During the COVID-19 pandemic, states kept people continuously enrolled in Medicaid in exchange for enhanced federal funding. With the end of continuous enrollment on March 31, 2023, states are required to complete an eligibility renewal for all Medicaid and CHIP enrollees by May 2024 – a process commonly referred to as “unwinding.” KFF survey data show that despite outreach, as of early November more than one-third (36%) of Medicaid enrollees had heard nothing at all about unwinding. As of January 2024, states had renewal outcomes for more than four in ten enrollees with over 14 million people disenrolled and more than 27 million reenrolled in Medicaid coverage. In December 2023, growing concern over loss of Medicaid coverage for children prompted federal officials to issue additional guidance with strategies to protect coverage and to write letters to nine states with large declines in Medicaid child enrollment, urging them to take up additional policy options to prevent disenrollments due to paperwork, or procedural, issues.

Data are important to help monitor how unwinding is going across states, but trackers and dashboards only tell part of the unwinding story. Medicaid eligibility is complex, and outcomes are the result of federal and state policy decisions but also the result of how those policies are implemented and how well eligibility and other systems work. This brief examines the perspectives of state officials and others involved in the unwinding process. KFF worked with PerryUndem to conduct interviews with representatives from Medicaid managed care plans, primary care associations, legal aid and other advocacy organizations, and navigator organizations in four states: Arizona, Florida, Indiana and Pennsylvania. In addition, the report draws on broader state input from interviews with Medicaid officials as part of the 23rd annual budget survey of Medicaid officials conducted by KFF and Health Management Associates (HMA) from June to September 2023 (early in the unwinding process). The brief provides information on outreach and engagement, renewal processes and coverage transitions, providing lessons for the ongoing unwinding process, as well as for how to conduct more effective Medicaid renewals generally in the future. Key takeaways include the following:

Communication and Engagement

States have used an array of outreach strategies and partnered with multiple entities involved in unwinding to reach Medicaid enrollees. All states reported using traditional communication campaigns with mailers and paid advertising, and some states have added text messaging and targeted outreach to certain populations, including users of long-term services and supports and people with limited English proficiency. To encourage consistent messaging and information, all four study states have developed toolkits for partner organizations that included printable and digital materials. Study states credited new strategies to update contact information, such as using the National Change of Address database and accepting updated contact information from managed care organizations (MCOs), with reductions in returned mail. While enhanced outreach efforts were generally viewed as positive, some participants said enrollees have been overwhelmed by the volume of contact they have received and, in some cases, unclear messages have led to confusion.

State engagement with those involved with unwinding was described as a positive aspect of unwinding, and feedback loops have helped identify early problems. Many states, including three of the study states, increased engagement and coordination with others involved in unwinding, holding regular meetings to provide updates and review data. In the study states, participants noted these meetings have provided an opportunity to create feedback loops to alert states to potential problems and build relationships in the process. In contrast, limited state engagement and communication contributed to more reports of problems with the unwinding process and frustration among groups involved with the unwinding.

Renewal Processes

The volume of renewals, systems issues, and staffing shortages have posed significant challenges to states. Across many states, older systems that require manual workarounds to meet federal requirements have exacerbated staffing shortages and negatively impact the processing of renewals. While systems are generally working well in Arizona and Indiana, Pennsylvania’s system was not designed to conduct ex parte renewals for a large number of Medicaid enrollees, increasing the burden on eligibility staff to manually process most renewals. Study state officials noted that staffing shortages and inexperienced staff have contributed to backlogs and disenrollments of people who are likely still eligible early in the process; these states responded with additional training and other efforts to increase staff.

States have taken steps to streamline renewal processes and increase ex parte, or automated, renewals. As of January 2024, all study states except Florida had adopted a range of 1902(e)(14) waivers and other flexibilities to increase ex parte rates and streamline renewals. Guidance from CMS in December 2023 announced these waivers will be available through the end of 2024 unless approved for a longer duration. A number of states, including Indiana, have also taken steps to increase ex parte renewals for people who qualify on the basis of disability or over age 65, referred to as non-MAGI populations. When asked about the most helpful flexibilities, states most often pointed to those allowing use of Supplemental Nutrition Access Program (SNAP) data to renew Medicaid, streamlining renewals for those with no and low income, and waiving the asset limit test. Officials in the study states have prioritized ex parte renewals, both automated and manual, as a strategy for reducing procedural disenrollments.

All four study states have increased the number of communication touch points with enrollees. In an effort to improve response rates, study states increased the number of enrollee contacts during the renewal process. For example, Pennsylvania went from sending one mailer ahead of the renewal notice to adding 11 enrollee contacts. States have also expanded communication modes to include emails, texts, and phone calls in addition to mailed notices.

Participants in all four study states reported that Medicaid renewal and termination notices can be difficult to understand. Participants described a variety of problems with notices, from lack of clarity on what actions or documentation are needed for renewal to misleading or incorrect information. Issues with notices were most acute in Florida where advocates have filed a lawsuit, contending notices are confusing, fail to explain why individuals lost Medicaid coverage, and sometimes include incorrect information.

Participants reported challenges getting through to call centers when enrollees needed assistance with their renewals, particularly for people with limited English proficiency. According to study participants, call center wait times are often long and it can be difficult to connect with someone able to assist with complicated cases. Advocates noted wait times were longer for those requesting a language other than English. These problems were echoed by state officials in a number of states.

Coverage Transitions

Some individuals who are disenrolled from Medicaid for procedural reasons are reenrolling after a gap in coverage. While most states are not reporting data on the number of people reenrolling in Medicaid, two study states (Arizona and Pennsylvania) are reporting these data. In Arizona, about half of people who complete their renewal during the 90-day reconsideration period have their coverage reinstated. States have increased communication with people procedurally disenrolled who may be eligible – Arizona and Pennsylvania send letters following disenrollment to let people know they still have time to regain their coverage without completing a new application. Participants noted that when process and systems issues result in disenrollment, it can undermine peoples’ trust in the system and can discourage them from completing their renewal or reapplying.

While children in some states are seamlessly transitioning to CHIP, in other states children are experiencing gaps in coverage. When children in Arizona and Indiana are found to be ineligible for Medicaid, the states automatically enroll them in CHIP, if eligible, without any action required from the family. Participants reported that challenges and glitches with a recent change in Pennsylvania to integrate the CHIP eligibility system with Medicaid have led to some children losing coverage. While information for children determined ineligible for Medicaid is automatically transferred to CHIP, slow processing times may lead to gaps in coverage for some children.

Participants reported that even with enhanced Marketplace premiums, affordability remains a barrier to enrollment. Respondents generally said that account transfers to the Marketplace were happening as expected; however, the number of people disenrolled from Medicaid who enroll in Marketplace coverage remains low in all study states. Participants said that for some people, the deductibles and cost sharing are too high. They also noted that not everyone is aware that Marketplace coverage is an option.

As states continue processing renewals for the more than half of enrollees whose eligibility must be still redetermined, the perspectives of state officials and others involved in unwinding provide valuable insights into what is working well and where there are challenges and room for improvement. States can make changes in the near term to help enrollees maintain Medicaid or transition to other coverage during the unwinding period, but they can also apply the lessons learned to make longer-term improvements to Medicaid renewal processes.

Introduction

During the COVID-19 pandemic, states kept people continuously enrolled in Medicaid in exchange for enhanced federal funding. With the end of continuous enrollment on March 31, 2023, states began the process of redetermining eligibility for all Medicaid enrollees and disenrolling those who are no longer eligible or whose eligibility could not be determined – a process commonly referred to as “unwinding.” KFF survey data show that despite outreach, as of early November more than one-third (36%) of Medicaid enrollees had heard nothing at all about unwinding. As of January 2024, states had renewal outcomes for more than four in ten enrollees with over 14 million people disenrolled and more than 27 million reenrolled in Medicaid coverage. Data are important to help monitor how unwinding is going across states, but trackers and dashboards only tell part of the unwinding story. Medicaid eligibility is complex, and outcomes are the result of federal and state policy decisions but also the result of how those policies are implemented and how well eligibility and other systems work.

