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\title{Recent Immigrants and Public Charge: \\ access to coverage and new legal arrivals' employment, self-employment and health insurance after Medicaid Expansions and the Marketplace}

%\author{M\'onica Garc\'ia-P\'erez\affilnum{1}}

%\affiliation{\affilnum{1}St. Cloud State University, Economics}

%corrauth{M\'onica Garc\'ia-P\'erez
%20 4th Ave S. 
%St, Cloud, MN 55112}

%\email{migarciaperez@stcloudstate.edu}

\begin{abstract}
This paper uses data from the American Community Survey from 2009 to 2016 to identify the effect of Medicaid expansions and the creation of the ACA Insurance Market Exchange (Marketplace) on low-income recent immigrants' employment, self-employment, and health coverage. There is increasing interest in the connection between public coverage and employment outcomes among low-income documented immigrants after the current administration proposed to include the use of Medicaid as a potential reason for denying green card and citizenship applications based on the public charge criteria. The paper finds little evidence on reduction of employment among those who are eligible in non-generous states. We find evidence of an increase in the likelihood of being self-employed in generous states that expanded Medicaid before the implementation of the Marketplace. The findings suggests that low-income immigrants are likely to be employed regardless of their years in the country and that access to public coverage only affects the likelihood of having public versus private coverage.
\end{abstract}

\keywords{Immigration, Healthcare Coverage, Public assistance programs, Welfare reform,  Immigration policy, Immigration legislation, Immigrant populations}

\maketitle

\section{Introduction}
\label{intro}
The debate on health reform in the U.S. has centered on average citizen's health coverage and access to affordable care.  Yet, the Affordable Care Act (ACA) has also likely impacted qualified immigrants' health coverage. Two of the three main ACA provisions are key in this analysis: the ACA Medicaid Expansion that provided a universal extension of Medicaid eligibility to all those individuals below 138\% of the Federal Poverty Level (FPL) (or earlier expansions)\endnote{Five states and DC expanded Medicaid before 2014. The ACA created incentive for states to expand earlier. We consider the states' earlier expansions in our analysis. However, these states later fully expanded Medicaid as reflected in the ACA provision. In the robustness section we include an additional variable that accounts for this 2014 ACA expansion (Table \ref{tab:secondaryACA}.}, and the creation of the Marketplace Insurance where individuals can purchase coverage and obtain financial support through tax credits if they are not eligible for Medicaid. The expansion extended the public coverage option to a selected number of eligible immigrants, while the Marketplace became available to most legal immigrants. Parallel to this, the discussion on immigration in the U.S. has centered on undocumented immigration and immigration reform. Yet, low-income documented immigrants have also faced difficulties in the society. They tend to show lower health insurance rates and employment levels than natives \cite{vanhook03}. 

In October 2018, the Trump administration proposed to redefine the status known as 'public charge' \endnote{Inadmissibility on Public Charge Grounds a Proposed Rule by the Homeland Security Department (83 FR 51114)  on 10/10/2018.}, to include in the list of public services the use of Medicaid (state and federal) as a public charge for inadmissibility determinations for green card and naturalization applications. That is, legal immigrants using Medicaid could get their residency or citizenship applications deny because they are seen as a public charge to society. Earlier versions of this proposal included the subsidy that eligible individuals could receive from the government when participating in the Insurance Exchange Market (the Marketplace created after the Affordable Care Act). The proponents claim that these changes should ensure ''that aliens subject to the \textit{public charge inadmissibility ground} are self-sufficient'' \cite{fr18}. The claim insinuates that access and usage to public health coverage reduces the incentives to work and increases the long-term reliance on public benefits among immigrants. The proposal directly targets low-income, currently qualified immigrants. 

To understand the definition of 'public charge', the idea is to consider whether a person searching for a permanent resident status is likely to be dependable on government assistance. Because documented immigrants are more likely to apply for a green card, and then later for naturalization\endnote{Most of the immigrants from the top source countries increased the naturalization rate among those eligible from 2005 to 2015. India and other South Asian countries reached rates of 80\% or above. Yet, immigrants from Latin American countries have among the lowest naturalization rates (about 40\%). Still, rates are higher than 30\% for all groups.}, this proposal would affect their likelihood of a successful application. 

Amidst this environment, understanding the impact of the ACA provisions, Medicaid Expansion and the Marketplace, and earlier Medicaid expansions, on recent immigrants' health coverage and employment status provides some evidence behind the proponents' claims.  Further, it allows us to evaluate how effective the programs have been in providing health insurance to this population, and whether they have influenced the likelihood of working, or being self-employed, among the targeted immigrants: qualified recent arrivals living in low-income families. This paper centers its focus on low-income legal new immigration.

