Overview and Implications of the ACA Marketplace Expansion to DACA Recipients

Note: This content was updated on December 10, 2024, to reflect a federal court’s ruling on the ACA coverage expansion to DACA recipients and President-elect Trump’s recent statements about “Dreamers”.

On May 3, 2024, the Biden-Harris Administration published new regulations extending eligibility for Affordable Care Act (ACA) Marketplace coverage to Deferred Action for Childhood Arrivals (DACA) recipients. Under these regulations, the definition of lawfully present will newly include DACA recipients for the purposes of eligibility to purchase coverage through the ACA Marketplaces and to receive premium tax credits and/or cost sharing reductions or to enroll in Basic Health Program (BHP) coverage in states with those programs. The regulation became effective November 1, 2024, allowing for enrollment during the 2025 Open Enrollment Period, which runs from November 1, 2024, to January 15, 2025. The Administration estimates that 100,000 uninsured DACA recipients will receive coverage under the new rule. However, on December 9, 2024, a federal court in North Dakota sided with a group of 19 states alleging the ACA health coverage expansion to DACA recipients violates the Administrative Procedure Act and blocked the expansion from being implemented in those states, leaving thousands of uninsured DACA recipients without an affordable coverage option. This brief provides an overview of the DACA program, discusses its status and potential impacts of the health coverage expansion, and highlights key issues to consider.

Overview of DACA

DACA was originally established via executive action in June 2012 to protect certain undocumented immigrants who were brought to the U.S. as children from removal proceedings and receive authorization to work for renewable two-year periods. To be eligible, individuals must have arrived in the U.S. prior to turning 16 and before June 15, 2007; be under the age of 31 as of June 15, 2012 (i.e., under age 43 as of 2024); be currently enrolled in school, have completed high school or its equivalent or be a veteran; and have no lawful status as of June 15, 2012. As of June 2024, there were over 530,000 active DACA recipients residing in the U.S. (Box 1).

Prior to the 2024 health coverage expansion, DACA recipients were ineligible for any federally funded health coverage. Previously, individuals with DACA status were not considered lawfully present for purposes of health coverage eligibility and remained ineligible for Medicaid, the Children’s Health Insurance Program (CHIP), and ACA Marketplace coverage despite having a deferred action status, which otherwise qualified for Marketplace coverage. These eligibility restrictions left DACA recipients with the same limited health coverage options as undocumented immigrants, who are ineligible for federally funded health coverage programs. Some states have fully state funded health coverage programs for low-income immigrants regardless of immigration status, including DACA recipients, but they vary in eligibility and scope of benefits.

While most DACA recipients are working and in good health, many face challenges accessing health coverage and care, including high uninsured rates. Based on KFF analysis of federal survey data, a majority of immigrants who are likely eligible for DACA are working and have self-reported excellent or very good health. However, data show that DACA recipients continue have high uninsured rates, reflecting their limited eligibility for coverage, as is the case for likely undocumented immigrants. Overall, half of likely undocumented immigrant adults in the U.S. lack health insurance coverage, significantly higher than their immigrant counterparts who are lawfully present (18%) or naturalized citizens (6%) (Figure 1).

ACA Marketplace Expansion to DACA Recipients

On May 3, 2024, the Biden-Harris Administration published new regulations making DACA recipients newly eligible to purchase ACA Marketplace coverage with premium tax credits and cost sharing reductions beginning November 1, 2024. Under these regulations, active DACA recipients will be considered lawfully present for the purposes of health coverage eligibility and will therefore be able to enroll in health insurance plans through the ACA Marketplaces for the first time during the 2025 ACA Open Enrollment Period between November 1, 2024, and January 15, 2025. Income-eligible DACA recipients will also qualify for premium tax credits and/or cost sharing reductions and be able to enroll in BHP coverage in states that have implemented it (currently MN and OR). DACA recipients will be able to start using their new ACA coverage as early as December 1, 2024, under the Special Enrollment Period.