Leading up to unwinding, the federal government issued guidance and provided states with the option to adopt a range of new policies to help promote continuity of coverage (in Medicaid for those who remain eligible or though other coverage for those who are no longer eligible). States have been engaged in unprecedented levels of new outreach, but the volume of redeterminations coupled with workforce shortages and systems issues present challenges. Focus groups with enrollees revealed that while many have been able to successfully renew Medicaid coverage, many were disenrolled due to confusion and barriers to completing the renewal process. While some who were disenrolled transitioned to other coverage, many who were disenrolled faced challenges navigating appeals and also experienced out of pocket costs or gaps in access to needed care. By December 2023, the federal government had issued additional guidance and sent letters to nine states with the largest amounts of children losing Medicaid urging them to do adopt additional federal strategies to prevent families from losing coverage due to paperwork, or procedural, issues. CMS identified the top five actions states could take to reduce procedural disenrollments: improve auto-renewal (or ex parte) rates, adopt additional unwinding waivers, partner with managed care plans, support coverage transitions, and reduce call center wait times.

To gain a better understanding of what is working well during the unwinding and where there may be  opportunities to improve processes, KFF worked with PerryUndem to conduct detailed interviews with state officials in Arizona, Indiana, and Pennsylvania, as well as with others involved in unwinding including representatives from Medicaid managed care plans, primary care associations (PCAs) representing federally qualified health centers (FQHCs), legal aid and other advocacy organizations, and navigator groups in Arizona, Florida, Indiana, and Pennsylvania. These states were selected because they provided early data, have a large and diverse Medicaid population, and, collectively, are geographically and politically diverse (see the Appendix for more information on key policies and characteristics in the study states).

In addition, as part of our Annual Medicaid Budget Survey for State Fiscal Years 2023 and 2024, KFF worked with Health Management Associates (HMA) to survey Medicaid directors in all 50 states and DC, as well as conduct a follow-up telephone interview, with the goal of identifying and tracking trends in Medicaid spending, enrollment, and policymaking. To address current issues, the survey and phone interview included questions regarding Medicaid unwinding. This report synthesizes themes from these interviews and the survey, examining the perspectives of states and other participants on outreach and engagement, renewal processes during the unwinding period, and coverage transitions. See the methods box at the end of this report for more detail.

This report describes state and other participant experiences with Medicaid unwinding to provide additional context for a range of policy options adopted by states through temporary 1902(e)(14) waivers to address unwinding challenges and unwinding data. These perspectives provide examples of innovation, as well as continued challenges, during the first months of unwinding. These interviews occurred over multiple months. State Medicaid unwinding is a quickly evolving landscape, as new data, greater experience, and CMS guidance influence what is happening in the field.

Outreach and Engagement

Outreach Strategies

Study states are using an array of strategies to reach out to enrollees. States have introduced new methods of communications and greatly increased their enrollee outreach, expanding the number of touchpoints before renewal. All four study states offered publicly available communication toolkits for partner organizations to use, which included printable materials like posters, postcards, and handouts, as well as digital materials for social media, email, or content that can be embedded into websites. Indiana has offered to print and distribute these materials to external groups at no cost. Study states have also used traditional press to raise awareness; in Pennsylvania, for example, participants commended the Secretary of the Department of Human Services for travelling across the state and holding numerous unwinding press conferences to raise awareness at the local level. To increase the reach of messaging, state officials referenced strategies such as translating outreach materials for non-English speakers. Arizona officials noted electronic communication as an effective method to reach transient populations.

Many entities involved with unwinding have been conducting outreach to amplify state efforts. Some MCOs, newly able to provide direct outreach to enrollees as a result of 1902(e)(14) waiver flexibilities adopted in three study states (Florida is the only state that has not adopted any of these waivers), mentioned they would like to see these flexibilities become permanent so they can continue this outreach after the unwinding period ends. Innovative approaches to outreach include virtual renewal training events (an Indiana MCO reported thousands of attendees for such an event) and coordination between MCOs and FQHCs so providers can work with individuals due for renewal. Some participants in Arizona and Florida noted that direct local marketing and word of mouth can be more effective than statewide ads.

Targeted outreach messages and multiple strategies to update contact information have helped to reduce returned mail. State officials reported that supplementing their outreach efforts with information from the National Change of Address (NCOA) database has been effective for automatically updating mailing addresses and targeting outreach. Pennsylvania conducted a call campaign to people identified via the database as having a change of address, while Arizona credits the NCOA database for a precipitous drop in returned mail. State officials and MCO representatives both reported that receiving contact information from MCOs has also been helpful. Arizona, Indiana, and Pennsylvania have obtained 1902(e)(14) waivers to obtain updated contact information from MCOs. In Arizona, an MCO representative reported that they are able to check enrollees’ contact information with the state’s files and, if needed, MCO staff can provide the updated information to the state.

Despite significant outreach, navigators and those providing legal aid noted that some messages have created confusion and not all enrollees were aware that Medicaid disenrollments had resumed. In Pennsylvania, participants provided examples of enrollees not receiving phone calls, text messages, or letters even after updating their contact information, leaving them unaware that they need to be on the lookout for renewal paperwork. Similarly, Florida participants encountered individuals who signed up for electronic notifications and then never received an email. An Indiana participant spoke of the opposite issue, however: enrollees were overwhelmed by the large number of calls they were receiving about renewing their coverage. Florida navigators and advocates commented that unclear messaging and poor translations led to confusion about renewals and coverage status for enrollees.

Stakeholder Coordination

Three of the study states hold regular meetings with groups involved in unwinding to coordinate efforts, and participants value this increased engagement. These states convene regular meetings, which began before the start of the unwinding period, to provide updates on unwinding plans, review the latest unwinding data, and share updated outreach materials and messages. Arizona holds large monthly meetings with about 100 participants as well as smaller meetings to focus on unwinding data that resulted in the state expanding its data reporting and developing a comprehensive unwinding dashboard. In Pennsylvania, the stakeholder meetings include multiple officials from the Department of Human Services, which administers Medicaid, and the state-based Marketplace, known as Pennie, and help to promote interagency coordination as well as coordination with stakeholders. Participants in Arizona, Indiana, and Pennsylvania all described the increased engagement with the state Medicaid agency as a bright spot during the unwinding. Florida was the only study state that did not have regular meetings with external groups involved in unwinding, though some study participants reported meeting with state officials individually. In lieu of meetings with the state, participants said they coordinated with each other to share information and experiences.

Feedback loops have helped states identify problems early in the unwinding process. Participants  noted that regular meetings provide a forum for sharing on-the-ground experiences and alerting states to problems people are encountering with the renewal process. State officials said getting input about potential problems enables them to assess the situation and determine whether changes to processes or policies are needed. While participants agreed that states did not address all issues or did not respond as quickly as they wanted in all cases, the willingness of states to communicate about issues and engage over possible solutions helped build trust in the process.

Where there has been limited state engagement and communication, there are more reports of problems with the unwinding process and frustration among others working on unwinding. While participants in Florida indicated they were able to work individually with staff involved in the unwinding to resolve problems with specific cases, they said it has been harder to address issues like long call center wait times and problems with notices at a more systemic level. The reported lack of communication from the state has created a more adversarial situation, leading to a civil rights complaint and a lawsuit. Florida participants also described using press conferences and media calls to raise awareness broadly and for the state without direct access to a state meeting.

Renewal Processes During the Unwinding

Eligibility Systems

While eligibility and renewal systems are generally working well in Arizona and Indiana, Pennsylvania is hampered by an outdated system that requires manual workarounds to comply with federal requirements. Arizona has prioritized automated eligibility processes for many years to help balance efficiency, cost effectiveness, and accountability. Officials noted that the state has added data sources and refined business rules for checking eligibility, which have increased ex parte rates and reduced demands on staff. Pennsylvania’s system, however, cannot conduct ex parte renewals for people enrolled in Medicaid and another program, such as SNAP or Temporary Assistance for Needy Families (TANF), or for non-MAGI enrollees. To address this limitation, the state implemented a mitigation plan requiring manual ex parte reviews before terminating coverage during the unwinding.

Respondents reported both benefits and drawbacks to having Medicaid eligibility systems that are integrated with other benefit programs. Integrated eligibility systems allow people to apply for and renew coverage for multiple benefit programs at once, and all four study states have Medicaid eligibility systems that are integrated with CHIP and social benefit programs like SNAP and TANF. Officials in Arizona and Indiana reported that data sharing across programs has helped improve ex parte renewal rates and simplify renewal processes. However, some Florida participants expressed concern that information provided during SNAP renewals, which occur more frequently than Medicaid renewals, can trigger a Medicaid review and potentially lead to people being disenrolled from Medicaid. State officials also reported that it can be more challenging to make changes to integrated systems because of the need to reconcile complex eligibility rules across programs.

