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Health Coverage and Care for Immigrants

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

  • In 2015, there were 23 million non-citizen immigrants residing in the United States, accounting for about 7% of the total U.S. population. Non-citizen immigrants include both lawfully present immigrants and undocumented immigrants. Many immigrants live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens.
  • Noncitizen immigrants are significantly more likely than citizens to be uninsured. Among the nonelderly population, 17% of lawfully present immigrants and four in ten (41%) undocumented immigrants are uninsured compared to less than one in ten (9%) U.S. born and naturalized citizens.
  • Changes proposed in the Better Care Reconciliation Act (BCRA) would further limit access to coverage and care for lawfully present immigrants. Specifically, the BCRA would make certain lawfully present immigrants ineligible for Marketplace coverage and tax credits. In addition, its proposed cuts to Medicaid could negatively affect coverage and care for lawfully present immigrants covered by the program and place further strains on other programs that serve immigrants.
  • Current immigration policies and attitudes towards immigrants may negatively affect their health coverage, access to care, and health outcomes. Increased fears among the immigrant community about deportation and use of public programs negatively affecting their immigration status may deter immigrant families from enrolling eligible family members in health coverage and seeking necessary health care for themselves and their children.

Introduction

This brief provides an overview of the noncitizen immigrant population and discusses key issues in health coverage and care for immigrants today. Immigrants and children in immigrant families have historically faced disproportionate barriers to accessing health coverage and care. The Affordable Care Act (ACA) offered new options to increase coverage for naturalized citizens and lawfully present immigrants, but undocumented immigrants remain ineligible for assistance. Increased fears among immigrants due to recent focus on immigration enforcement and proposed policies to limit immigrants’ use of public services may deter families from enrolling eligible children and adults in coverage and from obtaining needed care. In addition, changes proposed in the Better Care Reconciliation Act (BCRA) would further limit access to coverage and care for lawfully present immigrants. See here for methodology for the analysis included in this brief.

Overview of Noncitizen Immigrants

In 2015, there were 23 million noncitizen immigrants residing in the US, accounting for about 7% of the total population (Figure 1). About six in ten noncitizen immigrants were lawfully present immigrants, while the remaining four in ten were undocumented immigrants:1

  • Lawfully present immigrants are foreign-born individuals who have not become citizens but are lawfully residing in the United States. This group includes legal permanent residents (LPRs, i.e., “green card” holders), refugees, asylees, other humanitarian immigrants, and other temporary immigrants.
  • Undocumented immigrants are foreign-born individuals residing in the United States who are not legal residents. This group includes individuals who entered the country without authorization and individuals who entered the country legally and stayed after their visa expired.

Figure 1: Non-Citizen Immigrants as a Share of the Total U.S. Population, 2015

Many immigrants live in mixed immigration status families. Mixed status families may include members who are lawfully present immigrants, undocumented immigrants, and/or citizens. For example, more than one in five (23%) children in the U.S. are citizen children with at least one immigrant parent.2

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

Key Characteristics of Noncitizen Immigrants

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, 2015

Most nonelderly noncitizen immigrants live in a family with at least one full-time worker, but they are more likely than nonelderly citizens are to be low-income. 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, 2015

Health Coverage for Noncitizen Immigrants

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 (42% vs. 11%), and the uninsured rate for undocumented immigrant children is five times the rate for citizen children (25% 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, 2015

Lawfully present immigrants may qualify for Medicaid and CHIP but are subject to specific eligibility restrictions. To qualify for Medicaid and CHIP, lawfully present immigrants must have a “qualified” immigration status and many must wait five years after obtaining a qualified status before they may enroll. Some immigrants, such as those with temporary protected status or lawful temporary immigrants, are lawfully present but do not have a qualified status and are not eligible for Medicaid and CHIP (Appendix A). States have an option to eliminate the five-year waiting period and to cover the broader group of lawfully present immigrant children and pregnant women—including those 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

Undocumented immigrants are not eligible to enroll in Medicaid or CHIP. 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.