There exists the possibility of differential effects among qualified immigrants across public and private health policies due to two major reforms in 1996:  the Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA), and The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA). After these reforms, immigrants with less than 5 years in the country were not eligible for Federal benefits.\endnote{Some groups are exempt on this restriction, even if they later become legal permanent residents:Refugees, asylees, persons granted withholding of deportation/removal, Cuban/Haitian entrant, Amerasian, Iraqi or Afghan special immigrant status, trafficking survivor, among other immigration conditions raised from humanitarian concerns and actions.} While this law limited their access for federal resources to this group of immigrants, it also gave more flexibility to states to administer federal and state public assistance programs. Hence, some states decided to offer state-level public coverage to this eligible group subjet to the '5-year bar' \cite{fortuny11}. 

We call 'generous' states the areas that offer local Medicaid programs to adult qualified immigrants who are subject to the 5-year bar. Despite many states offering resources to children and pregnant women regardless of their immigration status, fewer states offer resources to adult qualified immigrants banned by the 5-year bar.  During our period of analysis, we identify eight states as 'generous' states: California (Medi-Cal), Colorado (Connect for Health), DC (DC Alliance), Hawaii (Medicaid), Massachusetts (ConnectorCare), Minnesota (MinnesotaCare), New York (NY Medicaid), and Pennsylvania (Medicaid).\endnote{(National Immigration Law Center, 2018). \cite{sommersetal13} shows details on the earlier expansions per state and DC, and the number of new enrollments due to these expansions. California and Connecticut have the larger numbers of new enrollments. } The rest of the states are called 'non-generous' states. We evaluate these groups separately and exploit the difference in timing across states on the implementation of earlier Medicaid expansions and the ACA Medicaid Expansions\endnote{The 2012 Supreme Court provision on the ACA Medicaid expansion made this part of the reform voluntary across states. This voluntary participation creates what is called the 'Medicaid coverage gap' (healthinsurance.org) where states implemented the program at different times or decided not to implemented at all. Table \ref{tab:list} shows each state's Medicaid implementation year. Further, by April 2010 six states (CA, CT, DC, MN, NJ, and WA) implemented earlier variations of the ACA Medicaid Expansion provision and expanded Medicaid to low-income adults through the new ACA option and/or Section 1115 waiver.}, and the Marketplace. In 'generous' states, regardless of years of residency, documented recent immigrants have access to public level coverage if eligible, and to the Marketplace and subsidy if applicable.There are different possible scenarios that we consider.  Although all states created the Insurance Exchange Market, some expanded Medicaid before or after it, and some did not expanded Medicaid at all among the non-generous group. This variation exist among both groups of states: 'generous' and 'non-generous'. We use this variations to evaluate the competing impact that these policies have on recent immigrants across the different types of states.  In general, the ACA provision referred as the Insurance Exchange Markets determines an expansion in access to affordable private coverage to all qualified recent immigrants through the Marketplace. Yet, the access to federal public coverage and its expansion is only available to qualified immigrants over the 5-year bar in all states. Meanwhile, all qualified immigrants regardless of the residency in the country have access to state-level coverage in 'generous' states. 

The relation between healthcare coverage and employment among the immigrant population was widely discussed after the 1996 Welfare Reform (see more in \cite{borjas02,vanhook03,borjas03}). Although PRWORA was about limiting access to the immigrant population, we expect similarities with regard to states and individuals' responses to changes in the access to health coverage. 

After PRWORA, the population most adversely affected (5-year banned qualified immigrants) increased labor participation and, despite the reduction on Medicaid due to the bill, the increase in employer sponsored insurance (ESI), due to higher employment, offset the negative impact, to the point of increasing the rate of coverage for this population \cite{borjas02,borjas03}. Some found, on average, an overall reduction in the insurance rate of immigrants. Nevertheless,  that reduction was also experienced by natives, and most of the reduction in coverage was driven by a sharp decrease in California \cite{borjas02}. Parallel to the individual response, some states started offering resources to immigrants subject to the 5-year bar. 

Given the increase in the access to affordable coverage, we infer there would be some 'crowd out' effect of public versus private coverage. As Medicaid eligibly expands to the groups that need this service, there is an incentive to either drop current private coverage\endnote{\cite{glied00} found that among young males, the cost of health insurance is the principal cause of the decline in their coverage rates.} or, if uninsured, decide to apply for public coverage.\endnote{Looking at the expansion of Medicaid eligibility to women and children, \cite{cutlergruber96}, found that 50\% of the increase in Medicaid was connected with reduction of employer sponsored insurance coverage, and the main reason behind this was employees taking Medicaid over private coverage.}  Furthermore, workers in low-paid jobs may have worse private plans and higher premiums, and they are more sensitive to changes in the cost of health coverage.  This combination makes them more likely to drop coverage as prices go up, or as cheaper competitive options arise \cite{okeke10}. For indirect changes of the expansion of Medicaid eligibility, \cite{yelowitz95} found that after a change in Medicaid eligibility targeted to children, due to an expansion on the eligibility cutoff, there was an increase in women's labor participation and a decrease in cash assistance participation.

