Health Coverage and Care of Immigrants
In 2021, there were 20.8 million noncitizens in the United States, accounting for about 6% 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, including over one in ten (12%) who are citizen children with at least one noncitizen parent.
Noncitizens are significantly more likely than citizens to be uninsured. In 2021, among the nonelderly population, one in four (25%) lawfully present immigrants and almost half (46%) of undocumented immigrants were uninsured compared to less than one in ten (8%) citizens. Among citizen children, those with at least one noncitizen parent were twice as likely to be uninsured as those with citizen parents (8% vs. 4%). Noncitizens are more likely to be uninsured than citizens because they have more limited access to private coverage due to working in jobs that are less likely to provide health benefits and they face eligibility restrictions for public coverage options, including Medicaid, the Children’s Health Insurance Program (CHIP), and Marketplace coverage. Those who are eligible for coverage also face a range of enrollment barriers including fear, confusion, and language and literacy challenges.
Reflecting their higher uninsured rates, noncitizen immigrants face increased barriers to accessing health care and use less health care than citizens. Among nonelderly adults, noncitizens are significantly more likely than citizens to report not having a usual source of care (33% vs. 20%), not having had a doctor’s visit in the past 12 months (32% vs. 20%), and going without needed medical care in the past 12 months due to its cost (10% vs. 7%). Reflecting this more limited access and use, immigrants have lower health care expenditures than their U.S.-born counterparts.
There has been some recent activity to expand access to health coverage for immigrants, but gaps remain. At the federal level, legislation has been proposed that would expand eligibility for health coverage for immigrants, though it faces no clear path to passage in Congress. At the state level, there has been continued take up of options to expand Medicaid and CHIP coverage for lawfully present immigrant children and pregnant people, and a small but growing number of states have expanded fully state-funded coverage to certain low-income people regardless of immigration status. However, many immigrants, particularly those who are undocumented, remain ineligible for coverage options.
Broad sustained efforts to rebuild trust and reduce fears about accessing programs and services will be important for supporting the health and well-being of immigrant families. The Biden Administration reversed prior Trump Administration changes to public charge rules, which may help reduce fears among immigrant families about participating in non-cash assistance programs, including Medicaid and CHIP. It also increased funding for Navigator programs that provide enrollment assistance to individuals, which is particularly important for helping immigrant families enroll in coverage. However, even with these actions, it will likely take time and sustained community-led efforts to rebuild trust and reduce fears surrounding the use of services among immigrant families. Addressing the needs of immigrants is of growing importance as the pandemic has likely worsened the health and financial challenges faced by immigrants and there has been increasing immigration activity in the U.S.-Mexico border region.
Overview of Immigrants
In 2021, there were 20.8 million noncitizens and 23.9 million naturalized citizens residing in the U.S., who accounted for about 6% and 7% of the total population, respectively (Figure 1). About six in ten noncitizens were lawfully present immigrants, while the remaining four in ten were undocumented immigrants (see Text Box 1).1 Many individuals live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens.
A total of 19 million or one in four children had an immigrant parent as of 2021, and the majority of these children were citizens (Figure 1). About 9.2 million or 12% were citizen children with at least one noncitizen parent.
Text Box 1: Overview of Lawfully Present and Undocumented Immigrants
Lawfully present immigrants are noncitizens who are lawfully residing in the U.S. This group includes lawful 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. Individuals who have received deferred action are authorized to be present in the U.S. However, individuals with Deferred Action for Childhood Arrivals status are not considered to have an immigration status that is eligible for federally-funded health insurance (see below).
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.
Uninsured Rates by Immigration Status
Although the majority of the nonelderly uninsured are citizens, noncitizens, particularly undocumented immigrants, are significantly more likely to be uninsured than citizens. As of 2021, more than three-quarters (77%) of the 27.5 million nonelderly uninsured were U.S.-born and naturalized citizens, while the remaining 23% were noncitizens (Figure 2). However, noncitizens, including lawfully present and undocumented immigrants, were significantly more likely to be uninsured than citizens. Among the nonelderly population, one in four (25%) lawfully present immigrants and almost half (46%) of undocumented immigrants were uninsured compared to 8% of citizens (Figure 3). Noncitizen children are also 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 than those with citizen parents.
Reflecting their higher uninsured rates, noncitizens face increased barriers to accessing care and use less health care than citizens (Figure 4). Research shows that having insurance makes a difference in whether and when people access needed care. Those who are uninsured often delay or go without needed care, which can lead to worse health outcomes over the long-term that may ultimately be more complex and expensive to treat. Among nonelderly adults, noncitizens are significantly more likely than citizens to report not having a usual source of care (33% vs. 20%), not having had a doctor’s visit in the past 12 months (32% vs. 20%), and going without needed medical care in the past 12 months due to its cost (10% vs. 7%). Research also shows that immigrants have lower health care expenditures than their U.S.-born counterparts as a result of lower health care access and use, although their out-of-pocket payments tend to be higher due to higher uninsured rates. Recent research further finds that, because immigrants, especially undocumented immigrants, have lower health care use despite contributing billions of dollars in insurance premiums and taxes, they help subsidize the U.S. health care system and offset the costs of care incurred by U.S.-born citizens.