Even where systems are working well, the volume of renewals poses challenges, and most system changes can take time to implement. State officials reported challenges “turning on” normal eligibility functions after three years of continuous enrollment, especially after states implemented changes to their systems during the pandemic that needed to be undone. In Arizona, officials noted that they are continually making changes to their systems, but at the start of the unwinding, the number of needed changes meant they could not test everything before going into production. Officials in Arizona and Indiana discussed having procedures for identifying problems and working closely with their vendors to fix things as they come up. However, because some systems changes can take longer to implement, states reported having to adopt manual workarounds for certain groups while developing more permanent changes.

Staffing

Respondents cited staffing shortages as an ongoing challenge contributing to slower processing of renewals and backlogs. Indiana officials noted that inexperienced eligibility staff coupled with staffing shortages led to renewal backlogs early in the unwinding, although the number of pending cases at the end of the month has since improved. Some respondents also noted that staffing shortages disproportionately affect certain communities. For example, Pennsylvania officials found that staffing shortages are more concentrated in urban areas where there is greater competition for workers. In Florida, participants echoed reports that staff shortages at call centers have led to longer wait times for Spanish-speakers compared to English-speakers.

Study participants noted that new and inadequately trained staff may be contributing to disenrollments of people who are still eligible. Federal guidance requires states to assess eligibility for all Medicaid pathways before disenrolling someone from coverage. However, according to participants, inexperienced staff may not be doing this full assessment before sending a termination notice. Participants in Pennsylvania noted this problem in counties with high turnover among eligibility workers and began adding information on additional eligibility pathways to paperwork they help people submit. Arizona officials acknowledged that training issues combined with the high volume of renewals each month increased the likelihood that staff would make mistakes or “cut corners” that could lead to incorrect eligibility determinations. They have sought to address this issue by providing additional training.

Streamlining Renewals

States have taken steps to streamline the renewal process and increase their ex parte renewal processes. Arizona and Indiana opted to align renewal dates for all household members to reduce the number of times a family must respond to a renewal request. Three of the study states have also adopted temporary federal flexibilities using 1902(e)(14) waivers to improve ex parte rates, especially for cases where no income or assets are returned from state databases (Table 1). Study states have also taken steps outside of the federal flexibilities to improve ex parte rates. For example, Indiana added the Asset Verification System in 2020, improving the state’s ability to conduct ex parte renewal for non-MAGI enrollees, which, as noted above, is a challenge in many states.

Most study state officials noted that federal flexibilities related to verifying income and assets have been particularly helpful for increasing ex parte rates. When asked which federal strategies they would like to see made permanent, Arizona and Indiana officials cited the zero- and low-income strategies. These waivers allow states to complete ex parte renewals in cases where no income data are returned from state databases if the state had verified or accepted an attestation of no income or income below 100% of the federal poverty level (FPL) in the past 12 months. Indiana officials said that unemployed people can have trouble producing documentation of zero income. Arizona officials also found that the zero- and low-income strategies are generally low-risk for erroneously renewing coverage for someone who is over-income. Officials argued that it is unusual for someone’s previously verified income to increase a large amount without that person’s higher income appearing in state databases.

While all respondents expressed concern over procedural disenrollment rates, state officials noted that strategies to increase ex parte renewals have helped to lower those rates. Notably, in guidance released in December 2023, federal officials pointed to analysis showing that increasing ex parte rates is the most effect strategy to reducing procedural disenrollments. Procedural disenrollments occur when there is no definitive determination of ineligibility, and high procedural disenrollment rates could mean that some people losing Medicaid may still be eligible. While disenrollment rates across study states are similar, there is greater variation in procedural disenrollment rates; procedural disenrollments as a share of completed redeterminations range from 28% in Indiana to 15% in Arizona (Table 2). In Arizona and Indiana, officials prioritized automated processes as a way to reduce the number of people needing to complete paperwork who could potentially lose coverage for procedural reasons. Similarly, Pennsylvania officials found that the manual ex parte process they have put in place is effective at reducing procedural disenrollments because eligibility workers look at every case before terminating coverage. Notably, Pennsylvania is one of 29 states (but the only study state) that had been conducting ex parte renewals at the household level, rather than the individual level, contributing to some inappropriate procedural terminations (as of December 2023, Pennsylvania has nearly completed reinstatements for affected enrollees). State officials also credited increased outreach efforts as a major factor in reducing procedural terminations.

In response to questions about procedural disenrollments, Arizona and Indiana are reporting additional data on the reason for procedural disenrollments on their unwinding dashboards. For example, Arizona added data to their state dashboard showing that roughly three-quarters of procedural terminations were among people who the state had identified as over-income or aging out of coverage. Indiana began adding footnotes to their monthly Centers for Medicare and Medicaid Services (CMS) unwinding reports showing about one-third of procedural terminations also had “a non-procedural” reason for termination (e.g., over the income or asset limit, moving out of state, or death). The differences in the share of people with a non-procedural reason for closure may be partially explained by different data matching procedures in each state. Study participants in both states have also requested data on procedural terminations by zip code, which they believe will help more effectively target outreach. In response, Arizona recently published an interactive map showing zip codes at “low” or “high” risk of disenrollment, but could not provide exact counts out of privacy concerns.

Enrollee Communication and Notices

All four study states have increased the number of communication touch points when enrollees cannot be renewed via ex parte processes, including sending multiple reminder notices through the mail, email, and text. Pennsylvania, for example, went from just sending a mailer 90 days ahead of renewal to adding 11 “touches,” which include reaching out 90, 60, 30, and five days before a renewal is due. Study participants noted that enrollees who enrolled in Medicaid for the first time during continuous enrollment needed additional reminders and education about completing Medicaid renewals. In Indiana, one participant said that they have begun a consumer campaign focused on encouraging individuals to open letters from the state after hearing from multiple people that they were ignoring incoming letters because they incorrectly assumed no action was needed.

Study participants in all four states reported that Medicaid renewal and termination notices can be difficult to understand and, in some cases, provide misleading or incorrect information. While participants noted myriad issues with notices, Florida advocates were the most critical of the state’s notices. In Florida, advocates have filed a lawsuit over notices, contending that termination notices are confusing, fail to explain why individuals lost Medicaid coverage, and sometimes include incorrect information. Florida participants also described situations where enrollees were requested to provide information or documentation that is not necessary for renewal and noted that it is often unclear which individuals have been denied coverage within a household. Arizona and Pennsylvania participants observed that, for some enrollees, the notices are not clear on what actions or documents are needed for renewal. Other areas of concern include poor translations and notices not being translated into requested languages. An Indiana participant said the notices informing parents that their child has been transitioned to CHIP coverage were confusing because families receive one notice about disenrollment from Medicaid and separate notice indicating enrollment in CHIP. Across multiple study states, participants also said that termination notices included language discouraging people from requesting continued benefits while they appeal their coverage denial.

Some states have made changes to fix incorrect information or to provide additional clarifying information in notices. While changing Medicaid notice language can be a lengthy process, participants reported situations in which states corrected notice language or adopted creative workarounds to improve information shared with enrollees. In Arizona, participants noted that early in the unwinding termination notices included incorrect information about maintaining coverage during an appeal; the state has since corrected the language. In Indiana, at the request of participants, the state added brightly colored inserts to notices that include additional clarifying information.

Assisting Enrollees with Renewals and Appeals

Participants involved in unwinding reported challenges getting through to call centers when enrollees needed assistance with their renewals, with some enrollees never receiving needed help. According to participants, call center wait times can be lengthy and it can be challenging to be connected to a staffer able to answer questions, especially for complicated cases. One Florida participant said some people will carry their phone on speaker phone for hours waiting to get through to the Florida Department of Children and Families (DCF) and sometimes calls can be disconnected. A Pennsylvania participant also noted long call center wait times for some enrollees. An Indiana participant observed the quality of call center assistance can vary, with some newer employees less able to resolve enrollees’ issues.

Non-English language speakers have experienced more difficulty with call centers. An Arizona advocate observed that individuals with limited English proficiency faced longer wait times and could sometimes have their calls dropped. In Florida, participants noted that while an English speaker may wait 30-45 minutes, a Spanish speaker could end up waiting hours. In Pennsylvania, a participant similarly reported that requesting a language other than English can lead to longer wait times, and occasionally if Spanish interpreter lines are busy, people will be rolled over to the English lines. In Indiana, one navigator noted that some call center staff will not allow bilingual navigators to join calls or speak on behalf of their client, requiring that a call center interpreter be used instead which can create additional confusion.