\section{Data}\label{data}
 This paper uses data from the American Community Survey\endnote{For further information about public version of the ACS see \cite{RefL}.}, one percent, from 2009 to 2016, to identify the effect of the earlier Medicaid expansions and the ACA expansion, and creation of the Insurance Market Exchange (Marketplace) on low-income recent immigrants' employment, self-employment, and health coverage. This is the largest annual representative sample of the country that offers a variety of indicators regarding individuals demographics, economics, and geographic residency. Yet, the ACS does not offer information on individual's legal immigration status. First, the goal is to evaluate whether there is a response in the likelihood to work and/or become self-employed after Medicaid is expanded to more low-income individuals (public charge).  Second, the paper test whether the simultaneous presence of private and public coverage options creates a crowd out effect towards public coverage among eligibles (crowd out effect). 

\input{tabsummary}

Because undocumented immigrants are directly excluded from these programs, we focus our attention on the non-citizen population less likely to be undocumented. We use conventional methodologies to identify the potential undocumented population in order to exclude them from our sample. In this manner, we focus on those who are at least high school graduates, are working age population (between 20 and 40 years old) that are not affected by other health and public benefits, likely to be eligible for Medicaid ($<$ 200 FPL), no DACA-eligible\endnote{The identification of DACA-eligible individuals allows us to exclude individuals that are not only likely unauthorized but also face different eligibility and barriers to access to public health coverage compared to recent arrivals \cite{monica19}. While undocumented immigrants and DACA recipients are not subject to the individual mandate on holding a health insurance, lawfully present immigrants are subject to this mandate regardless of the years residing in the country. Furthermore, DACA-recipients and unauthorized immigrants are excluded from the Marketplace.}, and have arrived 3 to 7 years prior to the survey year. We take advantage of the exogenous discontinuity from PRWORA's eligibility criteria and separate this group between those who have less than 5 years and those who have more than 5 years in the United States. Using years in the U.S., and limiting the sample to those who are around the 5-year band threshold, we also overcome the issue of endogeneity that previous literature on Welfare Reform and immigrants' health coverage have discussed.  The issue arises from the potential endogeneity of immigrants deciding to become naturalized citizens in preparation for the change in eligibility determined by PRWORA \cite{borjas03,vanhook03}. Our final sample contains 15,502 and 34,960 observations for recent immigrants with more than 5 years and less than 5 years in the U.S. respectively.

Compared to the most recent immigrants, immigrants living for 5 or more years in in the U.S. in our sample (5-7 years), are more likely to work (61\%  versus 54\%), being self-employed (9.7\% versus  6.3\%) and be White or Hispanic ( 45.4\% versus 39.7\% and 56.6\% versus 39\% respectively). Yet, they are less likely to have private coverage, ESI, self-paid coverage, or enrolled in school. Both groups are on average, equally likely to reside in 'generous' states, in states that have not expanded Medicaid, and, simultaneously, equally likely to have Medicaid coverage (Table \ref{tab:summary}). We account for these observable heterogeneity across the samples in our empirical approach.

\input{tabbeforeafter}

\input{expectations}

Table \ref{tab:beforeafter} offers a view of the trends on our key variables before and after the policies.  Although, we show the two policies separately, in certain cases states applied both simultaneously, so the changes we see in one group can also contain the impact of the implementation of the other policy.  This complexity is better evaluated in our empirical approach.  Overall, recent immigrants are  more likely to work in 'non-generous' states (about 5 percentage points more likely) but in 'generous' states recent arrivals are slightly more likely to be self-employed, especially after the ACA implementation (10.8\% and 7.3\% in 'generous' states versus 8.3\% and 5.4\% in non-generous states). The other significant change is that the rate of Medicaid coverage in 'generous' states went up more than in 'non-generous' states, but we don't see a decrease on ESI nor on self-paid coverage after the implementation of the policies.


