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 2017, there were 22 million noncitizens residing in the United States, accounting for about 7% of the total U.S. population. Noncitizens include lawfully present and undocumented immigrants. Many individuals lives in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens. One in four children has an immigrant parent and the majority of these children are citizens.
  • Noncitizens are significantly more likely than citizens to be uninsured. Among the nonelderly population, 23% of lawfully present immigrants and more than four in ten (45%) undocumented immigrants are uninsured compared to less than one in ten (8%) citizens. Moreover, among citizen children, those with at least one non-citizen parent are nearly twice as likely to be uninsured as those with citizen parents (7% vs. 4%).
  • Recent changes in immigration policy are leading to increased fears that may lead to declines in coverage among immigrant families and their citizen children. In particular, proposed changes to public charge policy that would newly consider use of certain non-cash programs, including Medicaid, when determining whether to deny an individual a green card or entry into the U.S., would likely lead to broad decreases in participation in Medicaid among immigrant families and their primarily U.S.-born children. Declines in coverage for families would increase barriers to care and financial instability, negatively affecting the growth and healthy development of their children.

Overview of Noncitizens

In 2017, there were 22 million noncitizens residing in the U.S., 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 Many individuals live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens.

  • 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.

Nearly 19 million or 25% of children had an immigrant parent as of 2017, and the large majority of these children were citizens. About 10 million or 13% were citizen children with a noncitizen parent.

Figure 1: Immigrants and Children of Immigrants as a Share of the Total U.S. Population, 2017

Health Coverage for Nonelderly Noncitizens

While most of the uninsured are citizens, noncitizens are at significantly higher risk of being uninsured. In 2017, three-quarters of the 27.4 million nonelderly uninsured were citizens. However, noncitizens, including lawfully present and undocumented immigrants, were significantly more likely to be uninsured than citizens. Among the total nonelderly population, 23% of lawfully present immigrants and more than four in ten (45%) undocumented immigrants were uninsured compared to less than one in ten (8%) citizens. Among nonelderly adults, lawfully present immigrants were more than twice as likely as citizens to be uninsured, and the uninsured rate for adult undocumented immigrants was nearly five times the rate for citizens (Figure 2). Immigrant children also are more likely to be uninsured than their citizen counterparts. Moreover, among citizen children, those with at least one non-citizen parent are significantly more likely to be uninsured as those with citizen parents (Figure 3).

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

Figure 3: Uninsured Rates among Children by Immigration Status and Parent Immigration Status, 2017

The higher uninsured rates among noncitizens reflect limited access to employer-sponsored coverage; eligibility restrictions for Medicaid, CHIP, and ACA Marketplace coverage; and barriers to enrollment among eligible individuals.

Limited access to private coverage

Although most nonelderly noncitizens live in a family with a full-time worker, they face gaps in access to private coverage. Nonelderly noncitizens are more likely than nonelderly citizens to live in a family with at least one full-time worker, but they also are more likely to be low-income (Figure 4). They have lower incomes because they are often employed in low-wage jobs and industries that are less likely to offer employer-sponsored coverage. Further, given their lower incomes, noncitizens face increased challenges affording employer-sponsored coverage when it is available or through the individual market.

Figure 4: Employment and Income among the Nonelderly Population by Citizenship Status, 2017

eligibility restrictions for medicaid, chip, and aca coverage

Lawfully present immigrants may qualify for Medicaid and CHIP, but are subject to certain eligibility 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 to enroll in Medicaid or CHIP regardless of their length of time in the country (Appendix A). For children and pregnant women, states can 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.2

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. 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. 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 coverage options.3

enrollment barriers among eligible individuals

Many uninsured lawfully present immigrants are eligible for coverage options under the ACA but remain uninsured, while uninsured undocumented immigrants are ineligible for coverage options. In 2017, nearly three-quarters of uninsured lawfully present immigrants were eligible for ACA coverage, including 29% who were eligible for Medicaid and 43% who were eligible for tax credit subsidies (Figure 5). Many lawfully present immigrants who are eligible for coverage remain uninsured because immigrant families face a range of enrollment barriers, including fear, confusion about eligibility policies, difficulty navigating the enrollment process, and language and literacy challenges. Uninsured undocumented immigrants are 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, 2017

Looking Ahead

Research shows that shifting immigration policies under the Trump administration that are focused on enhancing immigration enforcement and restricting immigration are leading to substantially increased fears among the immigrant community that are causing a growing number of families to turn away from programs and services, including Medicaid and CHIP.4 Further, in October 2018, the Trump administration published a proposed rule to make changes to public charge policy. Under these changes, officials would newly consider use of certain non-cash programs, including Medicaid, when determining whether someone is a public charge and should be denied a green card or entry into the United States. The changes would likely lead to broad decreases in participation in Medicaid and other programs among legal immigrant families and their primarily U.S.-born children.5 Declines in coverage for families would increase barriers to care and financial instability, negatively affecting the growth and healthy development of their children.

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 January 2019.

 

Endnotes
  1. The estimate of the total number of non-citizens in the US is based on the 2017 American Community Survey (ACS). The ACS does not include a direct measure of whether a non-citizen has legal status or not. We impute documentation status by drawing on methods underlying the 2013 analysis by the State Health Access Data Assistance Center (SHADAC) and the recommendations made by Van Hook et. al.. This approach uses the second wave of the 2008 Survey of Income and Program Participation (SIPP) to develop a model that predicts immigration status for each person in the sample; it then applies the model to a second data source, controlling to state-level estimates of total undocumented population as well as the undocumented population in the labor force from the Pew Research Center. See, “U.S. Unauthorized Immigrant Total Dips to Lowest Level in Decade,” available here: http://www.pewhispanic.org/2018/11/27/u-s-unauthorized-immigrant-total-dips-to-lowest-level-in-a-decade/.

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  2. Tricia Brooks, et al., Medicaid and CHIP Eligibility, March 2018 Enrollment, Renewal, and Cost Sharing Policies as of January 2018: Findings from a 50-State Survey, (Washington, DC: Kaiser Family Foundation, March 2018), https://www.kff.org/report-section/medicaid-and-chip-eligibility-enrollment-renewal-and-cost-sharing-policies-as-of-january-2018-findings-from-a-50-state-survey/.

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  3. Cindy Mann to State Official and Medicaid Director, August 28, 2012, Center for Medicaid and CHIP Services, "Re: Individuals with Deferred Action for Childhood Arrivals," SHO# 12-002, https://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-12-002.pdf.

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  4. Samantha Artiga and Barbara Lyons, Family Consequences of Detention/Deportation: Effects on Finances, Health, and Well-Being, (Washington, DC: Kaiser Family Foundation, September 2018), https://www.kff.org/disparities-policy/issue-brief/family-consequences-of-detention-deportation-effects-on-finances-health-and-well-being/.

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  5. Samantha Artiga, Rachel Garfield, and Anthony Damico, Estimated Impacts of the Proposed Public Charge Rule on Immigrants and Medicaid, (Washington, DC: Kaiser Family Foundation, October 2018), https://www.kff.org/disparities-policy/issue-brief/estimated-impacts-of-the-proposed-public-charge-rule-on-immigrants-and-medicaid/.

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