The Administration estimates that 100,000 uninsured DACA recipients will receive health coverage under the new rule which will likely result in improved access to care and financial security for DACA recipients and their families and ultimately improve health outcomes. Data from the 2023 KFF/LA Times Survey of Immigrants show that immigrants who lack health insurance coverage face a range of barriers accessing and using health care in the U.S. Uninsured immigrant adults are about three times as likely as their counterparts with insurance coverage to report not having a usual source of care other than an emergency room (42% vs. 13%) and not having had a doctor’s visit in the past 12 months (52% vs. 18%); they also are about twice as likely to report skipping or postponing care in the past 12 months (36% vs. 19%) (Figure 2). Uninsured immigrant adults also are more likely than those with insurance coverage to report unfair treatment by a health care provider and to report challenges obtaining respectful and culturally competent health care.

The coverage expansion will increase federal government costs for Marketplace subsidies and BHP coverage but may also have some positive economic impacts. In addition to the one-time cost related to changes to application and eligibility systems and processes, the government estimates increased federal expenditures of between $240 to $300 million per year for premium tax credits between 2025 and 2028 and $5 million per year for increased enrollment in BHPs. It also estimates that there might be a slight positive effect on risk pools given that DACA recipients tend to be young and healthy and that there could be positive economic impacts due to increased productivity of DACA recipients and other noncitizens from improved health outcomes. Other research also has found that immigrants pay more into the system through taxes and health insurance premiums than they utilize, helping to subsidize health care for U.S.-born citizens.

Issues to Consider

Outreach and enrollment efforts will be important for enrolling newly eligible DACA recipients into Marketplace coverage. Even among immigrants who are eligible for health coverage, many remain uninsured because of a range of enrollment barriers including immigration-related fears, confusion about eligibility, and cultural and linguistic challenges. Research shows that changes to immigration policy during the Trump Administration, including changes to public charge policies, increased these fears. The Biden-Harris Administration reversed many of the Trump-era policy changes, including changes to the public charge rule. However, a majority of immigrant adults, including nine in ten likely undocumented immigrant adults, still report uncertainty or an incorrect understanding of public charge. Amid the recent rise in anti-immigrant rhetoric, addressing misinformation and confusion about immigrants’ eligibility for government assistance and outreach and enrollment efforts from trusted individuals and organizations will be key for enrolling newly eligible DACA recipients into coverage.

The future of the DACA program and ACA Marketplace coverage expansion remain uncertain due to ongoing litigation and recent court rulings. Subject to ongoing litigation and court rulings challenging the legality of the DACA program, while the Department of Homeland Security (DHS) is accepting first-time DACA requests, it is unable to process them. However, DHS is continuing to process DACA renewal requests and related requests for employment authorization while it awaits a decision by the court. In addition, in August 2024, a group of 19 states filed a lawsuit against the federal government alleging that the ACA health coverage expansion to DACA recipients violates the Administrative Procedure Act. On December 9, 2024, a federal court in North Dakota granted the plaintiffs’ motion by blocking the ACA coverage expansion from being implemented in the 19 states that filed the lawsuit (AL, AR, FL, IA, ID, IN, KS, KY, MS, MT, ND, NE, NH, OH, SC, SD, TN, TX, VA). Elimination of the coverage expansion in some states could leave thousands of uninsured DACA recipients in those states without an affordable coverage option. Former President Trump tried to end DACA during his first term but was blocked by the Supreme Court in 2020. His campaign has said that he will try again to eliminate DACA protections if elected. However, in a recent interview, President-elect Trump indicated that he would work on addressing the status of “Dreamers” and indicated a willingness to work with Democrats on the issue, although the details of this proposed plan remain unclear.

The number of people who are eligible for DACA has been dwindling over time and there is no pathway to citizenship for DACA recipients. Given its eligibility requirements as well as legal challenges to the program, the number of people who can receive DACA has decreased over time from a high of 700,000 in 2017 to roughly 530,000 as of 2024. The American Dream and Promise Act of 2023 would provide a pathway to lawful permanent resident status and eventually citizenship for undocumented immigrants who were brought to the U.S. as children and who meet certain requirements. However, different versions of the Act have been proposed to Congress since 2001 but have never been passed suggesting that there is no clear pathway to passage of such legislation.