State Health Coverage for Immigrants and Implications for Health Coverage and Care

Note: This brief was updated on May 8, 2024 to reflect the final rule published on May 3, 2024 which will extend eligibility for health coverage to DACA recipients.

As of 2022, there were 21.2 million individuals who are noncitizen immigrants residing in the U.S., accounting for about 7% of the country’s total population. Among noncitizen immigrants, about six in ten are lawfully present immigrants while the remaining four in ten are undocumented immigrants. Noncitizen immigrants, particularly those who are undocumented, face significant barriers to accessing health coverage and care and are significantly more likely than citizens to be uninsured. These higher uninsured rates reflect more limited access to private coverage and eligibility restrictions for federally funded coverage options. Some states have taken up options in Medicaid and the Children’s Health Insurance Program (CHIP) to expand coverage for lawfully present immigrants and/or established fully state-funded programs to fill gaps in coverage for immigrants. This brief provides an overview of state take-up of these options and state health coverage programs for immigrants regardless of status. It also examines how health coverage and care for immigrants vary by state coverage policies using data from the 2023 KFF/LA Times Survey of Immigrants.

There has been increased state action to expand coverage to immigrants, including immigrant adults, in recent years although these efforts are limited by funding constraints. As of March 2024, 12 states and D.C. provide fully state-funded coverage for income-eligible children regardless of immigration status, six states plus D.C. provide fully state-funded coverage to some income-eligible adults regardless of status, and most states have taken up options in Medicaid and CHIP to expand coverage to lawfully present immigrant children and pregnant women. Data and research suggest that coverage expansions for immigrants are associated with lower uninsured rates, with immigrant adults in states that provide more expansive coverage half as likely to be uninsured as those in states with less expansive coverage (11% vs. 22%). Despite these expansions, uninsured rates remain high among noncitizen immigrants, with 18% of lawfully present immigrant adults and half of likely undocumented immigrant adults reporting being uninsured. It remains to be seen whether there will be continued movement to expand coverage for immigrants going forward and if existing expansions will be sustainable over time.

Health Coverage for Immigrants

Noncitizen immigrants have high uninsured rates because they have more limited access to private coverage due to working in jobs that are less likely to offer coverage and face eligibility restrictions for federally funded coverage options. Lawfully present immigrants may qualify for Medicaid and CHIP but are subject to eligibility restrictions that result in some, particularly recent immigrants, being ineligible to enroll even if they meet other eligibility criteria. For example, many must meet a five-year waiting period before qualifying for Medicaid or CHIP. Lawfully present immigrants can purchase coverage through the Affordable Care Act (ACA) Marketplaces and may receive tax credits for this coverage without a waiting period. Undocumented immigrants are ineligible 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 may help cover the costs for emergency care provided to immigrants who remain ineligible for Medicaid but are not coverage for individuals.

Medicaid and CHIP Options for Lawfully Present Immigrants

In general, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP, and many, including most lawful permanent residents or “green card” holders, must wait five years after obtaining qualified status before they may enroll even if they meet other eligibility requirements. 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. For children and pregnant people, states can eliminate the five-year wait and extend coverage to lawfully present immigrants without a qualified status. As of March 2024, 37 states plus D.C. have taken up this option for children and 30 states plus D.C. have elected the option for pregnant people (Figure 1). Michigan also has indicated plans to remove the waiting period for lawfully residing immigrant children and pregnant people.

A total of 22 states have also extended coverage to pregnant people regardless of immigration status through the CHIP From-Conception-to-End-of-Pregnancy (FCEP) option (Figure 2). Colorado plans to implement this coverage by January 2025. While other pregnancy-related coverage in Medicaid and CHIP requires 60 days of postpartum coverage, the CHIP FCEP option does not include this coverage. However, some states that took up this option provide postpartum coverage regardless of immigration status either through a CHIP state plan amendment or using state-only funding. Additionally, ten states (California, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New York, Oregon, Rhode Island, and Washington) have used state funding or CHIP health services initiatives to extend postpartum coverage to 12 months to individuals regardless of immigration status to align with the Medicaid extension established by the American Rescue Plan Act, and Maryland extends coverage for four months postpartum through its health services initiative.