Access to Health Coverage Among Immigrants
The higher uninsured rate among noncitizens reflects limited access to employer-sponsored coverage; immigrant eligibility restrictions for Medicaid, CHIP, and the Affordable Care Act (ACA) Marketplace coverage; and barriers to enrollment among eligible individuals. Although most nonelderly noncitizens live in a family with a full-time worker, they face gaps in access to private coverage since they are significantly more likely to be low-income and employed in low-wage jobs and industries that are less likely to offer employer-sponsored coverage (Figure 5). Given their lower incomes, noncitizens also face increased challenges affording employer-sponsored coverage when it is available or through the individual market. At the same time, immigrants face eligibility restrictions for Medicaid, the CHIP, and Marketplace coverage. Moreover, those who are eligible face a range of enrollment barriers, including fears and confusion about eligibility for programs.
Medicaid, CHIP, and Marketplace Eligibility for Immigrants
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 lawful permanent residents 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 people, states can eliminate the five-year wait and extend coverage to lawfully present immigrants without a qualified status. As of January 2022, 35 states have taken up this option for children and half have elected the option for pregnant individuals.
In December 2020, Congress restored Medicaid eligibility for citizens of Compact of Free Association (COFA) communities. COFA agreements are between the U.S. government and the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau. Certain citizens of these nations can lawfully work, study, and reside in the U.S., but they had been excluded from federally-funded Medicaid since 1996, under the Personal Responsibility and Work Opportunity Reconciliation Act. As part of a COVID-relief package, Congress restored Medicaid eligibility for COFA citizens who meet other eligibility requirements for the program effective December 27, 2020.
Lawfully present immigrants can purchase coverage through the ACA Marketplaces and may receive tax credits for this coverage. Like citizens, they can get tax credits to help pay for premiums and cost sharing that vary on a sliding scale based on income. Generally, these tax credits are available to people with incomes starting from 100% of the federal poverty level (FPL) who are not eligible for other affordable coverage. In addition, lawfully present immigrants with incomes below 100% FPL may receive tax credits 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 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. Under rules issued by the Centers for Medicare and Medicaid Services (CMS), individuals with Deferred Action for Childhood Arrivals status are not considered lawfully present for purposes of health coverage eligibility and remain ineligible for coverage options. 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 for undocumented immigrants.
States can extend Medicaid and CHIP coverage to pregnant people regardless of immigration status. Since 2002, states have had the option to provide prenatal care to people regardless of immigration status by extending CHIP coverage to the unborn child. As of January 2022, 18 states had adopted this option. In 2022, several additional states took up or passed legislation to take up this option, including Connecticut, Maine, and Maryland. Unlike other pregnancy-related coverage in Medicaid and CHIP, which requires 60 days of postpartum coverage, the unborn child option does not include this coverage. However, some states that took up this option provided postpartum coverage regardless of immigration status either through a CHIP state plan amendment or using state-only funding. In addition, the American Rescue Plan Act (ARPA) gave states the option to extend Medicaid postpartum coverage from 60 days to 12 months beginning in April 2022. Among the 37 states that have adopted this option, 7 states—California, Illinois, Maryland, Massachusetts, Minnesota, Rhode Island, and Washington—have extended the postpartum coverage to individuals regardless of immigration status; Connecticut will extend Medicaid-like state-funded coverage effective April 1, 2023 and Colorado will extend it effective 2025.
While uninsured undocumented immigrants are ineligible for federally funded coverage options, many uninsured lawfully present immigrants are eligible for coverage options under the ACA but remain uninsured. Prior to the pandemic, many uninsured lawfully present immigrants were eligible for ACA coverage. ARPA, enacted in 2021, further increased access to health coverage through temporary increases and expansions in eligibility for subsidies to buy health insurance through the health insurance Marketplaces and these enhanced subsidies will continue through 2025 under the Inflation Reduction Act (IRA). Despite being eligible for coverage, many 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. Research suggests that changes to immigration policy made by the Trump Administration contributed to growing fears among immigrant families about enrolling themselves and/or their children in Medicaid and CHIP even if they were eligible. In particular, changes to the public charge policy likely contributed to decreases in participation in Medicaid among immigrant families and their primarily U.S.-born children. The Biden Administration reversed many of these changes, including the changes to public charge policy, and has increased investments in outreach and enrollment assistance, which may facilitate increased enrollment of eligible uninsured immigrants.