Some participants in the study states noted challenges with timeframes for responding to renewal notices. Some study state participants noted that the timeframes to respond to a renewal notice or to find other coverage after receiving a termination notice are too short. Florida advocates wanted the state to consider adopting flexibilities offered by CMS to extend the timeframe for renewals to help address this issue. Participants in Pennsylvania also noted that the window to return renewal packets is short and results in difficulty submitting documents by the deadline, especially if there are mail delays.

In Arizona and Indiana, MCOs are able to help their members complete renewals and contract with outside vendors or navigator to provide that assistance. Generally, MCOs are prohibited from assisting enrollees with completing renewals; however, during the unwinding, Arizona and Indiana obtained 1902(e)(14) waivers that allow MCOs to help their members complete renewals. MCO respondents in both states said they are working with vendors because of the scale of the task and compliance concerns. In Arizona, an MCO participant spoke of how they have been able to pass on lists from the state of enrollees coming due for renewal to a vendor to do targeted outreach and education. This vendor collects information over the phone for members, helps gather supporting documents, and submits the renewal on their behalf. In Indiana, one MCO participant also used a vendor to set up an in-house call center for member renewal questions.

Coverage Transitions

‘Churning’ Back on to Medicaid

State officials and other study participants acknowledge that some individuals who are disenrolled from Medicaid for procedural reasons reenroll after a short period. At the time of the interviews, state officials explained they were just getting data on churn among those who were disenrolled for procedural reasons and had not had time to analyze the data. Both Arizona and Pennsylvania are now reporting data on the number of people reenrolling in Medicaid. Pennsylvania state officials mentioned they are considering working with a vendor to identify and follow up with individuals procedurally disenrolled who may still be eligible. Other participants also spoke about their experiences with enrollee churn. An Arizona participant noted that nearly half of individuals who re-apply during the reconsideration period are renewed, indicating that eligible individuals are being dropped and losing coverage. An MCO in Indiana said that the initial files shared by the state made it difficult to analyze churn, though the MCO is currently assessing improved data elements from the state. Study states have also implemented new communication methods to target people who are procedurally disenrolled. Both Arizona and Pennsylvania send letters following disenrollment to let people know they still have time to renew coverage.

Study participants reported that losing Medicaid despite being eligible creates confusion and distrust in the community, leading some people to choose not to reapply. Navigators and advocates described how being dropped from Medicaid, particularly because the state did not process their paperwork before the due date, causes some enrollees to lose trust in the ability of navigators and other to provide needed help and in the program overall. That frustration can lead them to give up on the process and not work to complete a renewal or reapply, if needed. Indiana community outreach groups, including chaplaincy programs, are working on rebuilding trust in the community to assist in getting people reenrolled.

Transitions to CHIP and the Marketplace

Arizona and Indiana auto-enroll eligible children into CHIP ensuring a seamless coverage transition, but other study participants reported gaps in coverage for some children transitioning to CHIP in Florida and Pennsylvania. When children in Arizona and Indiana are found to be ineligible for Medicaid, the states automatically enroll them in CHIP, if eligible, without any action required from the family. Though, as noted above, participants in Indiana said unclear notices about the transition created confusion for some families. Pennsylvania recently integrated CHIP into their Medicaid eligibility system, a project that had been planned for years, but coincided with the start of the unwinding period. Study participants reported that there were challenges with the rollout and system glitches have led to some children losing coverage. In Florida, participants noted that children no longer eligible for Medicaid have their information automatically transferred to CHIP; however, slow processing times lead to gaps in coverage for some children. A December 2023 letter from federal officials to Florida’s governor raised concerns about child disenrollments and encouraged the state to adopt additional strategies to reduce child disenrollments, such as utilizing more federal flexibilities as well as eliminating CHIP premiums and lockout periods, which help with transitions from Medicaid to CHIP.

Although many people who are no longer eligible for Medicaid qualify for subsidized Marketplace coverage, study participants said affordability remains a barrier to enrollment. Respondents generally said that account transfers to the Marketplace were happening as expected; however, the number of people disenrolled from Medicaid who enroll in Marketplace coverage remains low in all study states. Even with heavily subsidized premiums and cost-sharing for the lowest-income enrollees, participants said that for some people, the deductibles and cost sharing are too high. They also pointed out that not everyone is aware of Marketplace coverage as an option and that educating people about premiums, cost-sharing, benefits, and the Marketplace generally is an ongoing need. Awareness of the Marketplace is low in Pennsylvania, which launched its State-Based Marketplace, Pennie, during the pandemic. Pennsylvania’s statewide press campaign has been held jointly between the Department of Human Services and Pennie to increase awareness.

Navigators in states using the Federally-facilitated Marketplace (FFM) described problems with the quality of the contact information they receive through the Medicaid Assister Community (MAC) program. The purpose of the MAC is to provide navigators with lists of people disenrolled from Medicaid whom navigators are expected to contact with information about applying for Marketplace coverage. However, navigators participating in the program in the three study states using the FFM (Arizona, Florida, and Indiana) identified common challenges. They reported outdated or missing contact information, and some data erroneously included minors (who navigators cannot contact) and people who still qualified for Medicaid. The volume of people to contact overwhelmed navigators, with one organization reporting having to contact thousands of consumers each week; however, bad data meant the number of people who enroll in the Marketplace is low.

Looking Ahead

At the beginning of 2024, nine months into the unwinding process, states have completed renewals for less than half of all enrollees. While many who are disenrolled may “churn” back to Medicaid or transition to other coverage, many will likely become uninsured. People who are uninsured face more barriers to care, go without needed care and also may experience higher out of pocket costs and medical debt.

Data are important to help monitor how unwinding is going across states, but trackers and dashboards only tell part of the unwinding story. Medicaid eligibility is complex, and outcomes are the result of federal and state policy decisions but also the result of how those policies are implemented and how well eligibility and other systems work. Gaining perspectives from state officials, others involved with unwinding and enrollees provides valuable insights into what is working well and where there are challenges and room for improvement to efficiently identify those who are no longer eligible and help those who are eligible maintain coverage.

With more than half of renewals still to be completed, there is time to learn from experience. Key themes from the interviews include:

• Efforts to enhance outreach and stakeholder engagement such as:
  • Supplementing broad outreach strategies aimed at raising awareness with targeted messaging that is directed at certain populations who are at greater risk of not completing their renewals may help increase renewal response rates;
  • Use of the NCOA database and partnering with MCOs can help to reduce returned mail;
  • Collaborating with stakeholders to reach enrollees and also to establish feedback loops can help to continue to identify problems even as initial issues are addressed;
• Efforts to improve renewal processes that include:
  • Adopting federal flexibilities to streamline renewals and increase ex parte rates can simultaneously help to reduce the burden on overloaded staff and reduce procedural disenrollments among those who remain eligible;
  • Improving communication with enrollees, including notices and call center access, can reduce enrollee confusion and increase the likelihood that individuals are able to resolve problems;
• Efforts to smooth transitions to other coverage such as:
  • Auto enrollment of eligible children into CHIP can support seamless coverage transitions and reduce the number of children experiencing a gap in coverage; and
  • Greater coordination with the Marketplace can increase awareness of that coverage option and improvements to the MAC program, particularly enhancement of data quality, could lead to a greater number of people transitioning from Medicaid to Marketplace coverage.

States will continue the process of unwinding continuous enrollment through much of 2024. Any steps they take in the near term to improve systems and processes to help people who are still eligible maintain Medicaid and those who are no longer eligible transition to other coverage can reduce the number of people who become uninsured. Looking ahead, lessons learned from this experience can be used to inform policy changes and direct resources to more successful outreach and other strategies for reaching and communicating with enrollees and to make longer-term improvements to Medicaid renewal processes.

The appendix tables below summarize some of the key criteria used in selecting study states.

