Health Coverage of Immigrants

Summary

In 2018, there were 22 million noncitizens in the United States, accounting for about 7% of the total U.S. population. Noncitizens include lawfully present and undocumented immigrants. Many individuals live 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.

Most of the uninsured are citizens, but noncitizens are significantly more likely than citizens are to be uninsured. In 2018, more than three-quarters (76%) of the nearly 28 million nonelderly uninsured were citizens. However, among the 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 (9%) citizens. Moreover, among citizen children, those with at least one non-citizen parent are more likely to be uninsured compared to those with citizen parents (8% vs. 4%).

Growing research suggests that recent changes to immigration policy are contributing to growing fears among immigrant families about their and their children participating in Medicaid and CHIP. In particular, changes to public charge policy that allow federal officials to newly consider use of certain non-cash programs, including Medicaid for non-pregnant adults, when determining whether to provide certain individuals a green card or entry into the U.S. are leading to growing fears that will likely lead to coverage declines. Coverage declines would have important implications for the health and well-being of families and the health care system.

Coverage declines would have important implications for the health and well-being of families and the health care system. Research shows that health insurance is important for enabling families to access needed care, protecting families from unaffordable medical care costs, and promoting the healthy growth and development of children. Stable health insurance and affordable access to care also is important for supporting the response to growing health care needs stemming from the COVID-19 public health crisis. U.S. Citizenship and Immigration Services issued an alert in March 2019, encouraging all individuals with symptoms that resemble COVID-19 to seek necessary medical treatment or preventive services and noted that such treatment or services will not negatively affect future public charge tests.1

Overview of Immigrants

In 2018, there were 22 million noncitizens and 22 million naturalized citizens residing in the U.S., who each accounted 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.2 Many individuals live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens.

Figure 1: Immigrants and Children of Immigrants as a Share of the Total U.S. Population, 2018

Nearly 19 million or 25% of children had an immigrant parent as of 2018, and the large majority of these children were citizens. About 10 million or 13% were citizen children with a noncitizen parent. 

Health Coverage for Nonelderly Noncitizens

In 2018, more than three-quarters of the 27.9 million nonelderly uninsured were U.S.-born and naturalized citizens (Figure 2). The remaining 24% were noncitizens.

Figure 2: Nonelderly Uninsured by Citizenship Status, 2018

However, noncitizens, including lawfully present and undocumented immigrants, were significantly more likely to be uninsured than citizens. Among the 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 (9%) citizens (Figure 3).

Figure 3: Uninsured Rates among Nonelderly Population by Immigration Status, 2018

These differences in coverage also persist among children, with noncitizen children more likely to lack coverage compared to their citizen counterparts. Moreover, among citizen children, those with at least one noncitizen parent were significantly more likely to be uninsured as those with citizen parents (Figure 4).

Figure 4: Uninsured Rates among Children by Immigration Status and Parent Immigration Status, 2018

Barriers to Health Coverage for Noncitizens

The higher uninsured rate among noncitizens reflects 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 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 5). They have lower incomes because they are often employed in low-wage jobs and industries that are less likely to offer employer-sponsored coverage. Given their lower incomes, noncitizens also face increased challenges affording employer-sponsored coverage when it is available or through the individual market.

Figure 5: Employment and Income among the Nonelderly Population by Immigration Status, 2018

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.3

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.4

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 2018, nearly three-quarters of uninsured lawfully present immigrants were eligible for ACA coverage, including 27% who were eligible for Medicaid and 47% who were eligible for tax credit subsidies (Figure 6). 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 6: Eligibility for ACA Coverage among Nonelderly Uninsured by Immigration Status, 2018

Growing research suggests that recent changes to immigration policy are contributing to growing fears among immigrant families about their and their children participating in Medicaid and CHIP. Over the past few years, the federal government has implemented a range of policies to curb immigration, enhance immigration enforcement, and limit use of public assistance programs among immigrant families. A growing body of research shows that, amid this policy climate, some immigrant families are avoiding enrolling themselves and/or their children in public programs, including Medicaid.5 In particular, changes to public charge policy that allow federal officials to newly consider use of certain non-cash programs, including Medicaid for non-pregnant adults, when determining whether to provide certain individuals a green card or entry into the U.S., will likely lead to broad decreases in participation in Medicaid among immigrant families and their primarily U.S.-born children.6 Prior to implementation of the changes to public charge policy, reports indicated that some individuals were already disenrolling themselves or their children from Medicaid and/or CHIP or declining to renew or enroll themselves or their children in the programs despite being eligible.7

