Should Undocumented Immigrants Get Health Insurance?

The issue of providing insurance to illegal immigrants is a highly debated topic, with strong opinions on both sides. On the one hand, there are those who argue that everyone, regardless of immigration status, should have access to affordable health coverage as it is a basic human right. Proponents of this view highlight the positive impact on health outcomes and quality of life, as well as the contribution of immigrants to their communities and the country. On the other hand, some argue that offering insurance to those without legal status creates an unnecessary burden on taxpayers and incentives for illegal immigration. This debate has been inflamed by the recent increase in illegal border crossings, with some politicians and commentators portraying it as a crisis.

The impact of insurance coverage on immigrant health outcomes and quality of life

Overview

Undocumented immigrants are at a high risk of being uninsured because they have limited access to coverage options. Their high uninsured rates reflect limited access to employer-sponsored insurance and eligibility restrictions that bar them from participating in Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the Affordable Care Act (ACA) Marketplaces.

Undocumented immigrants face barriers to accessing care due to their high uninsured rates. Many 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.

The impact of insurance coverage

Research shows that having insurance improves health outcomes and reduces the risk of premature death. Coverage also reduces medical debt, lowers the risk of catastrophic health care costs, and improves financial well-being. Children with health insurance experience long-term health improvements and achieve greater academic and career success.

The impact on immigrants

Immigrants who have insurance coverage are more likely to access health care and less likely to postpone or skip medical appointments. They are also more likely to receive preventive care, such as screenings and dental care. This can lead to improved health outcomes and a better quality of life.

State-level initiatives

Some states have taken steps to expand coverage for immigrants, including immigrant adults. For example, 12 states and Washington, D.C., provide fully state-funded coverage for income-eligible children regardless of immigration status, and six states plus Washington, D.C., offer similar coverage for adults. These initiatives have been shown to reduce uninsured rates among immigrants and improve access to care.

However, many immigrants, especially those who are undocumented, remain ineligible for coverage options. Immigration-related restrictions and confusing, fluctuating policies contribute to fear and uncertainty among immigrants, deterring them from enrolling in health coverage programs even when they are eligible.

The challenges undocumented immigrants face in accessing insurance and healthcare

Undocumented immigrants face several challenges in accessing insurance and healthcare. Firstly, they often have limited access to private health insurance due to their employment in low-wage jobs that do not offer health benefits. This is further compounded by eligibility restrictions for federally funded coverage options such as Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and Affordable Care Act (ACA) Marketplace coverage. Even when undocumented immigrants are eligible for coverage, they face barriers to enrollment, including fear, confusion about eligibility rules, language barriers, and literacy challenges.

Undocumented immigrants are also more likely to be lower-income, making it difficult to afford employer-sponsored coverage or insurance on the individual market. They often delay or go without needed healthcare due to their uninsured status, which can lead to worse health outcomes in the long term. While they can obtain low-cost or free care through community health centers, this care is typically limited to preventive and primary services, making it challenging to access specialty care.

Furthermore, shifts in immigration policies have increased fears among immigrant communities, leading to decreased participation in health coverage programs and services, even for those who are eligible. The fear of deportation and the potential impact on their immigration status also discourages undocumented immigrants from seeking healthcare. Additionally, complex bureaucratic processes, including paperwork and registration systems, create obstacles to accessing healthcare.

To address these challenges, some states have expanded access to health coverage for undocumented immigrants, and there have been proposals at the federal level to increase eligibility. However, many undocumented immigrants remain ineligible for coverage options, and those who are eligible face significant barriers to enrollment.

State-level efforts to provide insurance coverage to undocumented immigrants

By 2025, Colorado and Minnesota plan to offer state-funded Medicaid-like coverage to income-eligible children, regardless of their immigration status. Additionally, two of these states, New Jersey and Vermont, also provide state-funded coverage to income-eligible pregnant people, regardless of their immigration status, with Vermont extending this coverage for 12 months postpartum.

As of March 2024, six states (California, Colorado, Illinois, New York, Oregon, Washington) and D.C. have also expanded fully state-funded coverage to some income-eligible adults, regardless of their immigration status. Some additional states cover some income-eligible adults who are not otherwise eligible due to their immigration status, using state-only funds, but they limit coverage to specific groups, such as lawfully present immigrants who are in the five-year waiting period for Medicaid coverage, or they provide more limited benefits.

Maryland and Minnesota have also indicated plans to extend coverage to adults.

