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Health Coverage of Immigrants

Key Takeaways
This brief provides an overview of health coverage for noncitizens and discusses key issues for health coverage and care for immigrant families today. It shows:

  • In 2016, there were 23 million noncitizens residing in the United States, accounting for about 7% of the total U.S. population. Noncitizens include both lawfully present and undocumented immigrants. Many noncitizens live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens.
  • Noncitizens are significantly more likely than citizens to be uninsured. Among the nonelderly population, 17% of lawfully present immigrants and nearly four in ten (39%) undocumented immigrants are uninsured compared to less than one in ten (9%) U.S. born and naturalized citizens.
  • Immigrants may face increased challenges accessing coverage and care due to increased fears within the community, reductions in funding for outreach and enrollment assistance, and uncertainty around funding for community health centers.

Overview of Noncitizens

In 2016, there were 23 million noncitizens residing in the US, accounting for about 7% of the total population (Figure 1). About six in ten noncitizens were lawfully present immigrants, while the remaining four in ten were undocumented immigrants:1

Figure 1: Non-Citizen Immigrants as a Share of the Total U.S. Population, 2016

  • Lawfully present immigrants are noncitizens who are lawfully residing in the U.S. This group includes legal permanent residents (LPRs, i.e., “green card” holders), refugees, asylees, and other individuals who are authorized to live in the U.S. temporarily or permanently.
  • 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.

Over 12 million children live with a noncitizen parent, and over eight in ten (82%) of these children are U.S.-born citizens.2 Many immigrant families include individuals with mixed immigration status, and may include lawfully present immigrants, undocumented immigrants, and/or citizens.

Key Characteristics of Nonelderly Noncitizens3

The large majority of nonelderly lawfully present and undocumented immigrants are adults (Figure 2). In particular, young adults (age 19-34) make up a large share of undocumented immigrant adults. More than four in ten nonelderly lawfully present and undocumented immigrants are parents.

Figure 2: Age and Parental Status among the Nonelderly by Citizenship Status, 2016

Figure 2: Age and Parental Status among the Nonelderly by Citizenship Status, 2016

Most nonelderly noncitizens live in a family with at least one full-time worker, but they are more likely to be low-income compared to nonelderly citizens. Nonelderly lawfully present and undocumented immigrants are as likely as nonelderly citizens are to live in a family with at least one full-time worker, but they are more likely than citizens are to be low-income, since they often work in low-wage jobs (Figure 3). Lawfully present immigrants have the same requirements as citizens to pay taxes and contribute to federal, state, and local taxes.

Figure 3: Employment and Income among the Nonelderly Population by Citizenship Status, 2016

Health Coverage for Nonelderly Noncitizens

Nonelderly lawfully present and #undocumented #immigrants are more likely to be uninsured than nonelderly U.S. citizens.

Nonelderly lawfully present and undocumented immigrants are significantly more likely to be uninsured than nonelderly citizens. Lawfully present immigrant children and nonelderly adults are about twice as likely as citizens to be uninsured, and uninsured rates for nonelderly undocumented immigrants are even higher (Figure 4). Among the nonelderly, undocumented immigrant adults are nearly four times as likely as citizen adults to lack coverage (40% vs. 10%), and the uninsured rate for undocumented immigrant children is nearly five times the rate for citizen children (23% vs. 5%). These higher uninsured rates reflect their more limited access to employer-sponsored coverage due to employment in jobs and industries that often do not offer coverage as well as more limited access to Medicaid and the Children’s Health Insurance Program (CHIP).

Figure 4: Uninsured Rates Among Nonelderly Adults and Children by Immigration Status, 2016

Lawfully present immigrants may qualify for Medicaid and CHIP, including the Affordable Care Act (ACA) Medicaid expansion to low-income adults, but are subject to certain restrictions. In general, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP and many, including most LPRs or “green card” holders, must wait five years after obtaining qualified status before they may enroll. Some immigrants with qualified status, such as refugees and asylees, do not have to wait five years before enrolling. Some immigrants, such as those with temporary protected status, are lawfully present but do not have a qualified status and are not eligible (Appendix A). For children and pregnant women, states can opt to eliminate the five-year wait and extend coverage to lawfully present immigrants without a qualified status. Over half of states have taken up this option for children and nearly half have elected the option for pregnant women.4

Lawfully present immigrants can purchase coverage through the ACA Marketplaces and may receive subsidies for this coverage. These subsidies are available to people with incomes from 100% to 400% FPL who are not eligible for other coverage. In addition, lawfully present immigrants with incomes below 100% FPL may receive subsidies if they are ineligible for Medicaid based on immigration status. This group includes lawfully present immigrants who are not eligible for Medicaid or CHIP because they are in the five year waiting period or because they do not have a “qualified” status.

Undocumented immigrants are not eligible to enroll in Medicaid or CHIP or to purchase coverage through the ACA Marketplaces. However, Medicaid payments for emergency services may be made on behalf of individuals who are otherwise eligible for Medicaid but for their immigration status. These payments cover costs for emergency care for lawfully present immigrants who remain ineligible for Medicaid as well as undocumented immigrants. 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. In addition, some states have state-funded health programs that provide coverage to some groups of immigrants regardless of immigration status. There are also some locally-funded programs that provide coverage or assistance without regard to immigration status.

