What is the immigrant health care coverage at the state level and implications for health care coverage and care?

As of 2022, there were 21.2 million people living in the U.S. who are non-citizen immigrants, about 7% of the total population. Among non-citizen immigrants, about six out of ten are legal immigrants and the remaining four out of ten are undocumented immigrants. Non-citizen immigrants, especially those who are undocumented, face significant barriers to accessing health insurance and care and are significantly more likely than citizens to be uninsured. Higher rates of uninsurance reflect more limited access to private insurance and restrictions on eligibility for federally funded insurance options. Some states have taken advantage of Medicaid and the Children's Health Insurance Program (CHIP) to expand coverage to lawfully present immigrants and/or have created fully state-funded programs to fill gaps in immigrant coverage. This brief provides an overview of states' use of these options and health insurance programs for immigrants regardless of their status. It also examines how immigrants' health coverage and care varies by state coverage policies, based on data from the 2023 Survey of Immigrants.

In recent years, states have increasingly taken steps to expand coverage for immigrants, including adult immigrants, although these efforts have been limited by fiscal constraints. As of June 2024, 12 states and the District of Columbia provide fully publicly funded coverage for income-eligible children regardless of immigration status, six states and the District of Columbia provide fully publicly funded coverage for some income-eligible adults regardless of status, and most states have used Medicaid and CHIP options to expand coverage for lawfully present immigrant children and pregnant women. Data and research show that expansions in immigrant coverage are associated with lower rates of uninsurance: adult immigrants in states with more coverage are half as likely to be uninsured as those in states with less coverage (11% vs. 22%). Despite these expansions, uninsurance rates among noncitizen immigrants remain high: 18% of legal adult immigrants and half of adult immigrants who are likely to be undocumented report being uninsured. It remains to be seen whether the movement to expand insurance coverage for immigrants will continue in the future and whether existing expansions will be sustainable over time.

Health insurance for immigrants

Noncitizen immigrants have high rates of uninsurance because they have more limited access to private insurance because they work in jobs that are less likely to offer coverage and face restrictions on eligibility for federally funded insurance options. Lawfully present immigrants can qualify for Medicaid and CHIP but are subject to restrictions that make some, especially recent immigrants, ineligible for the program even if they meet other criteria. For example, many must go through a five-year waiting period before being eligible for Medicaid or CHIP. Lawfully residing immigrants can purchase coverage through the Affordable Care Act (ACA) Marketplaces and receive tax credits for that coverage without a waiting period. Undocumented immigrants are not eligible to enroll in Medicaid or CHIP or purchase coverage through the ACA Marketplaces program. Medicaid payments for emergency services may be made on behalf of individuals who would otherwise be eligible for Medicaid if not for their immigration status. These payments can help cover the cost of emergency care provided to immigrants who are not eligible for Medicaid, but are not insurance coverage for individuals.

Medicaid and CHIP options for legal immigrants

In general, lawfully present immigrants must have "qualified" immigration status to be eligible for Medicaid or CHIP, and many of them, including most lawful permanent residents or green card holders, must wait five years after obtaining qualified status before they can enroll in the program, even if they meet other eligibility requirements. Some immigrants, such as those with Temporary Protected Status, are in the country legally but do not have qualified status and are not eligible for Medicaid or CHIP, regardless of length of stay. For children and pregnant women, states can waive the five-year waiting period and extend coverage to lawfully present immigrants without qualified status, which is known as a version of the Immigrant Children's Health Improvement Act (ICHIA). As of June 2024, 36 states plus the District of Columbia have utilized this option for children and 30 states plus the District of Columbia for pregnant women. Michigan reported plans to eliminate the waiting period for lawfully residing children and pregnant immigrants in August 2024, and Indiana plans to implement the option for children and pregnant women in 2025.

