The Complexities of U.S. Health Care and Immigration Status

The United States spends more on health care than any other country in the world, total and per capita.[i] Nevertheless, many people living in the United States struggle to gain access to health care, let alone adequate healthcare. The difficulties associated with health care access are especially profound for immigrants.

Noncitizens (i.e., lawfully present[1] noncitizens and undocumented immigrants[2]) have low rates of health insurance coverage and access to adequate health care services. In fact, immigrants make up the largest portion of the uninsured population in the country.[ii] Research findings suggest health care insurance causes a notable divide between immigrants and non-immigrants access to primary care[iii]—compared to United States citizens, noncitizens are significantly less likely to be insured[3]. In similar respect, children with U.S. citizenship are more likely to be uninsured when at least one parent is a noncitizen, whereas children whose parents are both citizens have higher insured rates; approximately 1 in 4 children (most of which are citizens) in the country has an immigrant parent.[iv] Overall, noncitizens and families of noncitizens face numerous challenges in accessing healthcare due to immigration status.

Access to Health Insurance

There is a higher uninsured rate of noncitizens in part due to limited access to employer-sponsored health coverage, eligibility restrictions among federal programs (e.g., Medicaid, Children’s Health Insurance Program (“CHIP”), and Affordable Care Act (“ACA”) Marketplace coverage)). Most low-income people living in the United States turn to Medicaid for health insurance coverage; however, not all immigrants are eligible for Medicaid or CHIP. Undocumented immigrants and temporary visa holders[4] are ineligible for Medicaid, except when in need of emergency room services[vi]; likewise, they are unable to purchase coverage through ACA Marketplaces.[iv][vii] Lawfully present noncitizens may qualify for programs like Medicaid and CHIP, but are subject to restrictions—many such individuals must wait five years after obtaining a “qualified” immigration status before they can enroll in such programs.[iv] Elderly immigrants also face difficulties accessing Medicare because they have not met the five year residency or ten year employment requirements.[5][vi] Furthermore, the Centers for Medicare and Medicaid Services (CMS) regulations categorize individuals with Deferred Action for Childhood Arrivals (“DACA”) status as not lawfully present, thus leaving them ineligible for choices in coverage.[iv] As a result, immigrants (both legal and unauthorized) often rely on a mix of safety-net clinics and hospitals for free or reduced-price medical care, such as state- and county-owned facilities, as well as charitable and religious facilities.[vi]

In contrast, one need not meet specific citizenship status requirements to obtain employer-based or direct-purchase insurance, or college-sponsored student insurance. Even so, these options remain unavailable to many immigrants for other reasons.[viii] One such reason immigrants are less often insured than U.S.-born citizens is due to a lower rate of employer-sponsored health insurance access. Despite higher employment rates among immigrants, immigrants are less likely to be offered employer-sponsored insurance at work. This is in part because immigrants frequently work in industries that are less likely to offer health insurance; however, more detailed analyses adjusting for industry differences demonstrate that immigrants are less likely to be offered employer-sponsored insurance.[vi] And while student insurance coverage may be a viable alternative, that coverage is temporary—such insurance is conditional to enrollment.

The Impact of Health Care Barriers

Those without health insurance face a number of barriers to accessing medical care and pay more in out-of-pocket costs when receiving that care.[vi] Significant enrollment barriers in obtaining healthcare related to non-citizenship include: immigration status, socioeconomic background, language barriers, confusion regarding policies on access to/enrollment in publicly funded healthcare, stigma, and fear that immigration status will result in higher billing.[iv][v][ix] Furthermore, limiting immigrants’ access to Medicaid and CHIP result in distorting the concept and provision of emergency care, undermines public health objectives that protect the public as a whole, limits health care access to eligible citizens, and impedes the effective and economic functions of the health care system.[x]

These barriers function as a significant deterrent to obtaining health care and seeking out medical treatment, even for noncitizens who do have access to health care.[iv][xi] As a result, immigrants are significantly less likely to use primary and preventive medical services, hospital services, emergency medical services, and dental care than U.S. citizens are[6].[vi] Consequentially, health problems remain unaddressed and may worsen, therefore impacting other aspects of life, such as the ability to maintain consistent employment. Delayed treatment often results in higher medical bills upon receiving treatment; without health insurance protections, so much as a single hospitalization can lead to significant debt and/or bankruptcy.[vi]

Even though providing health care access noncitizens remains subject to debate, there is a strong contention that health care reform would be most effective access to health care programs was expanded.[xii][xiii] In failing to include many immigrants from access to healthcare, the ACA undermines its goals of securing universal, affordable health care access, improving the general population’s health, and increasing efficiency in the health care system[xiv], whereas health care access to noncitizens promotes public health goals and helps implement a more cost-effective healthcare system[xii][xiii].

