain this trend. For instance, immigration-related policies can result in an aversion to enrolling into health insurance, even if eligible. 26 In addition, previous evidence shows that, compared with non-Latino people, Latinos were less likely to be aware of insurance marketplaces during the rollout of the ACA. 27 – 30 Navigating the health care system, insurance eligibility, and comprehensive benefits can be particularly difficult for those with limited or no English proficiency. 28 , 31 These barriers may have negatively impacted enrollment of Latino adults. Furthermore, previous evidence shows that Latino patients are more likely to receive assistance from insurance navigators 32 because of these barriers, which could explain a slower uptake. As noted previously, mixed-immigration-status households are at greater risk of being uninsured and may have benefited from this eligibility expansion at a differential rate; future studies are needed to explore the policy impact in this group. When comparing age groups (expanded Medicaid eligibility aged 50 to 64 years vs not eligible aged 30 to 49 years) within California and Oregon (sensitivity analysis), we found a decrease in private insurance rates among Spanish-speaking Latina and Latino patients. There are several possible explanations for this decrease. First, undocumented Latinos are not eligible for marketplace insurance plans in California and Oregon, so this decline is unlikely to be among those who became newly eligible for Medicaid. Second, it is possible that Latinos eligible for marketplace insurance switched from private insurance to Medicaid by becoming Medicaid eligible or by learning about their Medicaid eligibility, which could have been more frequent in mixed-immigration-status households. Third, marketplace insurance premiums have progressively increased in California and Oregon since 2021, 33 which may lead to less affordable plans and lower enrollment especially among older groups. Limitations The study findings should be interpreted in light of key limitations. First, while the 2021 Medicaid expansion aimed to increase Medicaid insurance for low-income undocumented populations, our study does not specifically look at that population. We cannot with certainty estimate the true association among those truly exposed to this policy change. Second, clinics included are part of the OCHIN network, which may not be representative of all primary care clinics in the United States. This visit-based study does not assess changes in patient-level insurance status and does not include individuals who do not seek care or who were not established before the 2021 expansion policy, which may underestimate the association, assuming the effects are stronger for the excluded population. We restricted our sample to those with care before and after the amendment and cannot estimate the impact of the eligibility expansion on patients who sought care only in the postperiod, which also likely underestimates the association. It is also possible that patients in our sample received care outside of our EHR networks; however, previous studies suggest that patients who visit CHCs continue to do so after insurance gain. 34 , 35 The higher change in Medicaid visits among Spanish-preferring Latinos may be attributable in part to the higher use of insurance navigation programs. The parallel trends assumption may not be satisfied for the private female English-speaking and Medicaid male English-speaking groups (both with null findings), and caution should be used when interpreting the results of these 2 estimates. Lastly, we adjusted for a number of confounders but unmeasured confounding may still exist. Conclusions The early findings of this retrospective study suggest that expanding Medicaid eligibility regardless of immigration likely improved access to health insurance for Latino patients receiving care in CHCs. Removing immigration-related restrictions to insurance enrollment could significantly reduce access disparities and improve health for all. ACKNOWLEDGMENTS This work was supported by a research grant (RSGI-23-1018762-01-HOPS) from the American Cancer Society and the Silver Family Innovation Fund. The research reported in this work was powered by PCORnet. PCORnet has been developed with funding from the Patient-Centered Outcomes Research Institute (PCORI) and conducted with the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) clinical research network. ADVANCE is a clinical research network in PCORnet led by OCHIN in partnership with Health Choice Network, Fenway Health, University of Washington, and Oregon Health and Science University. 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