Why more states are expanding health insurance for immigrants, even as the issue heats up the GOP establishment?

A growing number of states are opening taxpayer-funded health insurance programs for immigrants, including those living in the U.S. without permission, even as Republicans attack President Joe Biden over a surge in illegal southern border crossings.

Eleven states and Washington, D.C., provide full health insurance to more than 1 million low-income immigrants, regardless of their legal status, according to state data compiled by KFF Health News. Most of them are not authorized to live in the U.S., state officials said.

Enrollment in these programs could nearly double by 2025 as at least seven states begin or expand coverage. In January, Republican-controlled Utah will begin covering children regardless of immigration status, and New York and California will expand eligibility to cover more adults.

"These are kids, and we have a heart," said Utah Rep. Jim Dunnigan, a Republican who initially opposed his state's plan to cover children without legal status, but after compromises, including a cap on enrollment, agreed.

The Pew Research Center estimates that there are more than 10 million unauthorized people living in the United States. Immigrant advocates and academic experts point to two factors that explain the growing interest of state leaders in providing health care to this population: The Pandemic underscored the importance of insurance coverage in controlling the spread of infectious diseases, and some states are also focusing on people without legal status to further reduce the nation's record low uninsured rate.

Lawmakers said states also expanded coverage in response to requests from hospitals to reduce the financial burden of treating uninsured patients.

All states pay hospitals to provide emergency care to some unauthorized residents in emergency rooms, a program known as Emergency Medicaid. About a dozen states have extended coverage for such people for prenatal care only. Full government-provided health insurance is much rarer but increasingly common.

According to a KFF-Los Angeles Times study, half of people living in the U.S. without authorization are uninsured. This is more than five times the rate of uninsured U.S. citizens. Unauthorized immigrants are ineligible for federal health care programs. But states can use their own funds to provide insurance through Medicaid, the federal insurance program for low-income people.

California became the first state to begin offering insurance to immigrants regardless of legal status, starting with children in 2016.

"It's a real reflection of the conflict that exists in the country and how states are realizing that we can't ignore immigrant communities just because of their immigration status," said Adriana Cadena, director of the immigrant family advocacy group. Many of the millions of people without permanent legal residency have been in the United States for decades and have no path to citizenship, she said.

The expansion of health insurance in states comes amid growing Republican hostility toward migrants. In fiscal year 2023, the U.S. Border Patrol apprehended nearly 1.5 million people after they crossed the southern border, a record. Under Biden, GOP presidential candidates have portrayed the border as in crisis and the dangers of illegal immigration, such as rising crime rates, as the country's top domestic problem.

Simon Hankinson, a senior fellow at the conservative Heritage Foundation who specializes in immigration issues, believes states will regret expanding insurance for immigrants without permanent legal residency because of the costs. He noted that Illinois recently suspended enrollment in its program because of financial problems.

"We need to share resources with those who contribute to the community, not give benefits to those who haven't contributed, because I don't see how that math is going to work in the long run," Hankinson said. "Otherwise you create an incentive for people to come in and get free stuff."

According to the Pew Research Center, most unauthorized adults work, making up about 5% of the U.S. labor force. The state with the largest number of unauthorized residents with government-provided health insurance is California, which currently covers about 655,000 immigrants without regard to their legal status. In January, it will expand coverage to people ages 26-49 regardless of their immigration status, which will provide coverage to an additional 700,000 Californians.

Connecticut, Maine, Massachusetts, New York, Rhode Island, Vermont, Washington and Washington state also provide full coverage for some people living in the U.S. without authorization. New York and Washington State are expanding eligibility next year.

In recent years, Oregon, Colorado, and New Jersey have begun covering more than 100,000 people regardless of legal status. Minnesota will follow in 2025, covering an estimated 40,000 people.

While states are expanding coverage to people living in the U.S. potentially without authorization, some are imposing enrollment limits to control costs.

The cost of the program in Utah is capped at $4.5 million per year and enrollment will be about 2,000 children. Premiums will vary based on income but will not exceed $300 per year, and preventive services will be covered in full.

"The pandemic has shown that insurance coverage for everyone is necessary," said Cyriac Alvarez Valle, a senior policy analyst with the advocacy group Voices for Utah's Children. "It's going to have a huge impact on the lives of these children."

Without insurance, she said, many children use emergency rooms for primary care and can't afford medications, specialists or hospital care. "I'm not sure this will open the door to adults getting insurance as well, but it's a good step forward," Alvarez Valle said.

Colorado is also limiting enrollment for subsidized coverage under its program, capping it at 10,000 in 2023 and 11,000 in 2024. Seats for 2024 were filled within two days of enrollment beginning in November.

Adriana Miranda was able to provide coverage both years.

"You feel a lot more peace of mind knowing you won't owe hospitals as much," says Miranda, 46, who is enrolled in a private plan through OmniSalud, a program similar to Obamacare's Marketplace program in which low-income Coloradans without legal status can buy plans with reduced premiums.

Miranda left Mexico in 1999 and followed her two brothers to the United States. She now works for Lamar Unidos, a non-profit immigrant rights group.

Before she had health insurance, she said, she struggled to pay for her diabetes care and accumulated thousands of dollars in debt after foot surgery. Under the government program, she does not pay a monthly premium because of her low income, and she pays $40 for specialist visits.

"I was very happy, wasn't I? Because I was able to get it. But I know a lot of people who are also very needy were not able to get it," she said.

OmniSalud covers only a small fraction of the more than 200,000 people living in Colorado without authorization, says Adam Fox, deputy director of the Colorado Consumer Health Initiative. But starting in 2025, all low-income children will be able to be covered by Medicaid or a related children's health insurance program, regardless of immigration status.

"It is increasingly recognized that people, regardless of their immigration status, are part of society and should have access to health care on a regular and reliable basis," Fox says. "If they don't, it results in additional costs and trauma to health care systems and communities."