\section{Identifying the impact} \label{strategy}
The concerns behind immigrants using Medicaid focuses on the belief that this population could become a charge to society.  To evaluate this, we use a triple-difference method (DDD) to determine the effect of earlier Medicaid expansions and ACA Expansions, and the creation of the Marketplace on recent arrivals on employment, self-employment, and healthcare coverage.\endnote{Most of the recent literature on ACA expansion impact uses this methodology to exploit differences in policy implementations across geographic areas and types of policies\cite{freanetal17}. There are discussions on whether to include the earlier Medicaid expansions as part of the ACA-impact analysis in this literature. \cite{sommersetal16} shows the relevance of these earlier expansions in terms of expanding coverage, especially in areas with higher proportion of eligibles.} The inclusion of earlier Medicaid expansions are relevant in our analysis because our goal is to identify the change in our outcome variables due to accessibility. The earlier expansions were very generous in terms of expanding the income eligibility criteria among adults. Further, we differentiate between those residing more than 5 years versus those residing less than 5 years in the country, before and after the change of the policies (Medicaid expansion and the Marketplace creation) by type of state (generous versus non-generous) to estimate the effect of these changes. Further, we use the interaction of the the two policies to account for how they provide access to different types of coverage and target differently the pool of our targeted immigrants. In generous states, documented immigrants are all treated equally in terms of access to public coverage. Hence, after a Medicaid expansion we would not expect significant differences between the groups in terms of public coverage as both would be likely to increase public coverage. Furthermore, the issue is becomes more complex as in some cases after, or parallel to, the expansion of Medicaid some states also offered access to the Marketplace. Therefore, in these generous states we are able to look at the crowd out effect of public versus private among all groups. 

On the other hand, for non-generous states, we have a clear distinction between those who have access and those who do not.  The ACA expansion would be expected to only affect those who are eligible for federal public coverage (those with more than 5 years in the country).  In this case, we would expect an increase in public coverage among individuals who have lived more than 5 years in the U.S. and their responses in terms of employment and self-employment would show whether this new access to Medicaid affects those outcomes too.  

Table \ref{tab:expectations} show a summary of the expected effects of the relevant variables in the study. The indicator variables of general status such as individuals with more than 5 years in the county, Medicaid expansion at each state, and the creation of the Marketplace are presented in the first upper block. Based on the general immigration literature, as immigrants reside longer in the country they are more likely to be employed/self-employed, however, there are not  clear assumptions regarding public and private health coverage. Assimilation theory would make us assume that, overall, immigrants with more years residing in the country are more likely to have health coverage \cite{borjas02}.  With respect to Medicaid Expansion, the assumption is that access to it may discourage work (employment and self-employment), and generate a crowd out effect between public and private coverage, by substituting private/self coverage with public coverage. For the general population, the assumptions on the creation of the Marketplace consider a positive effect on employment, self-employment, private, and self-paid coverage.

The lower block of Table \ref{tab:expectations} shows the effects we expect from the policy changes by state type on eligible immigrants with more than 5 years in the country relative to those with less than 5 years in the country. Given the preliminary assumption that 'generous' states offer public coverage to all eligible immigrants regardless of their time of residency, there is not expectation of differential effects between immigrants based on their years of residency. Contrarily, in 'non-generous' states we would expect differences between immigrants based on their years of residence because of the 5-year bar. We would expect that a Medicaid expansion would positively affect Medicaid coverage, but it would negatively affect working, self-employment, private coverage, ESI coverage, and Selfpaid coverage. Meanwhile, the creation of the Marketplace offers a coverage opportunity to those who are subject to the 5-year bar in 'non-generous' states, this could positively affect their likelihood of working or being self-employed relative to those with more than 5 years. 


The baseline model looks like:
\begin{align} \label{eq:1}
Y_{ist} =&\beta_0 + \beta_1 M5Y_{ist} + \beta_2 ACAe_{st} + \beta_3 MKT_{t} +  \\
 &  \beta_4 M5Y_{ist} x ACAe_{st}  + \beta_5 M5Y_{ist} x MKT_{t} + \nonumber \\
 &  \beta_6 ACAe_{st} x MKT_{t} +  \nonumber \\
 &  \beta_7 M5Y_{ist} x ACAe_{st} x MKT_{t}+  \nonumber \\
 &  X_{ist} \eta + Z_{st} \alpha + \mu_s + \sigma_t + \epsilon_{ist} \nonumber
\end{align}
Due to our large samples, we are confident about estimating equation \ref{eq:1} assuming a linear probability model. The estimated coefficients are directly interpreted as marginal changes in the probability of the event. In equation \ref{eq:1}, $i$ represents an individual, $s$ geographic area, and $t$ year. The equation shows the general representation of the models we analyze.  $Y_{ist}$ represents binary variables that indicate: employment, self-employment, having Medicaid coverage, Private coverage, ESI coverage, and Own-paid coverage.  $M5Y$ represents a binary variable that is one if the individual has more than 5 years in the US and zero otherwise. The reference group is then immigrants with less than 5 years in the U.S.  $ACAe$ represents a binary variable that indicates whether the state implemented the ACA Medicaid expansion.  Meanwhile, $MKT$ is the binary variable representing the time when the Marketplace was created. $X_{ist}$ represents a vector with individual level information such as age, age at arrival, education attainment, sex, marital status, geographic residence, race, ethnicity.  $Z_{st}$ is the series of time varying state level and state-level time trends, unemployment rate, and in-state tuition for unauthorized immigrants. $\mu_s$ is a state/geographic fixed effects vector that controls for the unobserved heterogeneity across areas\endnote{PUMA fixed effects to account for the fractional implementation at local levels of early Medicaid Expansions \cite{sommersetal16}}. And $\sigma_t$ a vector of time fixed effects.  The standard errors $\epsilon_{ist}$ are clustered at the state-year level.  Our key estimated values are $\beta_1$ to $\beta_7$.  

