Health Coverage of Immigrants
In 2020, there were 22.1 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.
Noncitizens are significantly more likely than citizens to be uninsured. In 2020, among the nonelderly population, 26% of lawfully present immigrants and about four in ten (42%) undocumented immigrants were uninsured compared to less than one in ten (8%) citizens. Among citizen children, those with at least one noncitizen parent were significantly more likely to be uninsured as those with citizen parents (10% vs. 4%).
Research suggests that the changes to immigration policy enacted during the Trump administration contributed to increased fears among immigrant families about participating in programs and seeking services, including health coverage and care. These included policies focused on curbing immigration, enhancing immigration enforcement, and limiting the use of public assistance among immigrant families. The Biden administration reversed many of these changes and recently proposed a new rule that excludes non-cash benefits such as Medicaid and the Children’s Health Insurance Program (CHIP) from public charge determinations. However, ongoing efforts will likely be needed to reduce fears and rebuild trust among immigrant families.
The pandemic likely contributed to increased health and financial needs and declines in health coverage among immigrant families. Immigrants’ work, living, and transportation situations put them at increased risk for potential exposure to coronavirus. Noncitizen immigrants also faced risk of financial difficulties due to the pandemic, as many work in service industries, such as restaurants and food services, that suffered cutbacks during the early phases of the pandemic. At the same time, immigrants have had more limited access to COVID relief, and data suggest that immigration-related fears may have contributed to reluctance accessing COVID-19 vaccines.
Recent federal and state activity has focused on expanding access to health coverage for immigrants, but broad sustained efforts to rebuild trust and reduce fears also will be important for supporting the health and well-being of immigrant families. 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. In addition, states are continuing to take up federal options to expand Medicaid and CHIP coverage for lawfully present immigrant children and pregnant people. Moreover, several states have recently proposed or taken action to expand state-funded coverage to low-income people regardless of immigration status. Other recent activity may help increase enrollment among immigrants who are eligible for coverage options. As noted, the Biden Administration proposed new public charge rules, which may help reduce fears among immigrant families about participating in non-cash assistance programs, including health coverage. Further, the Administration increased funding for Navigator programs, which provide enrollment assistance to individuals. 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.
Overview of Immigrants
In 2020, there were 22.1 million noncitizens and 22.7 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 (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 19.2 million or one in four children had an immigrant parent as of 2020, and the majority of these children were citizens. About 9.7 million or 13% were citizen children with a 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 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. Individuals who have received deferred action are authorized to be present in the U.S. and therefore considered to be lawfully present. 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.
Health Coverage for Nonelderly Noncitizens
In 2020, more than three-quarters (76%) of the 27.3 million nonelderly uninsured were U.S.-born and naturalized citizens (Figure 2). The remaining 24% were noncitizens.
However, noncitizens, including lawfully present and undocumented immigrants, were significantly more likely to be uninsured than citizens. Among the nonelderly population, 26% of lawfully present immigrants and approximately four in ten (42%) undocumented immigrants were uninsured compared to 8% of citizens (Figure 3).
These differences in coverage also occur 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).
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.
Although most nonelderly noncitizens live in a family with a full-time worker, they face gaps in access to private coverage. Nonelderly noncitizens are as likely as nonelderly citizens to be living in a family with at least one full-time worker, but they 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.
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.
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 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, individuals with Deferred Action for Childhood Arrivals (DACA) status are not considered lawfully present 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 undocumented immigrants. 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 have adopted this option. 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, several states provide postpartum coverage, regardless of immigration status, either through a CHIP state plan amendment or using state-only funding. 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.
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. Prior to the pandemic many uninsured lawfully present immigrants were eligible for ACA coverage. The American Rescue Plan Act (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. It also includes incentives to states that have not yet adopted the ACA Medicaid expansion to do so and provides a new option for states to extend the length of Medicaid coverage for postpartum women. With the temporary changes under ARPA, approximately three-quarters (77%) of uninsured lawfully present immigrants were eligible for coverage, including 31% who were eligible for Medicaid and 46% who were eligible for ACA subsidies (Figure 6). 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.
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. 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 public charge policy that allowed federal officials to consider the 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., 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 recently proposed new public charge regulations that exclude use of Medicaid and CHIP, except for coverage of long-term institutionalized care, from public charge determinations.
The pandemic likely contributed to increased health and financial needs and declines in health coverage among immigrant families. Immigrants’ work, living, and transportation situations put them at increased risk for potential exposure to coronavirus and its variants. Noncitizen immigrants also faced financial difficulties due to the pandemic, as many work in service industries, such as restaurants and food services, that suffered cutbacks. Initial job losses at the start of the pandemic were particularly high among immigrants, which likely contributed to increased financial stress and potential loss of health insurance, although many employment losses have rebounded since earlier in the pandemic. At the same time, immigrants faced limits on access to COVID-19 relief, and ongoing immigration-related fears made some reluctant to access assistance, services, and COVID-19 vaccines. Some states and localities, such as California and New York, created programs to provide assistance to immigrants who were excluded from federal sources of COVID-19 assistance.
Proposals and Recent Actions to Increase Access to Health Coverage for Immigrants
Recent federal and state activity has focused on expanding access to health coverage for immigrants. Moreover, other recent activity may help increase enrollment among immigrants who are eligible for coverage options. However, beyond these actions, broad sustained community-led efforts will likely be key for reducing fears and rebuilding trust among immigrant families.
In December 2020, Congress restored Medicaid eligibility for citizens of Compact of Free Association (COFA) communities. Compacts of Free Association are agreements 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 (PRWORA). 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.