Conclusion

Although there are a number of ways in which U.S. immigrants may acquire medical coverage, the fact remains that significant barriers prevent acquisition of adequate healthcare due to immigrant status. In considering the goals set forth by the ACA and benefits of health care reform, there is incentive to expand health care coverage for noncitizens in the United States. While contentions on these issues remain, one may anticipate future steps toward health care expansion.

 

Citations:

[i] Gerald Anderson et al., Why the United States is So Different from Other Countries, Health Affairs, June 2003, vol. 22, No. 3, at 103.

[ii] ARTICLE: HEALTH JUSTICE FOR IMMIGRANTS, 4 U. Pa. J. L. & Pub. Aff. 235 at 237.

[iii] Siddiqi A, Zuberi D, Nguyen QC. The role of health insurance in explaining immigrant versus non-immigrant disparities in access to health care: comparing the United States to Canada, (Soc Sci Med., 2009), https://pubmed.ncbi.nlm.nih.gov/19767135/

[iv] Health Coverage of Immigrants, Kaiser Family Foundation (July 15, 2021) https://www.kff.org/racial-equity-and-health-policy/fact-sheet/health-coverage-of-immigrants/

[v] Immigration, Health Care and Health, Robert Wood Johnson Foundation (2015) https://www.rwjf.org/en/library/research/2017/09/immigration-status-and-health.html

[vi] Ku L. Why Immigrants Lack Adequate Access to Health Care and Health Insurance (Sept. 1, 2006) https://www.migrationpolicy.org/article/why-immigrants-lack-adequate-access-health-care-and-health-insurance

[vii] ARTICLE: HEALTH JUSTICE FOR IMMIGRANTS, 4 U. Pa. J. L. & Pub. Aff. 235 at 263

[viii] ARTICLE: HEALTH JUSTICE FOR IMMIGRANTS, 4 U. Pa. J. L. & Pub. Aff. 235 at 248-49

[ix] ARTICLE: HEALTH JUSTICE FOR IMMIGRANTS, 4 U. Pa. J. L. & Pub. Aff. 235 at 257.

[x] ARTICLE:The Consequences of Restricted Health Care Access for Immigrants: Lessons from Medicaid and SCHIP, 17 Ann. Health L. 175 at 176

[xi] ARTICLE: The Consequences of Restricted Health Care Access for Immigrants: Lessons from Medicaid and SCHIP, 17 Ann. Health L. 175 at 177.

[xii] Inst. Of Med., Uninsurance Facts & Figures (Nat’l Acad. of Sciences 2001).

[xiii]See generally Inst. Of Med., Hidden Costs, Value Lost-Uninsurance in America (Nat’l Acad. Of Sciences 2003).

[xiv] ARTICLE: HEALTH JUSTICE FOR IMMIGRANTS, 4 U. Pa. J. L. & Pub. Aff. 235 at 237

 

[1] Lawfully present noncitizens include legal permanent residents (a.k.a. “green card” holders, refugees, asylees, and other individuals authorized to live in the U.S. temporarily or permanently. Health Coverage of Immigrants, Kaiser Family Foundation (July 15, 2021) https://www.kff.org/racial-equity-and-health-policy/fact-sheet/health-coverage-of-immigrants/

[2] The term “undocumented immigrant” is generally used to refer to people without a valid federal immigration status by entering the country without inspection or by entering legally, but then overstaying or violating the terms of their visa. ARTICLE: HEALTH JUSTICE FOR IMMIGRANTS, 4 U. Pa. J. L. & Pub. Aff. 235 at 243

[3] In 2019, among the nonelderly population 25% (1 in 4) lawfully present and approximately 46% (a little more than 4 in 10) undocumented immigrants were uninsured, compared to a 9% (less than 1 in 10) uninsured rate for citizens

[4] e.g., individuals with student or temporary work visas

[5] However, elderly immigrants may be eligible for Medicaid if they meet necessary Medicaid criteria (financial and otherwise) Ku L. Why Immigrants Lack Adequate Access to Health Care and Health Insurance (Sept. 1, 2006).

[6] These statistics were gathered after controlling for the impacts of race/ethnicity, income, insurance status, and health status. Ku L. Why Immigrants Lack Adequate Access to Health Care and Health Insurance (Sept. 1, 2006)