The interaction between immigrant type and individual policies provides us information on whether particular policies affected these groups differently. There is a prior belief that recent arrivals with less than 5 years in the country in 'non-generous' states are unaffected by the expansion of Medicaid because of being directly excluded from the federal and state Medicaid programs.  Conversely, in generous states all recent qualified immigrants will be likely to be impacted by the universal Medicaid expansion. As the Marketplace was implemented equally across all states, and both types of recent immigrants are eligible to participate, we would expect they both are likely to be impacted by the increase of access to coverage.  Nevertheless, we need to keep in mind that there is still expectations that the variability across types of recent arrivals could be different. Most recent immigrants could fear participation in programs they qualify for, even if they are not considered in the list of 'public charge', just because of the anti-immigration environment. Further, the information about access to public resources targeted to immigrants could differ across states. 

\subsection{Policies impact in generous and non-generous states}
To evaluate the impact of the policies, we show the key regressors' estimated values in Table \ref{tab:mainmodel}.  The first columns of the table show the effect of the policies in generous states and the second set of columns the estimated effects in 'non-generous' states. Total number of observations and adjusted R-square are shown. Overall, the group of 'generous' states shows several significant effects compared to 'non-generous' states. For simplicity, we separate our recount of the analysis by type of state.

In generous states,  the impact of Medicaid Expansion alone decreased the likelihood of private and ESI coverage (about 3 to 5 percentage points respectively), but increased the likelihood of self-employment and self-paid insurance (about 2 percentage points in both cases) among all recent arrivals. There is a trade-off between public and private that is shown through the estimated interaction between Marketplace and Medicaid Expansion and it seems to be a large effect. But this happens mostly among recent arrivals with more than 5 years in the country. There are 3 percentage points more likely to have Medicaid coverage after the Expansion. Yet, for this population, the implementation of the Expansion and the Marketplace increased their likelihood of private, ESI, and self-paid coverage, and the effect on Medicaid in this situation, although negative, is not statistically significant. We did not have prior assumptions regarding the differential impact of the policies across type of immigrants. The interaction of Medicaid Expansion and Marketplace could also be capturing some specific elements of the years after the Marketplace was created between Montana and the other 'generous' states. Overall, we don't see a significant direct impact of the Medicaid expansion on employment. There is an increase on self-employment in these states.

In non-generous states, as we were expecting, the expansion of Medicaid together with the creation of the Marketplace increased the use of Medicaid among the recent arrivals not subject to the 5 year bar (by 5 percentage points).\endnote{Some effect of what it is called the Individual Mandate, might be now play a role in the increase in coverage we see across all types of insurance after the creation of the Marketplace.}  In general, the Marketplace increased the likelihood of private, ESI, and self-paid coverage; however, the recent arrivals not subject to the 5 year bar were not affected differently.  What these results also show is that individuals' employment levels were not affected by the offering of public health coverage.  If any effect is present, is the incorporation of Marketplace without the presence of Medicaid Expansion (reduction of 6.5 percentage points).  As the Marketplace was created, some firms may have seen the need to move their health coverage plans to the Marketplace. For individuals in low-income families, this could imply a reduction of their net salary as that transition could have implied higher insurance costs for the employees. Individuals with more than 5 years are able to balance out part of this effect as in their cases this transition may have resulted in a lower reduction of the likelihood to work (about 3 percentage points).  


\section{Robustness checks}
We implement a series of robustness checks on our analysis. All results are available in the online appendix of this publication.  First, we check for parallel pre-existing trends among the types of recent immigrants and between the different types of states. We find no evidence of pre-trends that could be affecting our results. Nevertheless, there exist concerns that states with larger pre-existing uninsurance rates have the incentive to expand public coverage, especially after the expansion is 100\% back up with Federal resources. In our case, this is relevant as long as there is a high correlation between uninsurance rates among the average population and among recent immigrants. Although there is not prior belief regarding this relationship, previous research done by \cite{courtemanche16} accounts for states' overall pre-treatment uninsured rate to control for this source of endogeneity. Accounting for this pre-treatment uninsurance rate results in a twice as large impact of the ACA Medicaid expansion on health coverage among the adult non-disable population. It also shows that the gap of public coverage between whites and non-whites is reduced. Different to this previous research, we control for state fixed effects and state-time trends, and we use a larger pre-treatment period. Further, given that our identification strategy relies on an ad hoc and pre-treatment 5-year cutoff that limits the access to public coverage to the population subject to that requirement, our work is less likely to suffer of this type of endogeneity. Nevertheless, there are other concerns with this population such as recent immigrants moving from non-generous states to generous states, or from non-expansion to expansion states \cite{borjas03}. We controlled in our models for individual migration to account for this.