Fully State-Funded Coverage

Beyond state take-up of options in Medicaid and CHIP, some states provide fully state-funded coverage to fill gaps in coverage for some individuals regardless of immigration status. States vary in the eligibility and scope of benefits offered through these coverage programs. These programs extend coverage to lawfully present immigrants who are in the five-year waiting period for Medicaid or CHIP or do not have “qualified status” and are ineligible for federally funded coverage as well as undocumented immigrants. These programs also extended coverage to Deferred Action for Childhood Arrivals (DACA) recipients who previously were not considered lawfully present for purposes of eligibility for federally-funded health coverage programs. However, effective November 1, 2024, new regulations will change the definition of lawfully present to include DACA recipients for purposes of eligibility to purchase coverage through the ACA Marketplaces and to receive tax credits to help pay for premiums and cost sharing.

As of March 2024, 12 states plus D.C. provide comprehensive state-funded coverage for children regardless of immigration status (Figure 3). These states include California, Connecticut, Illinois, Maine, Massachusetts, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and D.C. By 2025, Colorado and Minnesota plan to offer state-funded Medicaid-like coverage to income-eligible children regardless of immigration status. Additionally, two of these states (New Jersey and Vermont) also provide state-funded coverage to income-eligible pregnant people regardless of immigration status, with Vermont extending this coverage for 12 months postpartum.

As of March 2024, six states (California, Colorado, Illinois, New York, Oregon, Washington) plus D.C. have also expanded fully state-funded coverage to some income-eligible adults regardless of immigration status (Figure 4). Some additional states cover some income-eligible adults who are not otherwise eligible due to immigration status using state-only funds but limit coverage to specific groups, such as lawfully present immigrants who are in the five-year waiting period for Medicaid coverage, or provide more limited benefits.

• California extended state-funded Medicaid coverage to young adults ages 19-25 regardless of immigration status in January 2020, and adults ages 50 and older became eligible on May 1, 2022. The state further extended coverage to income-eligible adults ages 26 to 49 regardless of immigration status in January 2024, making all low-income immigrants in the state eligible for state-funded health coverage regardless of immigration status.
• Colorado uses state funds to provide Marketplace coverage with premium subsidies to individuals with incomes at or below 300% of the federal poverty level (FPL) regardless of immigration status through a section 1332 waiver. Colorado previously provided subsidized plans with $0 premiums through SilverEnhanced Savings, but the program has paused enrollment for 2024 due to funding constraints.
• D.C. provides health coverage to low-income residents regardless of immigration status through its longstanding locally funded Healthcare Alliance program.
• Illinois extended state-funded coverage to low-income individuals ages 65 and older regardless of immigration status through its Health Benefits for Immigrant Seniors (HBIS) program in December 2020. Coverage also was extended to low-income immigrants ages 42 to 64 regardless of immigration status through the Health Benefits for Immigrant Adults (HBIA) program in 2022. As of March 2024, Illinois has paused enrollment for both the HBIS and HBIA programs due to funding constraints.
• New York extended state-funded Medicaid coverage to individuals ages 65 and older regardless of immigration status beginning in 2023.
• Oregon extended state-funded coverage to all adults who meet income and residency criteria regardless of immigration status as of July 1, 2023.
• Washington uses state funds to provide Marketplace coverage with premium subsidies to individuals with incomes at or below 250% FPL regardless of immigration status through a section 1332 waiver. Starting July 2024, Washington will allow individuals regardless of immigration status with incomes up to 138% FPL to apply for coverage under a state-funded Medicaid-look alike program, subject to funding availability.