State Funded Coverage for Immigrants
Several states have expanded fully state-funded coverage for income-eligible children and pregnant individuals regardless of immigration status. As of December 2022, nine states (California, DC, Illinois, Maine, New York, Oregon, Rhode Island, Vermont and Washington) provide comprehensive state-funded coverage to all income-eligible children, regardless of immigration status. Massachusetts provides primary and preventive services to all children, regardless of immigration status or income. Connecticut plans to expand coverage to all children under age 12 in January 2023, with coverage continuing until age 19 if they remain eligible. New Jersey has proposed to expand coverage to children regardless of immigration status in its Fiscal Year 2023 budget and Colorado will do so by 2025.
A few states have also expanded fully state-funded coverage to adult immigrants. Through its longstanding locally funded Healthcare Alliance program, the District of Columbia provides health coverage to low-income residents regardless of immigration status. In January 2020, California extended state-funded Medicaid coverage to young adults ages 19-26 regardless of immigration status, and adults ages 50 and older became eligible on May 1, 2022. The state will further extend coverage to income-eligible adults ages 26 to 49, regardless of immigration status, no sooner than January 1, 2024. In December 2020, Illinois extended state-funded coverage to low-income individuals ages 65 and older who were not eligible for Medicaid due to their immigration status. As of July 2022, coverage was also extended to low-income immigrants ages 42 to 64, regardless of status, and proposed legislation would further expand this coverage to all adults ages 19 and older. In Oregon, the Cover All People Act extended state-funded coverage to all low-income adults who are not eligible due to immigration status, subject to available funding. As of July 1, 2022, coverage was available to those ages 19-25 or 55 and older. New York plans to extend state-funded Medicaid coverage to individuals ages 65 and older regardless of immigration status beginning in 2023. 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.
States can also provide state-funded premium subsidies to immigrants who are ineligible for federal premium subsidies in the Marketplace due to their immigration status. In Colorado, beginning in 2023, state residents with incomes up to 300% FPL who do not qualify for health insurance under the ACA or other public programs because of their immigration status will be eligible for state-funded premium subsidies to assist them in purchasing individual coverage outside of the ACA Marketplace. In December 2022, CMS approved a State Innovation Waiver from Washington that will allow all state residents regardless of immigration status to enroll in qualified health and dental plans through the state Marketplace and to benefit from state-funded subsidies effective January 1, 2024; the waiver does not affect eligibility for federally-funded subsidies.
Research suggests that state coverage expansions for immigrants can reduce uninsurance rates, increase health care use, and improve health outcomes. 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 pregnancy coverage regardless of immigration status was associated with higher rates of prenatal care utilization as well as improved outcomes including increases in average gestation length and birth weight among newborns.
Although noncitizen immigrants are as likely as citizens to work, they are significantly more likely to be uninsured due to more limited access to both public and private coverage. Federal legislation has been proposed that would expand immigrant eligibility for health coverage, though there is no clear path to passage in Congress. In the absence of federal action, some states are filling gaps in access to coverage for immigrants. However, many remain ineligible for any coverage options, contributing to barriers to access and use of care. Those eligible for coverage also face an array of barriers to enrollment, including fear and confusion about eligibility. The Biden Administration has enacted changes to public charge policies that are intended to reduce fears of enrolling in health coverage and accessing care and increased funding for outreach and enrollment assistance, which may help eligible immigrant families enroll and stay enrolled in coverage. However, even with increased eligibility and enhanced outreach and enrollment assistance, it will likely require time and sustained work, including community-led efforts, to rebuild trust and reduce fears among immigrant families about accessing health coverage and care. Addressing the needs of immigrants is of growing importance as the pandemic has likely worsened the health and financial challenges faced by immigrants and there has been increasing immigration activity in the border region.
|Appendix A: Lawfully Present immigrants by Qualified Status|
|Qualified Immigrant Categories||Other Lawfully Present Immigrants|
|Source: “Coverage for lawfully present immigrants,” HealthCare.gov, https://www.healthcare.gov/immigrants/lawfully-present-immigrants/.|
The estimate of the total number of noncitizens in the US is based on the 2021 American Community Survey (ACS) 1-year Public Use Microdata Sample (PUMS). The ACS data do not directly indicate whether an immigrant is lawfully present or not. We draw on the methods underlying the 2013 analysis by the State Health Access Data Assistance Center (SHADAC) and the recommendations made by Van Hook et. Al.1,2 This approach uses the Survey of Income and Program Participation (SIPP) to develop a model that predicts immigration status; it then applies the model to ACS, controlling to state-level estimates of total undocumented population from Pew Research Center. For more detail on the immigration imputation used in this analysis, see the Technical Appendix B.