Furthermore, we limit our sample to only individuals who are under the Medicaid threshold ($<$138 FPL) and our findings are the same. To further evaluate the impact of these policies changes and the possible individual enrollment endogeneity, our study compares those who are above and below the Medicaid income eligibility threshold. Table \ref{tab:eligvsnonelig} shows the results of the modified main model that includes a dummy variable called Medicaid Eligible that is one if the individuals family income is below the threshold. As expected, those who are eligible are more likely to enroll in Medicaid and less likely to enroll in other types of coverage. Also, More-than-5-years eligible individuals are less likely to work compared to similar non-eligible individuals but this effect is only present in generous states. It is noticeable that in non-generous states most of the significant effects are connected to Medicaid expansion and the Marketplace among the entire group of likely documented immigrants. 

We also separately focus on non-Hispanics and Hispanics to check for whether a narrower division improves our likelihood of capturing qualifying immigrants. The belief is that there is a higher chance of capturing undocumented immigrants in the sample containing Hispanics versus the one of only non-Hispanic. There is a variability in the effects across these samples, with non-Hispanic having significant impact to the creation of Marketplace in all types of states, while Hispanics having significant impacts on the expansion of Medicaid.  It is worth highlighting, that for Non-Hispanic, Marketplace positively affects the likelihood of working regardless of the presence of Medicaid expansion. Because there is still some chance that individuals with 5 or more year are applying for citizenship, and hence, changing the shape of our samples.  We also test the sensitivity of our results using a different bandwidth of years of arrival. Using 4 to 6 years, we obtain the same results.\endnote{Results in the appendix (Table \ref{tab:4to6}). The average time for a naturalization process the minimum possible time of adjustment is between one and one and a half year from the time of application.  For green card, the process can be sometimes faster, but green card holders are included in our sample as we are not able to differentiate non-citizens immigration status.} We also experiment with using only the sample of those above and below the 5 year threshold. Table \ref{tab:4to5} shows the results. There are not distinctive changes in the final outcomes of little evidence of Medicaid Expansion reducing the likelihood of working and evidence of a crowd-out effect of public versus private health coverage.

In our analysis, we identify the main Medicaid expansions across states and did not capture the secondary expansions that the states with earlier expansions implemented in 2014. Table \ref{tab:secondaryACA} shows the results when we include a dummy variable that accounts for the secondary expansion for these states. Our main analysis from Table \ref{tab:mainmodel} does not change. \cite{freanetal17} show that earlier expansions explain parts at least 10\% of the impact of the ACA expansions on health coverage. One possibility for not finding a large effect could be due to the relevance of California large earlier expansion. California also have a larger immigrant population among the group of generous states. It is very important to further evaluate the differences in the Medicaid expansions across the immigrant population as to include the elements that also varies about these earlier expansions and the secondary expansions that are parallels to the creation of the Marketplace.

\section{Is Medicaid usage a reason for public charge? We find no evidence}\label{conclusion}
This paper intends to further the discussion on the proposal to expand the immigrants' usage of Medicaid as a reason for public charge by looking at the impact of two main ACA provisions that affected qualified immigrants' health coverage in the United States. 

We focus our attention on recent arrivals that are likely to be documented to tackle the question on the effectiveness of these policies (Medicaid Expansion and Marketplace) on expanding health coverage among the targeted population and the likelihood of impacting individuals' employment status. The combination of these two effects is key for addressing the claim regarding the ability immigrants have to be 'self-sufficient' and not be considered a 'public charge'. Our work is very time sensitive as we face the possibilities of seeing the usage of Medicaid as a public benefit that would count for inadmissibility due to 'public charge' concerns on immigration applications.

After 5 years, immigrants increase the likelihood of employment. There are differential effects across states because of the differential treatment of immigrants above and below the threshold of 5 years. But this does not result in lower incentive to work in 'non-generous' states after 5 years of residence among the recent immigrants who are income-eligible for Medicaid. Because of previous access to state-funded public benefits, the impact of passing the 5 year bar is attenuated in 'generous' states. 