Most uninsured nonelderly lawfully present immigrants are eligible for coverage options under the ACA, while uninsured undocumented immigrants remain ineligible for coverage options. In 2016, 25% of uninsured nonelderly lawfully present immigrants were eligible for Medicaid, and 43% were eligible for tax credit subsidies (Figure 5). Many uninsured lawfully present immigrants are eligible but not enrolled in coverage because they face a range of enrollment barriers including fear, confusion about eligibility policies, difficulty navigating the enrollment process, and language and literacy challenges. Previous experience suggests that direct one-on-one outreach and assistance from trusted individuals is key for overcoming these barriers. Uninsured undocumented immigrants remain ineligible for coverage options due to their immigration status. In the absence of coverage, they remain reliant on safety net clinics and hospitals for care and often go without needed care.

Figure 5: Eligibility for ACA Coverage Among Nonelderly Uninsured by Immigration Status, 2016

Looking Ahead

Immigrants may face increased challenges accessing coverage and care due to increased fears, reductions in funding for outreach and enrollment assistance, and uncertainty around funding for community health centers. Since the Trump Administration has taken office, there has been increased focus on immigration enforcement and a changing climate toward immigrants that have increased fears among both lawfully present and undocumented immigrants.5 Recent focus groups with immigrant families show that these fears are leading to some decreased participation in Medicaid, CHIP, and other programs.6 In addition, fewer eligible immigrants may enroll in health coverage options due to recent cuts in federal funding for consumer outreach and enrollment assistance, particularly since direct one-on-one outreach and assistance is often key for overcoming the enrollment barriers faced by many immigrants. Lastly, there remains uncertainty around continued federal grant funding for community health centers, which are an important source of care for immigrants, particularly those who are uninsured.

Appendix A: Lawfully Present Immigrants by Qualified Status

Qualified Immigrant Categories Other Lawfully Present Immigrants
  • Lawful permanent resident (LPR or green card holder)
  • Refugee
  • Asylee
  • Cuban/Haitian entrant
  • Paroled into the US for at least one year
  • Conditional entrant granted before 1980
  • Granted withholding of deportation
  • Battered non-citizen, spouse, child, or parent
  • Victims of trafficking and his/her spouse, child, sibling or parent or individuals with pending application for a victim of trafficking visa
  • Member of a federally recognized Indian tribe or American Indian born in Canada
  • Granted Withholding of Deportation or Withholding of Removal, under the immigration laws or under the Convention against Torture (CAT)
  • Individual with Non-immigrant Status, includes worker visas, student visas, U-visa, and other visas, and citizens of Micronesia, the Marshall Islands, and Palau
  • Temporary Protected Status (TPS)
  • Deferred Enforced Departure (DED)
  • Deferred Action Status, except for Deferred Action for Childhood Arrivals (DACA) who are not eligible for health insurance options
  • Lawful Temporary Resident
  • Administrative order staying removal issued by the Department of Homeland Security
  • Resident of American Samoa
  • Applicants for certain statuses
  • People with certain statuses who have employment authorization
SOURCE: “Coverage for lawfully present immigrants,” HealthCare.gov, https://www.healthcare.gov/immigrants/lawfully-present-immigrants/, accessed July 2017.
Endnotes
  1. The estimate of the total number of non-citizens in the US is based on the March 2017 Current Population Survey (CPS), while the estimate of the legal/undocumented make-up of the non-citizen population is based on an extrapolation from estimates of the legal/undocumented non-citizen population from the Pew Research Center. Importantly, compared to other sources of data on the number of non-citizens in the US, the CPS captures fewer non-citizens. Specifically, the Pew Research Center estimates of the non-citizen population totaled to approximately 25 million U.S. residents in 2014, including approximately 11 million undocumented immigrants and 13 million legal immigrants, which is two million more non-citizens than the total captured by the CPS for that year. While our underlying imputation of legal immigration status relies on the distribution of the legal/undocumented immigrant population from Pew, our totals will not match due to the undercount of non-citizens in the CPS.

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  2. KFF analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement. For more detail about this imputation, see http://files.kff.org/attachment/Technical-Appendix-B-Immigration-Status-Imputation.

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  3. The remaining sections of this brief are limited to the nonelderly population since the ACA coverage expansions targeted the nonelderly.

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  4. Tricia Brooks, et al., Medicaid and CHIP Eligibility, Enrollment, Renewal and Cost-Sharing Policies as of January 2017: Findings from a 50-State Survey, (Washington, DC: Kaiser Family Foundation, January 2017), https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2017-findings-from-a-50-state-survey/.

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  5. Samantha Artiga and Petry Ubri, Living in an Immigrant Family in America: How Fear and Toxic Stress are Affecting Daily Life, Well-Being, & Health, (Washington, DC, Kaiser Family Foundation, December 2017), INSERT HTTP

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  6. Ibid.

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