Executive Summary

Asian immigrants represent a significant and growing share of the U.S. population, contributing to the country’s communities and economy and representing dozens of countries of birth and languages spoken. Many come to the U.S. on H-1B visas, which are used by the U.S. government to employ immigrants in highly specialized and often technical fields, or on student visas for higher education. Reflecting these immigration pathways, as a broad group, Asian immigrants typically fare well on socioeconomic measures. However, contrary to the model minority myth, the experiences of Asian people in the U.S., including Asian immigrants, are not monolithic, with some subgroups facing significant socioeconomic challenges. Moreover, the U.S. has a long history of exclusionary policies focused on Asian immigrants, contributing to ongoing anti-Asian sentiment and the “perpetual foreigner” stereotype, which intensified during the COVID-19 pandemic and with some recent laws restricting the actions of Chinese immigrants in particular. Increased data on Asian immigrant experiences is important for understanding their diversity of experiences and focusing initiatives, policies, and resources to address the challenges they face.

This report examines experiences of Asian immigrant adults in the U.S. and how they vary across different factors such as region or country of origin, income, and English proficiency. It is based on The Survey of Immigrants, conducted by KFF in partnership with the Los Angeles Times during Spring 2023, the largest and most representative survey focused on immigrants living in the U.S. to date. With its sample size of 3,358 immigrant adults¹ , the survey provides a deep understanding of immigrant experiences, reflecting their varied countries of origin and histories, citizenship and immigration statuses, racial and ethnic identities, and social and economic circumstances. KFF also conducted focus groups with immigrants from an array of backgrounds, which expand upon information from the survey (see Methodology for more details). Other reports from this survey include an overview report, a health and health care experiences report, and a report on politics and policy. Key takeaways from this report include:

A majority of Asian immigrants in the U.S. are from China, India, or the Philippines, are long-term U.S. residents, and are college-educated and employed; yet some face socioeconomic and language challenges. Asian immigrants include people born in China (21%), India (21%), the Philippines (17%), as well as smaller shares from other East, Southeast, South, and Central Asian countries. Three in four (74%) Asian immigrants have been in the U.S. for ten or more years and two-thirds (66%) are naturalized citizens. However, South Asian immigrants (including those from India) are more likely than East and Southeast Asian immigrants (including those from China and the Philippines) to be recent immigrants (15 vs. 7%) and less likely to be citizens (55% vs. 71%). Overall, four in ten (41%) Asian immigrants live in households with annual incomes of at least $90,000, with immigrants from South Asia (51%) more likely to have higher household incomes than immigrants from East and Southeast Asia (36%), likely reflecting differences in the shares with a college degree (71% vs. 48%). About half (49%) of Asian immigrants have limited English proficiency (LEP), including seven in ten (71%) Chinese immigrants.

Like immigrants overall, most Asian immigrants come to the US for better opportunities for themselves and their children and most feel that their lives are better as a result of coming, although they are somewhat less likely than other immigrants to say their safety is better off. Among Asian immigrants, those from China are particularly less likely to say that their safety is better as a result of immigrating to the U.S. with just one in three (34%) saying it is better as compared to at least half of Indian (52%) and Filipino (59%) immigrants. This may, in part, reflect increases in anti-Chinese sentiment during COVID-19 and recent laws targeting Chinese immigrants.

About one in three (36%) Asian immigrants report facing at least one form of discrimination or harassment in the community. These experiences include being treated worse than U.S.-born people in stores or restaurants (27%), in interactions with the police (17%), or when buying or renting a home (14%). One in five (20%) also say that the COVID-19 pandemic changed the way they are treated as an immigrant in a bad way, including about a quarter (27%) of Chinese immigrants. About four in ten (45%) with LEP also say that difficulty speaking or understanding English has made it hard for them to access health care or public assistance services or complete certain activities such as getting or keeping a job or interacting with the police.

While most Asian immigrants are faring well in employment and finances, reflecting higher educational attainment levels than other immigrant groups, those with lower household incomes face challenges. One in five (19%) living in households with lower incomes (less than $40,000 per year) have difficulty paying their bills each month, and one in three (32%) lower income Asian immigrants say they had problems paying for necessities such as housing, health care, utilities, or food in the past 12 months. Four in ten (44%) employed Asian immigrants, including half of those living in households with lower incomes, report experiencing at least one form of workplace discrimination asked about in the survey.

Reflecting their job patterns and higher incomes, a majority (64%) of Asian immigrant adults say they have private health coverage and only 4% report being uninsured. Highlighting the important role that coverage plays in access to health care, over eight in ten Asian immigrants say they have a usual source of care (86%) and a trusted doctor in the U.S. (84%) and only one in six (16%) report skipping or postponing health care for any reason in the past year. However, one in five (21%) report experiencing discrimination or unfair treatment in a health care setting due to their insurance status or ability to pay, their accent or ability to speak English, or their race, ethnicity, or skin color.

Four in ten (42%) of Asian immigrants say they don’t have enough information about U.S. immigration policies to understand how they impact their family, and many remain confused about how use of assistance for health care, housing, or food can impact immigration status. Among Asian immigrants with LEP, half (49%) say they do not have enough information about U.S. immigration policy. Seven in ten Asian immigrants, say they are unsure (55%) whether the use of non-cash benefits to help pay for health care, housing, or food can impact the likelihood of being approved for a green card or incorrectly believe this to be the case (15%). The share who incorrectly believe this to be the case is higher among noncitizens and immigrants who have been in the U.S. for less than 10 years as compared to their naturalized citizen and 10+ year resident counterparts.

Who Are Asian Immigrants?

Country/Region of Origin: One in five (21%) Asian immigrants in the U.S. are from China, an additional 17% are from the Philippines and 29% from other East and Southeast Asian countries (such as Korea, Japan, and Thailand).²  About one in five (21%) are from India with an additional 7% hailing from other South Asian countries (such as Bangladesh, Pakistan, and Sri Lanka). Asian immigrants also include those from Central Asia (including Kazakhstan, Uzbekistan, and others). See here for a list of regional groupings.

Census Region: Four in ten Asian immigrants live in the West (43%), a quarter (24%) live in the South, one in five (21%) live in the Northeast and a smaller share (12%) live in the Midwest. Almost half of Asian immigrants live in one of three U.S. states: California (31%), New York (9%), or Texas (8%).

Time in country: Similar to the overall immigrant population, most Asian immigrants are long-term U.S. residents. About three in four (74%) have lived in the U.S. for ten or more years, 14% have been in the U.S. for five to nine years, while one in ten (10%) have been in the U.S. for less than five years. Higher shares of immigrants from India have been in the U.S. for less than five years (16%) as compared to immigrants from the Philippines (6%) and this is also true for South Asian immigrants overall (15%) as compared to East and Southeast Asian immigrants (7%).

Employment: Similar to the overall immigrant population, two-thirds (64%) of Asian immigrants are currently employed for pay, including three-quarters (74%) of those ages 18-64; 17% of employed Asian immigrants are self-employed or the owner of a business.

Parental Status: About one in three (34%) Asian immigrants are the parent of a child under 18 living in their household, and the vast majority (81%) of this group say at least one of their children was born in the U.S.

English Proficiency: Similar to the total immigrant population, almost half (49%) of Asian immigrants have limited English proficiency (LEP, defined as speaking English less than very well), with shares with LEP about twice as high (71%) among immigrants from China as compared to their counterparts from India (32%) and the Philippines (34%). LEP rates are also higher among immigrants from East and Southeast Asia overall (56%) as compared to immigrants from South Asia (38%). About one in three Asian immigrants say they speak English very well (32%) and an additional one in five (19%) say they speak English exclusively. Asian immigrants speak a wide variety of languages at home, including one in five (21%) who speak some form of Chinese, one in ten (13%) who speak Filipino or Tagalog, and one in ten (10%) who speak Vietnamese. Other languages spoken by Asian immigrants include Urdu, Hindi, Korean, Japanese, and many others.

Immigration Status: Two-thirds (66%) of Asian immigrants are naturalized U.S. citizens, while about three in ten (29%) say they have a valid visa or green card, and 5% are likely undocumented. Among Asian immigrants, those from the Philippines have the highest shares (80%) of naturalized citizens followed by immigrants from China (60%); immigrants from India include lower shares of naturalized citizens (49%) which could in part be due to 16% of them being more recent immigrants (less than five years). In general, the shares of Asian immigrants who are naturalized citizens are higher among immigrants from East and Southeast Asia (71%) as compared to those from South Asia (55%).

Educational Attainment: A majority (54%) of Asian immigrants have a college degree or higher, about one in six have completed some college (18%), and about a quarter (26%) have a high school education or less. Those with a college degree or higher include much higher shares of immigrants from India (83%) as compared to immigrants from China (56%) or the Philippines (52%) and this is also true for South Asian immigrants overall (71%) as compared to East and Southeast Asian immigrants (48%).