Recent federal legislation has been proposed that would expand immigrant eligibility for health coverage, though there is no clear path to passage in Congress. In 2021, the Health Equity and Access Under the Law (HEAL) Act and Lifting Immigrant Families Through Benefits Access Restoration Act (LIFT the BAR) Act were introduced into Congress. Both acts would remove the five-year waiting period for health coverage and other assistance programs that currently apply to many lawfully present immigrants under the 1996 PRORWA rules. They also would expand the definition of lawfully present immigrants to include Deferred Action for Childhood Arrivals (DACA) recipients and certain other immigrants who are authorized to be in the U.S., so that they could qualify for federally funded health care programs. In addition, the HEAL Act would allow undocumented immigrants to access health insurance coverage through the ACA Marketplaces and to be eligible for subsidies to offset the cost of this coverage. Both acts also would ensure that lawfully present immigrants with incomes below 100% FPL may receive subsidies if they are ineligible for Medicaid based on immigration status if they live in a state that has not expanded Medicaid.
Several states have proposed or taken action to expand coverage for immigrant children and pregnant individuals. Currently, six states (California, DC, Illinois, New York, Oregon 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. Several states will extend Medicaid-like, state-funded coverage to immigrant children, including Maine and Vermont in July 2022, and Connecticut to children under age nine in January 2023. New Jersey has also proposed to expand coverage to children currently ineligible due to immigration status in the FY 2023 Governor’s budget. A number of states also provide state-funded pregnancy coverage regardless of immigration status, including DC, New Jersey, and New York. DC plans to adopt the CHIP unborn child option in 2022 along with Connecticut and Maine, and Vermont will extend state-funded Medicaid-like coverage to pregnant individuals regardless of immigration status in July 2022. The American Rescue Plan Act gives states the option to extend Medicaid postpartum coverage from 60 days to 12 months beginning in April 2022. Five states—California, Connecticut, Massachusetts, Minnesota, and Washington—that are planning to take up this option will also extend the coverage to postpartum individuals who are not eligible due to immigration status. California and Illinois recently implemented 12 months postpartum coverage regardless of immigration status through CHIP Health Services Initiatives amendments.
Some states are also taking action to expand fully state-funded coverage to adult immigrants. California Governor Gavin Newsom’s 2022-2023 proposed budget would provide fully state-funded Medicaid coverage to all income-eligible adults, ages 26 to 49, regardless of immigration status, no sooner than January, 1 2024. The state previously extended state-funded Medicaid coverage to young adults ages 19-26 regardless of immigration status, and adults ages 50 and older will become eligible on May 1, 2022. In December 2020, Illinois extended state-funded coverage to low-income individuals ages 65 and older who were not eligible due to their immigration status. As of May 2022, coverage will also be extended to low-income immigrants ages 55 to 64, regardless of immigration status, and proposed legislation would further expand this coverage to all adults ages 19 and older. In Oregon, the Cover All People Act, will extend state-funded coverage to all low-income adults who are not eligible due to immigration status, starting on July 1, 2022, subject to available funding. Prior to this recent state activity, only the District of Columbia’s locally-funded Healthcare Alliance program, created in 1999, provided health coverage to low-income residents regardless of immigration status. 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 income up to 300% FPL who do not qualify for health insurance under the Affordable Care Act or other public programs because of their immigration status will be eligible for state-funded premium subsidies to assist them in purchasing individual coverage.
The Biden Administration has proposed changes to public charge policies that are intended to reduce fears of enrolling in health coverage and accessing care. As noted, after taking office, the Biden administration reversed public charge policies implemented by the Trump Administration that had made some immigrant families more reluctant to access health coverage and care for themselves and their children. More recently, on February 24, 2022, the Administration proposed new public charge regulations that would exclude use of Medicaid and CHIP, except for coverage of long-term institutionalized care, from public charge determinations. The proposed rule would largely codify the 1999 field guidance that has been guiding public charge determinations since the Biden Administration reversed the 2019 Trump Administration changes to public charge policy. The rule would define a public charge as someone “likely at any time to become primarily dependent on the government for subsistence, as demonstrated by either the receipt of public cash assistance for income maintenance or long-term institutionalization at government expense,”. It also specifies factors that can be considered in public charge determinations and notes that public charge determinations must be made on the totality of circumstances. The proposed rule will be in a 60-day public comment period, until April 25, 2022, prior to it being finalized.
The Administration has also increased funding for outreach and enrollment assistance, which may help eligible immigrant families enroll and stay enrolled in coverage. In August 2021, CMS announced $80 million in funding for 60 Navigator programs in 30 states with Federally-Facilitated Marketplaces for the 2022 plan year, significantly higher than the annual funding awarded in 2018-2020. Navigator programs must provide information that is culturally and linguistically appropriate and can assist individuals with renewing Medicaid coverage and help those who are no longer eligible for Medicaid transition to coverage through the marketplaces. This assistance may be particularly important for helping immigrant families enroll in and maintain coverage given the complex eligibility requirements for immigrants and potential linguistic barriers and fears of negative immigration consequences.
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. The pandemic has likely worsened the health and financial challenges faced by immigrants, as they have been at increased risk for exposure, have had more limited access to assistance, and have more limited access to health care. Recent federal and state activity has focused on expanding immigrant eligibility for health coverage. Moreover, the Biden Administration’s changes to public charge policy and increased funding for outreach and enrollment assistance may help increase access to health coverage for immigrant families. 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.
|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 non-citizens in the US is based on the 2020 Current Population Survey (CPS). The CPS 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 CPS, 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.