The creation of the Marketplace impacts recent arrivals in different ways.  In 'non-generous' states, private affordable care increases the ratio of insured recent arrivals by having the option of subsidized insurance coverage, especially for those who are not eligible for Medicaid. However, when both policies are implemented (Medicaid expansion and Marketplace), recent arrivals in low-income families choose Medicaid over private coverage. But our estimate on the difference between groups is attenuated in 'generous' states because the option was open for both those with less than 5 years of residency and those with more than 5 years of residency.

Thus, restrictive federal policies and national-level proposals targeting immigrants in low-income families can undermine the effectiveness of policies that are working on smoothing the assimilation of recent immigrants.  The usage of public services in our analysis was not complemented with a reduction in the likelihood of being employed. On the contrary, in 'generous' states we found an increase in the likelihood of self-employment during the implementation of Medicaid expansions. 

\section{Is public coverage crowding out private coverage? Yes, we find evidence.}
There is evidence of a possible crowd-out between Medicaid and private coverage when the Medicaid expansion and the ACA Marketplace are implemented at the same time. As recent immigrants are eligible for Medicaid, and the eligibility criteria is expanded, individuals are less likely to have private, ESI, or self-paid healthcare coverages and more likely to have Medicaid. This finding is consistent with the general literature on public versus private coverage and the expansion in the access to public coverage among the general population in the United States \cite{cutlergruber96}. 

The crowding out effect is present in the effect of Medicaid Expansion on all recent immigrants', and those with more than 5 years', type of healthcare coverage in 'generous' states and in the effect of Medicaid Expansions on recent immigrants with more than 5 years in the country in 'non-generous' states. The increase of private healthcare coverage among recent immigrants in all states connects to the creation of the Marketplace. As noted by \cite{cutlergruber96}, public coverage tends to be more generous to private insurance for low-income individuals which may result in better future health outcomes or more resources for health institutions to cover for the uninsured. Also, providing insurance to a larger group of individuals may reduce the risk pool for coverage. Because the ACA included incentive mechanisms to promote preventive care, some of the public resources are targeted to affect individuals' behavior to improve health outcomes and to address costly chronic conditions.

This work main contribution is introducing the discussion of the impact of Medicaid Expansions and the ACA Marketplace on eligible immigrants labor market outcomes and health coverage. This timely discussion parallels the current interest to further limiting the access to public coverage among eligible immigrants by making adding the use of Medicaid as a reason to deny citizenship applications on the base of public charge. The evidence is not there on this belief. Even the increase on the usage of public coverage against private coverage may result in a more efficient distribution of resources if public coverage results in better and more comprehensive care.  

\begin{landscape}
\input{tabmainmodel} 
\end{landscape}

\begin{acks}
Thank you to the participants at the WEIA and the ASSA meetings annual conferences, discussants, and colleagues.  All errors are my own. 
\end{acks}
\begin{funding}
The author received no financial support for the research, authorship, and/or publication of this article.
\end{funding}
%%%%%%%%%%%%%%%%%%% FOOTNOTES
\theendnotes
%%%%%%%%%%%%%%%%%%% REFERENCES
%Harvard (name/date)
\bibliographystyle{SageH}
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\end{thebibliography}


%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%  Supplementary Material %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

\begin{sm}
% The appendix command is issued once, prior to all appendices, if any.
\setcounter{table}{0}
\setcounter{figure}{0}
\renewcommand{\thetable}{A\arabic{table}}
\renewcommand*{\thepage}{A\arabic{page}}
\renewcommand{\thefigure}{A\arabic{figure}}
%
%\section{Appendix}
%%%%%%%%%%
\begin{figure}[htbp]
\centering
   \subfloat[Employment\label{subfiga}]{%
       \includegraphics[width=0.35\textwidth]{working.png}
     }
     \hfill
		   \subfloat[Medicaid\label{subfigb}]{%
       \includegraphics[width=0.35\textwidth]{medicaid.png}
     }
     \hfill
		   \subfloat[ESI\label{subfigc}]{%
       \includegraphics[width=0.35\textwidth]{esi.png}
     }
     \hfill
		   \subfloat[Self-paid\label{subfigd}]{%
       \includegraphics[width=0.35\textwidth]{ownpaid.png}
     }
     \hfill
	
  \caption{Pre-Trends: Recent Arrivals} \label{fig:pre_trends}
	\scriptsize  Note: The graph shows the trend of the mean difference of recent arrived immigrants on the likelihood of having only ESI healthcare coverage by years in the United States since survey year and the presence of state-only public assistance. State-only public assistance corresponds to those states that use state-only resources to offer health coverage to lawfully residing immigrants subject to the 5-year ban. Samples is from 2009 to 2016 and includes all non-citizens graduated from high school ages 20 to 40 who arrived 3 to 7 years before survey year.  After 5 years in the country, legal present/resident individuals qualify for public (federal and state funded) health assistance.
\end{figure}


