Health Coverage and Care of Undocumented Immigrants

Introduction

Recently, many of the Democratic presidential candidates indicated support for expanding health coverage to undocumented immigrants. To help inform the implications of such an expansion, this brief provides an overview of current health coverage and care for undocumented immigrants.

Undocumented immigrants are at high risk of being uninsured because they have limited access to coverage options. They face barriers to accessing care due to their high uninsured rates.

Overview of Undocumented Immigrants

Undocumented immigrants are foreign-born individuals residing in the U.S. without authorization. This group includes individuals who entered the country without authorization and individuals who entered the country lawfully and stayed after their visa or status expired. The primary reasons individuals immigrate to the U.S. are for better job opportunities, to reunite with family, and for increased safety.¹ Undocumented immigrants account for roughly four in ten noncitizens, while the remaining six in ten are lawfully present immigrants. Many immigrant families include people with mixed immigration status, and the majority of children with a noncitizen parent are U.S.-born citizens.

It is estimated that there were 10.5 million undocumented immigrants residing in the U.S. as of 2017, accounting for about 3% of the total U.S. population.² Estimates from the Pew Hispanic Center show that the number of undocumented immigrants in the U.S. has been declining since 2007 (Figure 1).³ This decline largely reflects a large decrease in the number of new undocumented immigrants. As a result, an increasing share of undocumented immigrants are people who have been living in the U.S. for many years. As of 2017, about two-thirds (66%) of undocumented immigrant adults in the U.S. had been in the U.S. for more than 10 years, up from 41% in 2007.⁴

Figure 1: Estimates of Number of Undocumented Immigrants Living in the U.S., in Millions, 2006-2017

Health Coverage for Undocumented Immigrants

Undocumented immigrants are at high risk of being uninsured. Among the total nonelderly population, 45% of undocumented immigrants were uninsured compared to about one in four (23%) lawfully present immigrants and less than one in ten citizens (8%) as of 2017 (Figure 2). Although noncitizens are more likely to be uninsured than citizens, citizens still account for the majority of the nonelderly uninsured, since noncitizens account for a small share of the overall population.

Figure 2: Uninsured Rates among the Nonelderly Population by Immigration Status, 2017

The higher uninsured rate among undocumented immigrants reflects limited access to health coverage options.

• Undocumented immigrants are not eligible to enroll in Medicare, Medicaid, or CHIP or to purchase coverage through the ACA Marketplaces. Under rules issued by the Centers for Medicare and Medicaid Services, individuals with Deferred Action for Childhood Arrivals (DACA) status are not considered lawfully present and remain ineligible for these coverage options.⁵ Since 2002, states have had the option to provide prenatal care to women regardless of immigration status by extending CHIP coverage to the unborn child. As of January 2019, 16 states had adopted this option.⁶
• Although most nonelderly undocumented immigrants live in a family with a full-time worker (Figure 3), they have limited access to employer-sponsored coverage. They are often employed in low-wage jobs and industries that are less likely to offer employer-sponsored coverage. Further, undocumented immigrants are more likely than other groups to be low-income, making it challenging to afford employer-sponsored coverage when it is available.

Figure 3: Employment and Income among the Nonelderly Population by Citizenship Status, 2017

Current coverage among undocumented immigrants reflects a limited array of private coverage and some state- or locally-funded programs. Some undocumented immigrants may get coverage through their employer or as a spouse or dependent of an employee. Undocumented immigrants can also purchase private coverage on the individual market outside of the ACA Marketplaces, although many may not be able to afford this coverage due to their limited incomes and lack of subsidies to offset the costs of this coverage. Some undocumented immigrants may also be covered through student health programs. Six states (CA, IL, MA, NY, OR, and WA) and DC use state-only funds to cover income-eligible children regardless of immigration status.⁷ In June 2019, California approved an expansion in coverage for income-eligible young undocumented immigrant adults through age 25.

Health Care for Undocumented Immigrants

Given their higher uninsured rates, many undocumented immigrants delay or go without needed care. Research shows that having insurance makes a difference in whether and when people access needed care.⁸ Those who are uninsured often delay or go without needed care, which can lead to worse health outcomes over the long-term that may ultimately be more complex and expensive to treat.⁹

Undocumented immigrants can obtain low-cost care through community health centers. However, care available through clinics is often limited to preventive and primary care, leaving them to face challenges in accessing specialty services.

Under federal law, hospitals are required to screen and stabilize every patient who seeks emergency care. Medicaid helps offset costs borne by hospitals in providing emergency care to undocumented immigrants by providing payments to hospitals for emergency care provided to individuals who are otherwise eligible for Medicaid but for their immigration status.

Immigrants spend less on health care, compared to their U.S. born counterparts.¹⁰ They also make larger out-of-pocket health care payments compared to nonimmigrants.¹¹ Immigrants have lower spending, in part, because they use less care due to their low coverage rates and limited access to care. They also tend to be younger and healthier than nonimmigrants, although this difference decreases over time as immigrants spend longer in the United States.¹²

Current Issues

Research shows that shifting immigration policies under the Trump administration are leading to substantially increased fears among the immigrant community, affecting undocumented immigrants as well as lawfully present immigrants and citizen children of immigrants.¹³ Growing reports suggest that these fears are causing families to turn away from utilizing programs and services for themselves as well as their children, who are primarily U.S. born citizens and may qualify for Medicaid and CHIP.¹⁴ The administration is pursuing additional changes to public charge policies that may lead to even larger decreases in participation in Medicaid among lawfully present immigrants and citizen children of lawfully present and undocumented immigrants.¹⁵ Declines in coverage for families would increase barriers to care and financial instability, negatively affecting the growth and healthy development of their children.

Although the Democratic presidential candidates have indicated support for expanding coverage to undocumented immigrants, to date, there are no detailed proposals. The impact and costs of such an expansion would depend on how individuals are covered (e.g., through private coverage, Medicare, or Medicaid), what benefits are provided, and premium and cost-sharing levels. Some of the cost would be offset by existing resources currently going toward care for undocumented immigrants. An expansion would also likely shift the balance of how costs of care for undocumented immigrants are borne across the federal government, state and local government, private entities, and individuals. California’s recently approved expansion would cover young adults through the state’s Medicaid program using state-only dollars. The state has budgeted $98 million dollars for the expansion in the first year, which is estimated to cover 90,000 people.¹⁶ Even if coverage is expanded, fears among immigrant families could limit participation.