Eligibility for ACA Coverage Options for Noncitizen Immigrants

The ACA expanded coverage options for lawfully present immigrants, although they continue to face eligibility restrictions for Medicaid. Thirty-two states, including DC, have implemented the ACA Medicaid expansion to adults with incomes up to 138% of the federal poverty level (FPL). Lawfully present immigrant adults may qualify for the Medicaid expansion, but they must have a qualified immigration status and are subject to the five-year waiting period before they may enroll. Lawfully present immigrants also can purchase coverage through the ACA Marketplaces and may receive subsidies to offset the cost of this coverage, which 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 for Marketplace coverage if they are ineligible for Medicaid based on their 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 ineligible for ACA coverage options. Undocumented immigrants were ineligible for Medicaid prior to the ACA and remain ineligible. They also are prohibited from purchasing coverage through a Marketplace or receiving premium subsidies.

Most uninsured nonelderly lawfully present immigrants are eligible for coverage options under the ACA, while uninsured undocumented immigrants remain ineligible for coverage options. As of 2016, 17% of uninsured nonelderly lawfully present immigrants were eligible for Medicaid, and half (50%) 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 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 as of 2016

Current Issues

Changes proposed in the BCRA would further limit access to coverage and care for lawfully present immigrants.

  • BCRA would make some lawfully present immigrants ineligible to purchase Marketplace coverage. As noted, under current law, lawfully present immigrants are eligible to purchase coverage through the Marketplace and receive tax credit subsidies for this coverage. BCRA would limit eligibility for Marketplace coverage and tax credits to lawfully present immigrants who have a qualified status. This means certain groups of lawfully present immigrants would become ineligible to purchase coverage through the Marketplace or receive tax credits, including people here on a work or student visa and people in the process of gaining permanent resident status like those who are newly married to U.S. citizens. This restriction would also exclude individuals from the Federated States of Micronesia, Republic of the Marshall Islands, and Republic of Palau who work and reside in the United States under Compacts of Free Association (COFA).
  • BCRA would make large reductions in federal funding for Medicaid that could lead to cutbacks in coverage for lawfully present immigrants enrolled in the program and increase pressures on other state programs that serve immigrants. Medicaid is an important source of coverage for lawfully present immigrants, covering more than one in four (25%) nonelderly lawfully present immigrants. BCRA would make significant reductions in Medicaid by eliminating enhanced federal financing for the ACA Medicaid expansion to low-income adults and capping the amount of federal funding provided to states. The Congressional Budget Office estimates that these changes will result in a $772 billion reduction in federal funding for Medicaid over 10 years and that enrollment will decline by 15 million by 2026 compared to current law.4 In response to these cuts, states will likely need to make cutbacks in their Medicaid programs, such as eligibility reductions, elimination of optional benefits, and/or reductions in provider payments. These reductions could result in coverage losses and increased barriers to care for lawfully present immigrants covered by the program. Moreover, the reductions could increase financial pressures and strains on other state programs that serve immigrants.

Increased fear within the immigrant community will likely deter immigrant families, including those with citizen children, from enrolling eligible individuals in health coverage and from using health care. The Administration has increased immigration enforcement activities and signaled interest in making it more difficult for low-income immigrants who use certain benefits, including Medicaid or CHIP, to enter the country or obtain lawful permanent status.5 These actions have increased fears of deportation and use of public programs among immigrant communities, including mixed status families with citizen children. These fears may deter them from enrolling eligible family members in health coverage and seeking necessary health care for themselves and their children, which may lead to negative health consequences and further widen disparities in health and health care for immigrant families.

Samantha Artiga is with the Kaiser Family Foundation. Anthony Damico is an independent consultant to the Kaiser Family Foundation.

Appendix

The Henry J. Kaiser Family Foundation Headquarters: 2400 Sand Hill Road, Menlo Park, CA 94025 | Phone 650-854-9400
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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.