%
\input{tablist},
%


%
\begin{landscape}
\small{
\input{tabnonhispanic}
Note: Original data is from the 2009-2016 years of 1\% ACS. All dependent variables are binary variables equal to 1 if the characteristics is met. Robust standard errors in parenthesis and clustered at state-year level. Each column reports the corresponding estimates for each depending variable. The definition of 'generous' state corresponds to states with state-funded Medicaid coverage offered only to qualified immigrants subject to the 5-year bar. Each block of types of states uses a different sample identified in the table but are all restricted to individuals likely to be documented immigrants with at least a high school degree, recent arrivals between 3 and 7 years of having arrived to the United States, and ages 20 to 40 years old.  All models are control for other additional independent variables: demographic characteristics (age, race, ethnicity, sex, and marital status), geographic location (live in metro area), whether the individual recently moved to the current state, education level (some college and college or more), cohort (age at entry US), PUMA fixed effects, state fixed effects, year fixed effects, state-specific time trends, unemployment rate, and in-state tuition. * Significance at the 10\% level. ** Significance at the 5\% level. *** Significance at the 1\% level.}
\end{landscape}
%
\begin{landscape}
\small{
\input{tabhispanic}
Note: Original data is from the 2009-2016 years of 1\% ACS. All dependent variables are binary variables equal to 1 if the characteristics is met. Robust standard errors in parenthesis and clustered at state-year level. Each column reports the corresponding estimates for each depending variable. The definition of 'generous' state corresponds to states with state-funded Medicaid coverage offered only to qualified immigrants subject to the 5-year bar. Each block of types of states uses a different sample identified in the table but are all restricted to individuals likely to be documented immigrants with at least a high school degree, recent arrivals between 3 and 7 years of having arrived to the United States, and ages 20 to 40 years old.  All models are control for other additional independent variables: demographic characteristics (age, race, ethnicity, sex, and marital status), geographic location (live in metro area), whether the individual recently moved to the current state, education level (some college and college or more), cohort (age at entry US), PUMA fixed effects, state fixed effects, year fixed effects, state-specific time trends, unemployment rate, and in-state tuition. * Significance at the 10\% level. ** Significance at the 5\% level. *** Significance at the 1\% level.}
\end{landscape}
%
\begin{landscape}
\small{
\input{tab138fpl}
Note: Original data is from the 2009-2016 years of 1\% ACS. All dependent variables are binary variables equal to 1 if the characteristics is met. Robust standard errors in parenthesis and clustered at state-year level. Each column reports the corresponding estimates for each depending variable. The definition of 'generous' state corresponds to states with state-funded Medicaid coverage offered only to qualified immigrants subject to the 5-year bar. Each block of types of states uses a different sample identified in the table but are all restricted to individuals likely to be documented immigrants with at least a high school degree, recent arrivals between 3 and 7 years of having arrived to the United States, and ages 20 to 40 years old.  All models are control for other additional independent variables: demographic characteristics (age, race, ethnicity, sex, and marital status), geographic location (live in metro area), whether the individual recently moved to the current state, education level (some college and college or more), cohort (age at entry US), PUMA fixed effects, state fixed effects, year fixed effects, state-specific time trends, unemployment rate, and in-state tuition. * Significance at the 10\% level. ** Significance at the 5\% level. *** Significance at the 1\% level.}
\end{landscape}

%
\begin{landscape}
\small{
\input{tabeligvsnonelig}
Note: Original data is from the 2009-2016 years of 1\% ACS. All dependent variables are binary variables equal to 1 if the characteristics is met. Robust standard errors in parenthesis and clustered at state-year level. Each column reports the corresponding estimates for each depending variable. The definition of 'generous' state corresponds to states with state-funded Medicaid coverage offered only to qualified immigrants subject to the 5-year bar. The definition of Medicaid eligible uses 138\% FPL as the cutoff. Each block of types of states uses a different sample identified in the table but are all restricted to individuals likely to be documented immigrants with at least a high school degree, recent arrivals between 3 and 7 years of having arrived to the United States, and ages 20 to 40 years old.  All models are control for other additional independent variables: demographic characteristics (age, race, ethnicity, sex, and marital status), geographic location (live in metro area), whether the individual recently moved to the current state, education level (some college and college or more), cohort (age at entry US), PUMA fixed effects, state fixed effects, year fixed effects, state-specific time trends, unemployment rate, and in-state tuition. * Significance at the 10\% level. ** Significance at the 5\% level. *** Significance at the 1\% level.}
\end{landscape}

%
\begin{landscape}
\input{tab4to6}
\end{landscape}

\begin{landscape}
\input{tab4to5}
\end{landscape}

\begin{landscape}
\input{tabsecondaryACA}
\end{landscape}

\end{sm}

\end{document}