Household Income: Four in ten (41%) Asian immigrants live in households with annual incomes of at least $90,000, and another 29% live in households with annual incomes of $40,000 to less than $90,000. About one in four (27%) live in households with lower incomes (less than $40,000 per year). Immigrants from India (62%) are much more likely to have higher household incomes compared with immigrants from China (41%) and the Philippines (37%), reflecting differences in educational attainment. Overall, immigrants from South Asia (51%) are more likely than immigrants from East or Southeast Asia (36%) to have higher household incomes.

Reasons For Coming And Life In The U.S.

Like immigrants overall, a majority of Asian immigrants cite better opportunities and a better future for their children as reasons for moving to the U.S., with high shares of immigrants from East and Southeast Asia also citing having more rights or freedoms as a reason. Among Asian immigrants, at least three in four say better economic and job opportunities (86%), educational opportunities (79%), and a better future for their children (75%) are a reason they moved to the U.S. Smaller shares say they came to the U.S. to have more rights or freedoms (66%), to join or accompany family members (51%), or to escape violent or unsafe conditions (34%). However, the share citing more rights and freedoms as a reason is higher among immigrants from East and Southeast Asia (71%) compared with those from South Asia (52%).

Majorities of Asian immigrants feel that their educational and financial situations are better as a result of moving to the US, even among those with lower incomes and those who are noncitizens (Figure 1). Overall, more than seven in ten Asian immigrants say their financial (76%) and employment (73%) situation are better, and eight in ten (82%) say their or their children’s educational opportunities are improved. Regardless of immigration status, income, or time in the U.S., a majority of Asian immigrants report they are doing better on these measures. However, the shares reporting they are doing better in terms of finances and employment are somewhat lower among noncitizens, more recent immigrants, and those with lower incomes (less than $40,000 per year) compared to their citizen, longer-term immigrant (10+ years), and higher income (at least $90,000 per year) counterparts. Moreover, those from China are less likely to say they are doing better on financial and employment measures than those from India and the Philippines.

About half (54%) of Asian immigrants say their safety is better as a result of moving to the U.S.  and roughly one in five (17%) say it is worse, with those from East and Southeast Asia, noncitizens, and recent immigrants more likely to say it is worse (Figure 2). In comparison, among immigrants overall, about two in three (65%) say their safety is better as a result of immigrating. Asian immigrants from East and Southeast Asia are about twice as likely as those from South Asia to say their safety is worse (21% vs. 7%), a pattern largely driven by the one-third (33%) of immigrants from China who say this. In addition, noncitizens (26%) and recent immigrants (less than five years) (28%) are about twice as likely as naturalized citizens (12%) and longer-term immigrants (10+ years) (14%), respectively, to say that their safety is worse because of moving to the U.S. These feelings about safety may, in part, reflect the rise in anti-Asian hate incidents during the COVID-19 pandemic.

Eight in ten (81%) Asian immigrants, regardless of country or region of birth, citizenship status, and length of time in the country, feel that their standard of living is better than their parents’ was at their age, and six in ten (63%) feel that their children’s standard of living will be better than theirs (Figure 3). Optimism for their children’s future standard of living is higher among Asian immigrants with lower educational attainment (high school or less) (69%) and LEP (69%) compared with those who have completed college (58%) and are English proficient (57%).

Experiences With Discrimination And Unfair Treatment

Like immigrants overall, a majority of Asian immigrants feel most people in their neighborhood (69%) and the state (63%) they live in are welcoming to immigrants (Figure 4). Overall, 5% say that most people in their neighborhood are not welcoming to immigrants, and about one in ten (9%) say that people in their state are not welcoming. The remaining shares say they are unsure if people in their neighborhood (26%) and state (28%) they live in are welcoming to immigrants.

One in five (20%) Asian immigrants feel the COVID-19 pandemic has negatively impacted the way that they are treated as an immigrant, higher than the shares for Black (11%), Hispanic (9%), and White immigrants (7%). Immigrants from East and Southeast Asia (25%) are much more likely than those from South Asia (8%) to say that the pandemic changed how they are treated as an immigrant in a bad way, largely driven by the 27% of Chinese immigrants who say this compared with about one in ten Indian (7%) and Filipino (12%) immigrants (Figure 5). These patterns likely reflect the strong anti-Chinese rhetoric perpetuated by the Trump Administration, which repeatedly blamed China for the spread of the COVID-19 pandemic.

About one in three (36%) Asian immigrants say they have ever received worse treatment than U.S.-born people in stores or restaurants (27%), in interactions with the police (17%), or when buying or renting a home (14%), with those under age 65 and who are noncitizens particularly likely to report these experiences (Figure 6). Asian immigrant adults younger than 65 (38%) are more likely than their older counterparts (29%) to say they have ever experienced at least one form of worse treatment, as are noncitizen Asian immigrants (42%) compared with those who are naturalized citizens (34%).

About three in ten Asian immigrants say they have ever experienced anti-immigrant harassment such as being told to go back to where they came from (32%) or being criticized for speaking a language other than English (29%), with higher shares of Chinese immigrants and those with LEP reporting harassment (Figure 7). About one in three East and Southeast Asian immigrants say they have ever been criticized or insulted for speaking a language other than English (34%) or were told to “go back to where you came from” (35%) compared with about one in five South Asian immigrants (17% and 22%, respectively). Chinese immigrants are more likely than Indian and Filipino immigrants to report experiencing these forms of harassment, which may in part, reflect the growth in anti-Chinese rhetoric during the COVID-19 pandemic as well as recent laws restricting actions among Chinese immigrants. In addition, Asian immigrants with LEP (34%) are more likely than their English proficient counterparts (24%) to say they were criticized for speaking a language other than English, although there are no differences in the share saying they have been told “they should go back where you came from” by English proficiency. Roughly twice as many Chinese immigrants (71%) have LEP than do Filipino (34%) or Indian (32%) immigrants, which could further explain some of the differences in experiences of harassment by country of origin.

About four in ten (45%) Asian immigrants with LEP say that difficulty speaking or understanding English has made it hard for them to access certain services or complete certain activities, with this share rising to over half among those with LEP who also have lower educational attainment, lower incomes, or are noncitizens. About half (49%) of Asian immigrants have LEP, meaning they speak English less than very well, including 71% of immigrants from China. Among this group, about four in ten(45%) say that difficulty speaking or understanding English has ever made it hard for them to do at least one of the following: get health services (26%), get or keep a job (23%), or get help from the police (22%), apply for government help with food, housing, or health coverage (19%), or receive services in a store or restaurant (18%), (Figure 8). Among Asian immigrants with LEP, those with lower educational attainment, lower incomes (less than $40,000 per year), and who are noncitizens face disproportionate language challenges with over half of these groups experiencing at least one of these difficulties.

Employment and Financial Situation

Most Asian immigrants are employed, predominantly in salaried jobs. Two-thirds (64%) of Asian immigrants are employed for pay, including three-quarters (74%) of those ages 18-64. About one in five (17%) of employed Asian immigrants are self-employed or the owner of a business. Asian immigrants are more likely than immigrants overall to be salaried, with about half receiving a salary (48%), four in ten (40%) being paid an hourly rate, and one in ten (9%) being paid by the job (Figure 9). However, pay type varies starkly among Asian immigrants, largely driven by differences in educational attainment. Among Asian immigrants, those who are college graduates are about four times as likely as those with a high school diploma or less (65% vs. 17%) to be in a salaried position. Reflecting these differences, pay type also varies by region and country. For example, about eight in ten (83%) Indian immigrants have a college degree compared with about half of Chinese (56%) and Filipino (52%) immigrants, and consequently are more likely to be salaried (67% vs. 51% vs. 32%, respectively). English proficiency also makes a difference, with half of Asian immigrants with LEP working hourly jobs, compared to about one in three (32%) who are English proficient.

About one in five (22%) employed Asian immigrants say they are overqualified for their current jobs, that is, having more skills and education than the job requires, including about three in ten (31%) lower income Asian immigrants. Employed Asian immigrants with a college degree or higher (22%) or with some college education (33%) are more likely to feel overqualified than those with a high school education or less (9%). Similarly, those with lower incomes (less than $40,000 per year) (31%) are more likely to feel this way compared those with higher incomes (at least $90,000 per year) (18%). These data likely reflect some Asian immigrants taking jobs different from their previous work or training in their countries of origin, as described by some focus group participants.