Coverage declines would have important implications for the health and well-being of families and the health care system. Research shows that health insurance is important for enabling families to access needed care, protecting families from unaffordable medical care costs, and promoting the healthy growth and development of children. Stable health insurance and affordable access to care also is important for supporting the response to growing health care needs stemming from the COVID-19 public health crisis. U.S. Citizenship and Immigration Services issued an alert in March 2019, encouraging all individuals with symptoms that resemble COVID-19 to seek necessary medical treatment or preventive services and noted that such treatment or services will not negatively affect future public charge tests.8

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 March 2020.
Endnotes
  1. U.S. Citizenship and Immigration Services, “Public Charge,” https://www.uscis.gov/greencard/public-charge, accessed March 16, 2020.

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  2. The estimate of the total number of non-citizens in the US is based on the 2018 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, “5 facts about illegal immigration in the U.S.,” available here: https://www.pewresearch.org/fact-tank/2019/06/12/5-facts-about-illegal-immigration-in-the-u-s/.

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  3. Tricia Brooks, Lauren Roygardner, and Samantha Artiga, Medicaid and CHIP Eligibility, Enrollment, and Cost Sharing Policies as of January 2019: Findings from a 50-State Survey, (Washington, DC: Kaiser Family Foundation, March 2019), https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-and-cost-sharing-policies-as-of-january-2019-findings-from-a-50-state-survey/.

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  4. 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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  5. Jennifer Tolbert, Samantha Artiga, and Olivia Pham, Impact of Shifting Immigration Policy on Medicaid Enrollment and Utilization of Care among Health Center Patients, (Washington, DC: Kaiser Family Foundation, October 2019), https://www.kff.org/medicaid/issue-brief/impact-of-shifting-immigration-policy-on-medicaid-enrollment-and-utilization-of-care-among-health-center-patients/;

    Hamutal Bernstein, Dulce Gonzalez, Michael Karpman, Stephen Zuckerman, One in Seven Adults in Immigrant Families Reported Avoiding Public Benefit Programs in 2018, (Washington, DC: Urban Institute, May 2019), https://www.urban.org/research/publication/one-seven-adults-immigrant-families-reported-avoiding-public-benefit-programs-2018; and,

    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), https://www.kff.org/disparities-policy/issue-brief/living-in-an-immigrant-family-in-america-how-fear-and-toxic-stress-are-affecting-daily-life-well-being-health/.

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  6. Samantha Artiga, Rachel Garfield, and Anthony Damico, Estimated Impacts of Final Public Charge Inadmissibility Rule on Immigrants and Medicaid Coverage, (Washington, DC: Kaiser Family Foundation, September 2019), https://www.kff.org/disparities-policy/issue-brief/estimated-impacts-of-final-public-charge-inadmissibility-rule-on-immigrants-and-medicaid-coverage/.

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  7. Jennifer Tolbert, Samantha Artiga, and Olivia Pham, Impact of Shifting Immigration Policy on Medicaid Enrollment and Utilization of Care among Health Center Patients, (Washington, DC: Kaiser Family Foundation, October 2019), https://www.kff.org/medicaid/issue-brief/impact-of-shifting-immigration-policy-on-medicaid-enrollment-and-utilization-of-care-among-health-center-patients/; and,

    Samantha Artiga and Olivia Pham, Addressing Health and Social Needs of Immigrant Families: Lessons from Local Communities, (Washington, DC: Kaiser Family Foundation, October 2019), https://www.kff.org/disparities-policy/issue-brief/addressing-health-and-social-needs-of-immigrant-families-lessons-from-local-communities/.

     

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  8. U.S. Citizenship and Immigration Services, “Public Charge,” https://www.uscis.gov/greencard/public-charge, accessed March 16, 2020.

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