In addition to these states, Maryland plans to allow income-eligible individuals to purchase Marketplace coverage regardless of immigration status through a section 1332 waiver without subsidies, pending waiver approval by the Centers for Medicare and Medicaid Services (CMS). Minnesota plans to allow income-eligible individuals regardless of immigration status to enroll in MinnesotaCare, a state-subsidized sliding scale program for low-income residents no sooner than 2025, subject to funding availability.

Impact of State Coverage Expansions on Health Care Access and Use

Data suggest that state coverage options for immigrants make a difference in their health coverage and health care access and use. The 2023 KFF/LA Times Survey of Immigrants shows that immigrants residing in states with more expansive coverage policies for immigrants have higher rates of health coverage, are less likely to postpone or go without care, and are more likely to receive care and to have a trusted health care provider compared to their counterparts living in states with less expansive coverage policies, as described below. (See Box 1).

Immigrant adults in states that provide more expansive coverage, including the ACA Medicaid expansion for low-income adults and at least some state-funded coverage for immigrants, are half as likely to be uninsured as those in states with less expansive coverage (11% vs. 22%). This difference is driven by higher rates of Medicaid and other public coverage (including state-funded coverage) in states with more expansive coverage compared to those with less expansive policies (23% vs. 9%) while rates of private and Medicare coverage are similar (Figure 5).

Reflecting higher rates of health coverage, immigrant adults in states with more expansive policies are somewhat less likely to say they skipped or postponed care due to cost. Immigrants in states with more expansive policies are half as likely to report delaying or going without medical care (4% vs. 10%) or dental care (7% vs. 14%) due to cost than those in less expansive states (Figure 6).

Differences in use of care among immigrants by state coverage policies are smaller, which may reflect use of safety-net resources available to uninsured immigrants such as community health centers and emergency rooms. Most (77%) immigrant adults in the U.S. report seeking health care in the past year. The shares reporting seeking health care are slightly lower in states with less expansive coverage (74%) compared to those in states with more expansive coverage (79%), although the majority still report seeking care. This pattern may reflect use of safety-net resources available to uninsured immigrants such as community health centers or emergency rooms. Immigrant adults are more likely than U.S.-born adults to say they rely on community health centers (CHCs) as their usual source of care, reflecting CHCs’ in providing free or low-cost care to low-income and uninsured populations and their ability to provide culturally and linguistically appropriate care. Immigrants in states with less expansive policies are somewhat more likely to say they use a CHC (33% vs. 28%) and somewhat less likely to say they use a private doctor’s office (39% vs. 44%) (Figure 7). Immigrant adults in states with less expansive policies are also less likely to report having a medical provider they trust to answer questions about their health than those in more expansive states (68% vs. 78%).

Other research suggests that state coverage expansions for immigrants can reduce uninsurance rates, increase health care use, lower costs, and improve health outcomes. Noncitizen children are more likely to be uninsured and experience more delays in health care due to cost than their citizen siblings. Citizen children with a noncitizen parent are also more likely to be uninsured than citizen children with U.S-born parents. California’s 2016 expansion to cover low-income children regardless of immigration status was associated with a 34% decline in uninsurance rates. Similarly, a study found that children who reside in states that have expanded coverage to all children regardless of immigration status were less likely to be uninsured, to forgo medical or dental care, and to go without a preventive health visit than children residing in states that have not expanded coverage. Other research has found that expanding Medicaid coverage to pregnant people regardless of immigration status was associated with higher rates of prenatal care and improved outcomes including increases in average gestation length and birth weight among newborns, while more restrictive state coverage policies were associated with reduced postpartum care utilization. The cost of providing insurance to immigrant adults through Medicaid expansion was also found to be less than half the per person cost of doing so for U.S-born adults. Recent estimates also suggest that the state-funded expansion to all immigrants regardless of status in California could reduce poverty among noncitizen immigrants and their families.