State-Funded Health Coverage for Immigrants as of July 2023
Note: This content was updated on July 27, 2023 to add information about Illinois’ temporary pause and cap on its health benefits programs for adults and seniors, respectively.
As of 2021, there were 20.8 million noncitizen immigrants residing in the U.S., accounting for about 6% 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.1 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.
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 provide health benefits and face eligibility restrictions for federally funded coverage options. Lawfully present immigrants may qualify for Medicaid and the Children’s Health Insurance Program (CHIP) but are subject to certain eligibility restrictions that result in some, particularly recent immigrants, from 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. Undocumented immigrants are ineligible to enroll in Medicaid and CHIP and 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.
Some states provide fully state-funded coverage to fill gaps in coverage for immigrant children. As of July 2023, 12 states plus D.C. provide comprehensive state-funded coverage to income-eligible children regardless of immigration status (Figure 1). Colorado currently is using state funds to offer Marketplace coverage with no premium cost for individuals with incomes up to 138% of the federal poverty level (FPL) regardless of immigration status. By 2025, Colorado plans to offer state-funded Medicaid-like coverage to income-eligible children regardless of immigration status. Massachusetts provides primary and preventive services to all children, regardless of immigration status or income.
A few states have also expanded fully state-funded coverage to adult immigrants, including those who are undocumented. Five states plus D.C. cover income-eligible adults regardless of immigration status as of July 2023 (Figure 1). Through its longstanding locally funded Healthcare Alliance program, DC 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. However, beginning July 2023, Illinois paused enrollment in its Health Benefits for Immigrant Adults (HBIA) program, which covers individuals ages 42 through 64, and placed an enrollment cap of 16,500 for FY2024 on its Health Benefits for Immigrant Seniors (HBIS) program which covers individuals 65 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 extended state-funded Medicaid coverage to individuals ages 65 and older regardless of immigration status beginning in 2023. As noted above, Colorado uses state funds to provide Marketplace coverage with no premium costs to people with incomes below 138% FPL regardless of immigration status using state funds. Minnesota will allow individuals regardless of immigration status to enroll in MinnesotaCare, a state-subsidized sliding scale program for low-income residents no sooner than 2025. 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.
Some states have also extended coverage to pregnant women regardless of immigration status through the CHIP unborn child option or using state funding. States have the option to extend CHIP coverage from conception to birth, called the unborn child option, which effectively extends coverage to pregnant people who meet eligibility requirements without regard to immigration status. As of July 2023, 20 states have taken up this option (Figure 2). While other pregnancy-related coverage in Medicaid and CHIP requires 60 days of postpartum coverage, the unborn child 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. Seven states (California, Illinois, Maryland, Massachusetts, Minnesota, Rhode Island, and Washington) have also 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 postpartum coverage extension option established by the American Rescue Plan Act. In addition, Vermont provides coverage to income eligible pregnant women regardless of immigration status using state-only funds, and, as noted above, Colorado is using state funds to offer Marketplace coverage with no premium cost for income-eligible individuals regardless of immigration status.
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 among children who are not citizens; 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, postpartum care utilization, as well as improved outcomes including increases in average gestation length and birth weight among newborns.
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.