State-level efforts in practice

• California extended state-funded Medicaid coverage to young adults ages 19–25, regardless of immigration status, in January 2020, and adults ages 50 and older became eligible on May 1, 2022. The state further extended coverage to income-eligible adults ages 26 to 49, regardless of immigration status, in January 2024, making all low-income immigrants in the state eligible for state-funded health coverage, regardless of immigration status.
• Colorado uses state funds to provide Marketplace coverage with premium subsidies to individuals with incomes at or below 300% of the federal poverty level (FPL), regardless of immigration status, through a section 1332 waiver.
• Washington uses state funds to provide Marketplace coverage with premium subsidies to individuals with incomes at or below 250% FPL, regardless of immigration status, through a section 1332 waiver. Starting in July 2024, Washington will allow individuals, regardless of immigration status, with incomes up to 138% FPL to apply for coverage under a state-funded Medicaid-look-alike program, subject to funding availability.
• Oregon extended state-funded coverage to all adults who met income and residency criteria, regardless of immigration status, as of July 1, 2023.
• Illinois extended state-funded coverage to low-income individuals ages 65 and older, regardless of immigration status, through its Health Benefits for Immigrant Seniors (HBIS) program in December 2020. Coverage was also extended to low-income immigrants ages 42 to 64, regardless of immigration status, through the Health Benefits for Immigrant Adults (HBIA) program in 2022.
• New York extended state-funded Medicaid coverage to individuals ages 65 and older, regardless of immigration status, beginning in 2023.
• Vermont created the Immigrant Health Insurance Plan, starting in 2022, which provides health coverage to children under age 19 and pregnant women who are not eligible for Medicaid due to their immigration status.
• Connecticut's HUSKY (Medicaid/CHIP) program covers income-eligible undocumented kids up to age 12, and this will extend to age 15 starting in July 2024.
• Hawaii is considering legislation in 2024 (carried over from 2023) that would allow the state to “purchase health care services” for uninsured immigrants who aren’t eligible for Medicaid, CHIP, or coverage through the exchange, and whose incomes are up to 150% of the poverty level.

The role of federal policies and restrictions in immigrant access to insurance and healthcare

Federal policies and restrictions play a significant role in determining immigrant access to insurance and healthcare in the United States. While some policies provide a pathway to coverage, others impose limitations and barriers. Here is an overview of the role of federal policies and restrictions in this context:

Policies Enabling Access to Insurance and Healthcare for Immigrants:

• The Affordable Care Act (ACA) Marketplace: Lawfully present immigrants can enroll in health plans through the ACA Marketplace during open enrollment or special enrollment periods. They may also be eligible for subsidies if their income falls within the subsidy-eligible range.
• Medicaid and the Children's Health Insurance Program (CHIP): Lawfully present immigrants may qualify for Medicaid and CHIP, but they are subject to certain eligibility restrictions. Most immigrants need a "qualified" immigration status and must wait five years after obtaining it to enroll. However, some states have expanded coverage to include immigrant children and pregnant individuals regardless of their immigration status.
• State-Funded Coverage Initiatives: Several states have implemented their own programs to provide affordable health coverage to immigrants who are barred from federal programs due to their immigration status. For example, California, Connecticut, Illinois, and other states offer comprehensive state-funded coverage for children, and some states also cover pregnant individuals.
• DACA Recipient Inclusion: The Biden administration's rule change, effective November 1, 2024, allows Deferred Action for Childhood Arrivals (DACA) recipients to enroll in Marketplace health coverage and access income-based subsidies.

Federal Restrictions Limiting Immigrant Access to Insurance and Healthcare:

• Restrictions on Undocumented Immigrants: Undocumented immigrants are generally ineligible for federal programs such as Medicaid, CHIP, and ACA Marketplace coverage. They often face challenges in accessing private insurance due to their immigration status.
• Eligibility Requirements: Lawfully present immigrants must typically have a "qualified" immigration status and meet specific criteria, such as a waiting period, to be eligible for programs like Medicaid and CHIP.
• Confusion and Fear: Many immigrants, especially those who are undocumented, fear accessing assistance programs due to confusing and fluctuating immigration policies. They worry about potential negative consequences on their immigration status or chances of obtaining a green card.
• Language and Literacy Barriers: Language barriers and literacy challenges further hinder immigrants' understanding of eligibility rules and navigation of the enrollment process, contributing to lower enrollment rates.
• Limited Access to Employer-Sponsored Coverage: Noncitizen immigrants often work in low-wage jobs that are less likely to offer employer-sponsored health coverage. Even when coverage is available, their lower incomes may make it challenging to afford the associated costs.

The potential benefits of providing insurance coverage to undocumented immigrants

Providing insurance coverage to undocumented immigrants has several potential benefits. Firstly, it can reduce the financial burden on the healthcare system by preventing avoidable emergency room visits and hospitalizations. Undocumented immigrants often delay or forgo necessary medical care due to a lack of insurance, which can result in more complex and expensive treatments over time. Providing insurance coverage would allow them to access primary and preventive care, reducing the need for costly emergency care.

Secondly, it can improve public health outcomes and reduce health disparities. Currently, undocumented immigrants face significant barriers to accessing healthcare, resulting in higher uninsured rates and limited access to specialty services. By providing insurance coverage, they would have better access to regular medical care, improving their overall health and reducing health disparities.

Thirdly, it can lead to more efficient use of tax dollars. Undocumented immigrants already pay billions of dollars in federal, state, and local taxes, and a significant portion of the taxes collected goes towards subsidizing emergency care for uninsured patients. By providing insurance coverage, tax dollars can be used more efficiently to provide routine care, preventing costly emergency room visits and hospitalizations.

Additionally, expanding insurance coverage to undocumented immigrants can help support mixed-status families, where some members may be citizens or lawful permanent residents. This would ensure that all family members have access to the necessary healthcare services, promoting overall family well-being.

Lastly, it can contribute to a more inclusive and equitable society. Providing insurance coverage to undocumented immigrants recognizes their inherent worth and value as members of society, regardless of their legal status. It also aligns with the principles of fairness and equality, ensuring that everyone has the opportunity to maintain their health and well-being.

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