A total of 22 states and the District of Columbia have also expanded coverage to pregnant people regardless of immigration status through CHIP's From Conception to End of Pregnancy (FCEP) option. Colorado plans to implement this coverage by January 2025. While other pregnancy-related programs under Medicaid and CHIP require 60-day postpartum coverage, the FCEP option under CHIP does not provide this coverage. However, some states that have taken advantage of this option provide postpartum coverage regardless of immigration status, either through an amendment to the CHIP state plan or using state-only funding. In addition, ten states that have implemented the FCEP option (California, Connecticut, Illinois, Maine, Maine, Massachusetts, Minnesota, New York, Oregon, Rhode Island, and Washington) have used state funding or CHIP Medicaid initiatives to expand postpartum coverage to 12 months for individuals regardless of immigration status to comply with the Medicaid expansion established by the American Savings Plan Act, and Maryland is expanding coverage to four months postpartum as part of its initiative to provide.

Fully government-funded coverage

In addition to states taking advantage of Medicaid and CHIP programs, some states provide fully publicly funded insurance to fill gaps in coverage for some people, regardless of their immigration status. States vary in eligibility and the scope of benefits offered under these programs. These programs cover lawfully residing immigrants who are in the five-year waiting period for Medicaid or CHIP or who do not have "qualified status" and are not eligible for federally funded insurance, as well as undocumented immigrants. These programs also extended their coverage to Deferred Action for Childhood Arrivals (DACA) recipients who were not previously considered lawfully present in the country for purposes of eligibility for federally funded health insurance programs. However, effective November 1, 2024, the new rules will change the definition of lawful presence to include DACA recipients for purposes of eligibility to purchase coverage under the ACA Marketplaces and to receive tax credits for premiums and cost-sharing.

As of June 2024, 12 states and the District of Columbia provide comprehensive public coverage for children regardless of immigration status. These states include California, Connecticut, Illinois, Maine, Massachusetts, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and the District of Columbia. By 2025, Colorado and Minnesota plan to offer state-funded Medicaid-like coverage to children with eligible income, regardless of immigration status. In addition, two of these states (New Jersey and Vermont) also offer state-funded coverage to pregnant women with eligible income, regardless of immigration status, with Vermont extending this coverage for 12 months after delivery.

As of June 2024, six states (California, Colorado, Illinois, New York, Oregon, Washington) and the District of Columbia have also expanded fully state-funded coverage for certain income-eligible adults regardless of immigration status. Some other states cover some income-eligible adults who are not otherwise eligible because of immigration status using only state funds, but limit coverage to certain groups, such as lawfully present immigrants who are on a five-year waiting period for Medicaid coverage, or provide more limited benefits.

• Section 1332 marketplace coverage waiver
• New York
• Oregon
• Washington Section

In addition to these states, Maryland plans to allow individuals with eligible income to purchase Marketplace insurance regardless of immigration status under the unsubsidized Section 1332 waiver, pending approval of the waiver by the Center for Medicare and Medicaid Services (CMS). Minnesota plans to allow individuals with eligible income, regardless of immigration status, to enroll in MinnesotaCare, a state-subsidized sliding scale program for low-income residents, no earlier than 2025, subject to funding availability.

The impact of state insurance coverage expansions on health care access and utilization

The data suggest that immigrants' state-level health insurance coverage options affect their health insurance coverage, access to and utilization of health care. A 2023 survey of immigrants shows that immigrants living in states with more extensive immigrant coverage policies have higher levels of health insurance coverage, are less likely to delay or not get health care, are more likely to get health care, and have a trusted health care provider compared to their counterparts living in states with less extensive coverage policies, as described below.

The Immigrant Survey 2023 is a nationally representative survey designed to explore the immigrant experience and includes questions related to access to health care. Survey data was analyzed by the prevalence of health insurance coverage for immigrants in the state in which they reside. States were classified as having less, moderate, and more extensive coverage policies based on whether states have adopted the ACA Medicaid program's expansion to low-income adults in general, Medicaid and CHIP options to cover immigrants, and/or provide state-funded insurance to at least some groups (e.g., children) regardless of immigration status, as shown below:

Broader coverage. States were considered to have broader coverage if they implemented the ACA Medicaid expansion for low-income adults, used Medicaid and CHIP options to cover immigrants, and provided state-funded coverage to at least some groups (e.g., children) regardless of immigration status. Even if state-funded coverage only applies to children, having such coverage may reduce immigrant adults' concerns about applying for coverage for themselves if they are eligible for other options.