About four in ten (44%) employed Asian immigrants say they have ever experienced at least one form of workplace mistreatment in the U.S. asked about in the survey. These include being given fewer opportunities for promotion (30%), being paid less (28%), not getting paid for all the hours they worked or for overtime (15%), being given worse shifts (12%) than their U.S.-born counterparts, or being harassed or threatened in the workplace because they are an immigrant (8%) (Figure 10). The share who say they were given worse shifts or had less control over their work hours is about twice as high for lower income Asian immigrants (less than $40,000 per year) compared to their higher income counterparts (at least $90,000 per year) (17% vs. 8%).

Asian immigrants have higher incomes than immigrants overall, but income varies widely among subgroups in part due to variations in educational attainment. Many Asian immigrants come to the U.S. on H-1B visas, which are used by the U.S. government to employ immigrants in highly specialized and often technical fields, which has a direct impact on the types of industries Asian immigrants work in as well as on their incomes. Consequently, about four in ten (41%) Asian immigrants live in households with annual incomes of at least $90,000 and an additional one in three (29%) live in households with annual incomes of $40,000 to less than $90,000. About one in four (27%) live in households with lower incomes (less than $40,000 per year). However, income varies widely among Asian immigrants. Those from India (62%) are much more likely to have higher household income (at least $90,000 per year) compared with those from China (41%) and the Philippines (37%). Overall, immigrants from South Asia (51%) are more likely than immigrants from East or Southeast Asia (36%) to have higher household incomes (at least $90,000 per year). This pattern likely reflects differences in educational attainment as about eight in ten Indian immigrants are college graduates compared with about half of Chinese and Filipino immigrants.

Reflecting these income patterns, most Asian immigrants do not report problems paying for basic needs or monthly bills, but those with lower incomes report more financial difficulties. Most (58%) Asian immigrants say they are able to pay all their monthly bills and have some money left over, (33%) say they are just able to pay their monthly bills, and about one in ten (8%) say they have difficulty paying their bills each month. However, the share who say they have difficulty paying their monthly bills rises to about one in five (19%) among those with lower household incomes (less than $40,000 per year) (Figure 11). Similarly, one in five (20%) Asian immigrants overall say they had problems paying for necessities such as housing, food, health care, or utilities in the past 12 months, but roughly one in three (32%) of those with lower incomes (less than $40,000 per year) say this (Figure 12).

Health And Health Care Experiences

Reflecting their job patterns, a majority (64%) of Asian immigrant adults report having private health insurance coverage and only 4% report being uninsured (Figure 13). High rates of private coverage and low uninsured rates among Asian immigrant adults likely reflect their higher incomes as well as higher rates of employment in management, business, and science occupations, which are more likely to offer employer-sponsored coverage. Asian immigrants with higher educational attainment (78%), higher incomes (at least $90,000 per year) (89%), and those who are English proficient (71%), are more likely than their lower educational attainment (38%), lower income (less than $40,000 per year) (29%), and LEP (56%) counterparts to have private health coverage (Figure 14).

The large majority of Asian immigrants have a usual source of care and a trusted health care provider in the U.S. Reflecting their high rates of health coverage, roughly nine in ten (86%) Asian immigrant adults say they have a place other than an emergency room where they usually go when they are sick or need health advice, with most saying they go to a private doctor’s office (56%) and about one in five (21%) saying they use a community health center (CHC) (Figure 15). Use of CHCs as a usual source of care is higher among Asian immigrants who are noncitizens (28%) and those with LEP (25%) compared with their citizen (18%) and English proficient (18%) counterparts, reflecting their role as a national network of safety-net primary care providers serving low-income and medically underserved communities. Research shows that CHCs offer linguistically and culturally competent care to underserved racial and ethnic groups as well as people with LEP and that these services can positively impact patient satisfaction. About eight in ten Asian immigrants (84%) say they have a trusted health care provider in the U.S. However, noncitizens are less likely than citizens to say they have a trusted provider (74% vs. 90%).

Reflecting that most Asian immigrants have health coverage and a regular source of care, about one in seven (16%) say they skipped or postponed health care services in the past year, but this share rises to about three in ten (29%) among recent immigrants. (Figure 16). Chinese immigrants (21%) also are more likely than Indian (12%) and Filipino (11%) immigrants to say they went without or postponed health care even though there are no significant differences in rates of health coverage and in the shares saying they have a usual source of care by country of birth, suggesting that the differences could be driven by cultural and linguistic barriers experienced by Chinese immigrants or other unidentified factors. Overall, 6% of Asian immigrants (representing 40% of those who skipped or postponed care) say their health got worse as a result of skipping or postponing care.

About one in five (21%) Asian immigrants who have sought or received health care in the U.S. say they have ever been treated unfairly by a health care provider, with those who are lower income reporting higher levels of unfair treatment than their higher income counterparts. Overall, 14% of Asian immigrants say they have ever been treated unfairly by a health care provider due to their accent or ability to speak English, 13% report unfair treatment due to their racial or ethnic background or skin color, and 11% cite unfair treatment due to their insurance status or ability to pay (Figure 17). A third (33%) of lower income (less than $40,000 per year) Asian immigrants say that they experienced discrimination or unfair treatment in a health care setting for at least one of these reasons compared with 15% of higher income (at least $90,000 per year) Asian immigrants. Asian immigrants with LEP (27%) also are more likely than their English proficient counterparts (16%) to say they experienced unfair treatment when seeking health care, including one in five (21%) who say it was due to their accent or ability to speak English.

Confusion and Worries About Immigration Policies

While only 5% of Asian immigrants are likely undocumented, 14% of Asian immigrants overall and 26% of those who are noncitizens say they have ever worried that they or a family member could be detained or deported. Moreover, 7% of Asian immigrants overall and 11% of those who are noncitizens say immigration-related fears have led them to avoid things such as talking to the police, applying for a job, or traveling (Figure 18). Only 4% of Asian immigrants overall say they have avoided applying for a government program that helps pay for food, housing, or health care in the past 12 months because they didn’t want to draw attention to their immigration status or the immigration status of someone in their family. This could partly reflect limited need for these types of assistance given that most Asian immigrants do not report financial challenges.

About four in ten (42%) Asian immigrants say they do not have enough information about U.S. immigration policy to understand how it affects them or their family, with shares higher among those with lower incomes, those who have been in the U.S. fewer than five years, and those with LEP (Figure 19). About half of Asian immigrants with lower incomes (less than $40,000 per year) (52%), who have been in the U.S. for fewer than five years (55%), and with LEP (49%) say they do not have enough information about U.S. immigration policies as compared to about four in ten with higher incomes (at least $90,000 per year) (37%), who have been in the country for 10 or more years (40%), and who are English proficient (36%).

Most Asian immigrants are uncertain about how using assistance for food, housing, and health care may affect one’s immigration status. Under longstanding U.S. policy, federal officials can deny an individual entry to the U.S. or adjustment to lawful permanent resident status (a green card) if they determine the individual is a “public charge” based on their likelihood of becoming primarily dependent on the government for subsistence. In 2019, the Trump Administration made changes to public charge policy that newly considered the use of previously excluded noncash assistance programs for health care, food, and housing in public charge determinations. However, this policy was rescinded by the Biden Administration in 2021, meaning that the use of assistance for health care, food, and housing is not considered for public charge tests, except for long-term institutionalization at government expense. However, a majority (55%) of Asian immigrants say they are “not sure” whether use of public programs that help pay for health care, housing, or food can decrease one’s chances for green card approval and another 15% incorrectly believe this to be the case (say “yes”) (Figure 20). Among Asian immigrants, noncitizens (21%) and those who have been in the country for less than 10 years (25%) are more likely to report an incorrect understanding of the rules compared to their citizen (13%) and 10+ year (13%) immigrant counterparts.

The KFF/LA Times Survey of Immigrants is a partnership survey conducted by KFF and the LA Times examining the U.S. immigrant experience.

The survey was conducted April 10-June 12, 2023, online, by telephone, and by mail among a nationally representative sample of 3,358 immigrants, defined as adults living in the U.S. who were born outside the U.S. and its territories. Respondents had the option to complete the survey in one of ten languages: English (n=2,435), Spanish (n=627), Chinese (n=171), Korean (n=52), Vietnamese (n=22), Portuguese (n=16), Haitian-Creole (n=13), Arabic (n=9), French (n=9), and Tagalog (n=4). These languages were chosen as they are most commonly spoken by immigrant adults from countries of focus for the survey with limited English proficiency (LEP), based on the 2021 American Community Survey (2021).

