Health Coverage of Immigrants

Summary

In 2019, there were 21.3 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 2019, among the nonelderly population, 25% of lawfully present immigrants and more than four in ten (46%) undocumented immigrants were uninsured compared to less than one in ten (9%) citizens. Among citizen children, those with at least one noncitizen parent are more likely to be uninsured compared to those with citizen parents (9% vs. 5%).

Research suggests that the changes to immigration policy enacted by the Trump administration contributed to increased fears among immigrant families about participating in programs and seeking services, including health coverage and care. These include policies focused on curbing immigration, enhancing immigration enforcement, and limiting the use of public assistance among immigrant families.

The pandemic has 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 face risk of financial difficulties due to the pandemic, as many are working in service industries, such as restaurants and food services, that have suffered cutbacks. Initial job losses amid the pandemic were particularly high among immigrants.Given their low incomes, job loss could lead to significant financial pressures and increase the share who are uninsured, as people lose access to employer-sponsored insurance or are no longer able to afford coverage.

Restrictions limit immigrants’ access to COVID-relief, and ongoing immigration-related fears are making some reluctant to access assistance, services, and COVID-19 vaccines. Although noncitizen immigrants face increased risks associated with the pandemic, restrictions limit immigrants’ eligibility for federal health and financial relief provided in response to COVID-19. Moreover, even though the Biden administration has reversed many immigration policy changes made by the Trump administration that increased fears, recent data suggest that ongoing immigration-related fears are contributing to reluctance to access assistance and services as well as COVID-19 vaccines.

Overview of Immigrants

In 2019, there were 21.3 million noncitizens and 22.9 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 18.6 million or one in four children had an immigrant parent as of 2019, and the majority of these children were citizens. About 9.4 million or 12% were citizen children with a noncitizen parent.

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Figure 1: Immigrants and Children of Immigrants as a Share of the Total U.S. Population, 2019

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.

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 2019, more than three-quarters of the 28.9 million nonelderly uninsured were U.S.-born and naturalized citizens (Figure 2). The remaining 23% were noncitizens.

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Figure 2: Nonelderly Uninsured by Citizenship Status, 2019

However, noncitizens, including lawfully present and undocumented immigrants, were significantly more likely to be uninsured than citizens. Among the nonelderly population, 25% of lawfully present immigrants and more than four in ten (46%) undocumented immigrants were uninsured compared to 9% of citizens (Figure 3).

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Figure 3: Uninsured Rates Among Nonelderly Population by Immigration Status, 2019

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).

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Figure 4: Uninsured Rates Among Children by Immigration Status and Parent Immigration Status, 2019

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.

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Figure 5: Employment and Income Among Nonelderly Population by Immigration Status, 2019

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 women, states can eliminate the five-year wait and extend coverage to lawfully present immigrants without a qualified status. As of 2021, 35 states have taken up this option for children and half have elected the option for pregnant women.

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.

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. 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.

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. 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, nearly eight in ten (79%) uninsured lawfully present immigrants were eligible for ACA coverage, including 27% who were eligible for Medicaid and 52% 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.

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Figure 6: Eligibility for ACA Coverage Among Nonelderly Uninsured by Immigration Status

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. The Trump administration implemented a range of policies to curb immigration, enhance immigration enforcement, and limit use of public assistance programs among immigrant families. Research shows that, amid this policy climate, some immigrant families avoided enrolling themselves and/or their children in public programs, including Medicaid. 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 has since reversed many of these changes, including the changes to public charge policy.

Impact of the Pandemic on Immigrant Health Coverage

The pandemic has 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 face risk of financial difficulties due to the pandemic, as many are working in service industries, such as restaurants and food services, that have suffered cutbacks. Initial job losses amid the pandemic were particularly high among immigrants.Given their low incomes, job loss could lead to significant financial pressures for them and their families and may increase the share who are uninsured, as people lose access to employer-sponsored insurance or are no longer able to afford coverage.

Restrictions limit immigrants’ access to COVID-19 relief, and ongoing immigration-related fears are making some reluctant to access assistance, services, and COVID-19 vaccines. Although noncitizen immigrants face increased risks associated with the pandemic, restrictions limit immigrants’ eligibility for federal health and financial relief provided in response to COVID-19. Moreover, even though the Biden administration has reversed many immigration policy changes made by the Trump administration, recent data suggest that ongoing immigration-related fears are contributing to reluctance to access assistance and services as well as COVID-19 vaccines. For example, surveys of Hispanic adults and Asian community health center patients show some are continuing to avoid participating in assistance programs for health, housing, or food due to immigration-related fears. Data also suggest that immigration-related fears are contributing to reluctance to access COVID-19 vaccines among Hispanic adults even though all individuals are eligible for the vaccine regardless of immigration status.

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 U.S. for at least one year
  • Conditional entrant granted before 1980
  • Granted withholding of deportation
  • Battered noncitizen, 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
  • Citizens of the Marshall Islands, Micronesia, and Palau who are living in one of the U.S. states or territories (referred to as Compact of Free Association or COFA migrants) (Effective December 27, 2020 COFA migrants are considered “qualified noncitizens” and are eligible for Medicaid, if they meet all of the eligibility criteria for their state.)
  • 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/.
Endnotes
  1. 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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