Moderately Expanded Coverage. States were classified as having moderately expanded coverage if they implemented the ACA Medicaid expansion for low-income adults and took advantage of at least two options for expanding coverage for immigrants available in Medicaid and CHIP, including covering lawfully residing children or pregnant immigrants without a five-year waiting period or adopting the Conception to Termination of Pregnancy CHIP option to cover income-eligible pregnant people regardless of immigration status.

Less extensive coverage. States were considered to have less coverage if they did not implement the ACA Medicaid expansion for low-income adults and/or used fewer than two options to expand Medicaid or CHIP coverage to immigrants and did not offer them publicly funded health insurance for immigrants.

Immigrant adults in states that provide more extensive coverage, including ACA Medicaid expansion for low-income adults and at least some state-funded coverage for immigrants, are half as likely to be uninsured as those in states with less extensive coverage (11% vs. 22%). This difference is driven by higher rates of Medicaid and other public programs (including state-funded coverage) in states with more extensive coverage compared to states with less extensive policies (23% vs. 9%), while coverage rates for private programs and Medicare are similar.

Reflecting higher levels of health insurance coverage, adult immigrants in states with broader policies are slightly less likely to say they miss or delay health care because of cost. Immigrants in states with broader policies are half as likely to report delaying or not getting health care (4% vs. 10%) or dental care (7% vs. 14%) because of cost as immigrants in states with less broad policies.

There is less variation in health care utilization among immigrants by state policies on insurance coverage, which may reflect the use of safety-net resources available to uninsured immigrants, such as community health centers and emergency rooms. A majority (77%) of adult immigrants in the U.S. report having sought medical care in the past year. The rate of seeking medical care is slightly lower in states with less coverage (74%) compared to states with more coverage (79%), although a majority still report seeking medical care. This pattern may reflect the use of safety net resources available to uninsured immigrants, such as community health centers or emergency rooms. Immigrant adults are more likely than U.S. natives to say they rely on community health centers (CHCs) as their usual source of health care, reflecting the ability of CHCs to provide free or low-cost care to low-income and uninsured populations and their ability to provide culturally and linguistically sensitive care. Immigrants in states with less expansive policies are slightly more likely to say they use a CHR (33% vs. 28%) and slightly less likely to say they use a private physician (39% vs. 44%). Immigrant adults in states with less expansive policies are also less likely to report that they have a health care provider they trust to answer questions about their health than residents of states with more expansive policies (68% vs. 78%).

Other studies show that expanding insurance coverage for immigrants can reduce uninsurance, increase health care utilization, lower costs, and improve health outcomes. Noncitizen children are more likely to be uninsured and more likely to delay health care because of cost than their citizen siblings. Citizen children with noncitizen parents are also more likely to be uninsured than citizen children with U.S.-born parents. A 2016 expansion of a program in California to cover low-income children regardless of immigration status resulted in a 34% reduction in uninsurance rates. Similarly, the study found that children living in states that expanded coverage to all children regardless of immigration status were less likely to be uninsured, to forgo medical or dental care, and to miss preventive health screenings than children living in states that did not expand coverage. Other studies have found that expanding Medicaid coverage to pregnant women, regardless of immigration status, was associated with higher rates of prenatal care and better outcomes, including increased average gestational length and birth weight, while more restrictive state coverage policies were associated with reduced use of postpartum care. The cost of providing coverage to adult immigrants under the Medicaid expansion was also found to be less than half the cost per person for adult Americans. Recent estimates also suggest that state-funded Medicaid expansion for all immigrants, regardless of their status in California, can reduce poverty among noncitizen immigrants and their families.