Teams from KFF and The Los Angeles Times worked together to develop the questionnaire and both organizations contributed financing for the survey. KFF researchers analyzed the data, and each organization bears the sole responsibility for the work that appears under its name. Sampling, data collection, weighting, and tabulation were managed by SSRS of Glenn Mills, Pennsylvania in collaboration with public opinion researchers at KFF.

Respondents were reached through one of three sampling modes: an address-based sample (ABS) (n=2,661); a random digit dial telephone (RDD) sample of prepaid (pay-as-you go) cell phone numbers (n=565); and callbacks to telephone numbers that that were previously randomly sampled for RDD surveys and were identified as speaking a language other than English or Spanish (n=132). Respondents from all three samples were asked to specify their country of birth and qualified for the survey if they were born outside of the U.S.

Project design was informed by a pilot study conducted from January 31-March 14, 2022 among a sample of 1,089 immigrants in collaboration with SSRS. Prior to fielding the pilot study, KFF and SSRS conducted interviews with experts who had previous experience surveying immigrants. These conversations informed decisions on sampling, modes of data collection, recruitment strategies, and languages of interviews. The pilot test measured incidence of immigrant households across four different sample types and offered a short survey in 8 different languages both online and on the telephone. Based on the results of the pilot test, the following recruitment and data collection protocol was implemented:

Sampling strategy and interview modes:

The ABS was divided into areas (strata), defined by Census tract, based on the incidence of immigrants among the population overall and by countries of origin. Within each stratum, the sample was further divided into addresses that were flagged by Marketing Systems Group (MSG) as possibly occupied by foreign-born adults and unflagged addresses. To increase the likelihood of reaching immigrant adults, strata with higher incidence of immigrant households overall, and of immigrants from certain countries of origin were oversampled.

Households in the ABS were invited to participate through multiple mail invitations: 1) an initial letter in English with a short paragraph of instructions in each of the 10 survey languages on the back; 2) a reminder postcard in English plus up to two additional languages; 3) a follow-up letter accompanied by hardcopy questionnaires in English and one additional language; and 4) a final reminder including short messages in all 10 languages. For mailings 2 and 3, additional languages were chosen by using flags to identify the language other than English likely spoken at home. Invitation letters requested the household member ages 18 or older who was born outside of the U.S. with the most recent birthday to complete the survey in one of three ways: by going online, dialing into a toll-free number, or returning the completed paper questionnaire. In addition, interviewers attempted outbound calls to telephone numbers that were matched to sampled addresses. ABS respondents completed the survey online (n=2,087), over the phone (n=105), or by mail on paper (n=469). The random sample of addresses was provided by MSG.

The RDD sample of prepaid (pay-as-you-go) cell phone numbers was obtained through MSG. The prepaid cell phone component was disproportionately stratified to effectively reach immigrants from different countries based on county-level information. To increase the likelihood of reaching immigrant adults, counties with higher incidence of immigrants overall, and of certain countries of origin were oversampled.

The callback sample included 132 respondents who were reached by calling back telephone numbers that were previously randomly sampled for SSRS RDD surveys within two years and coded by interviewers as non-English or non-Spanish speaking.  as having respondents speaking languages other than English or Spanish.

Incentives:

Initial mailings to the ABS sample included $2 as part of the invitation package, and respondents received a $10 incentive if they completed the survey in the first two weeks after the initial mailing. In order to increase participation among under-represented groups, the incentive increased to $20 for those who did not respond within the first two weeks. ABS phone respondents received this incentive via a check received by mail, paper respondents received a Visa gift card by mail, and web respondents received an electronic gift card incentive. Respondents in both phone samples received a $25 incentive via a check received by mail.

Questionnaire design and translation:

In addition to collaboration between KFF and the LA Times, input from organizations and individuals that directly serve or have expertise in issues facing immigrant populations helped shaped the questionnaire. These community representatives were offered a modest honorarium for their time and effort to review questionnaire drafts, provide input, attend meetings, and offer their expertise on dissemination of findings.

After the content of the questionnaire was largely finalized, SSRS conducted a telephone pretest in English and adjustments were made to the questionnaire. Following the English pretest, Research Support Services Inc. (RSS) translated the survey instrument from English into the nine languages outlined above and performed cognitive testing through qualitative interviews in all languages including English. The results of the cognitive testing were used to adjust questionnaire wording in all languages including English to ensure comprehension and cohesiveness across languages and modes of interview. As a final check on translation and its overlay into the web and CATI program, translators from Cetra Language Solution reviewed each question, as it appears in the program, and provided feedback. The questionnaire was revised and finalized based on this feedback.

Data quality checks:

A series of data quality checks were run on the final data. The online questionnaire included two questions designed to establish that respondents were paying attention and cases were monitored for data quality. Fifteen cases were removed from the data because they failed two or more quality checks, failed both attention check questions, or skipped over 50% of survey questions. An additional 67 interviews were removed after deemed ineligible by SSRS researchers (they were not U.S. immigrants).

Weighting:

The combined sample was weighted to adjust for the sampling design and to match the characteristics of the U.S. adult immigrant population, based on data from the Census Bureau’s 2021 American Community Survey (ACS). Weighting was done separately for each of 11 groups defined by country or region of origin (Mexico, China, Other East/Southeast Asia, South Asia, Europe, Central America, South America, Caribbean, Middle East/North Africa, Sub-Sahara Africa, all others). The samples were weighted by sex, age, education, race/ethnicity, census region, number of adults in the household, presence of children in the household, home ownership, time living in the U.S., English proficiency, and U.S. citizenship. The overall sample was also weighted to match the share of U.S. adult immigrants from each country/region of origin group. The weights take into account differences in the probability of selection for each of the three sample types. This includes adjustment for the sample design and geographic stratification, and within household probability of selection. Subgroup analysis includes data checks to ensure that the weighted demographics of subgroups are within reasonable range from benchmarks whenever possible.

The margin of sampling error including the design effect for the full sample is plus or minus 2 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

Focus group methodology:

As part of this project, KFF conducted 13 focus groups with immigrant adults across the country to help inform survey questionnaire development, provide deeper insights into the experiences of immigrant groups that had a smaller sample size in the survey, and to provide a richer understanding of some of the survey findings.

Two rounds of focus groups were completed. The first round of 6 groups was conducted between September-October 2022 virtually among participants living across the country who are Hispanic immigrants (conducted in Spanish), Asian (excluding Chinese) immigrants (conducted in English), or Chinese immigrants (conducted in Mandarin Chinese). The groups were separated by gender, lasted 90 minutes, and included 5-7 participants each.

The second round of groups were conducted in-person between May-June 2023 in Los Angeles, CA and Fresno, CA with Hispanic immigrants conducted in Spanish; and in Houston, TX and Irvine, CA with Vietnamese immigrants conducted in Vietnamese. In addition, virtual groups were conducted among participants living in the Texas border region (Hispanic immigrants), the Miami, FL region (Haitian immigrants), and nationally (Black immigrants from sub-Saharan Africa). Groups were mixed gender, lasted between 90 minutes and two hours, and were conducted in English, Spanish, Vietnamese, and Haitian-Creole with 5-8 participants each.

For each group, participants were chosen based on the following criteria: Must be at least 18 years of age and have been born outside of the U.S. and its territories; for groups conducted in languages other than English, must speak English “less than very well” and be able to speak conversationally in the group’s language (i.e., Spanish). In addition, groups were chosen to represent a mix of household composition, including at least some participants who are parents; a mix of household income levels, with a preference for recruiting lower income participants; a mix of health insurance types; and a mix of immigration statuses. Goodwin Simon Strategic Research (GSSR) recruited and hosted the first round of focus groups. PerryUndem recruited and hosted the second round of focus groups. The screener questionnaire and discussion guides were developed by researchers at KFF in consultation with the firms who recruited and hosted the groups. Groups were audio and video recorded with participants’ permission. Each participant was given $150-$175 after participating.

1. The sample includes 1,318 adults who self-identified as Asian or, in a small number of cases, as Pacific Islander. ↩︎
2. Country of birth-level estimates among Asian immigrants are only available for China, India, and the Philippines due to sample size limitations. China includes Macau, Hong Kong, Taiwan, and Mongolia. ↩︎