Health Insurance in the United States
The complex nature of the United States healthcare system can present numerous barriers to access for immigrants. With the patchwork mosaic of healthcare coverage options that varies from state to state, understanding where and how to sign up for health insurance can be baffling. It can be even more difficult for a recently arrived immigrant to make an informed decision about the ideal plan for themselves and their family that will provide an optimal amount of coverage for healthcare services to meet their needs while also remaining within their budget.
The health insurance landscape in the United States is complex. As of 2018, 55.1% of Americans received private health insurance from their employers, although this percentage is lower than it was before the passage of the Affordable Care Act (ACA). Conversely, the percentage of Americans covered by Medicaid, which is a joint federal-state funded program for low-income households, and Medicare, a federally run program for seniors age 65 years and older, has increased since the passage of the ACA. However, there are still barriers to insurance for immigrants, regardless of immigration status. As evidence of this, the Kaiser Family Foundation reports that in 2017, uninsured rates among the non-elderly US population were 8% for citizens, 23% for lawfully present immigrants, and 45% for undocumented immigrants.
Healthcare options for Undocumented Immigrants
Many types of health insurance and healthcare are inaccessible to undocumented immigrants. For example, undocumented individuals are ineligible to enroll in Medicare, Medicaid, and the Children's Health Insurance Program (CHIP), and they cannot purchase coverage through ACA marketplaces. Other categories of immigrants who are considered lawfully present, such as DACA and TPS recipients, are also unable to purchase coverage through the above options. On a positive note, as of 2019, 16 states have opted to provide prenatal care to pregnant women regardless of immigration status by extending CHIP benefits to the unborn child.
Immigrants in many communities around the country can access health care services at community health centers, regardless of their immigration status. However, this care is often limited to preventative and primary care, which leaves many types of specialty care inaccessible to undocumented immigrants. Because of these difficulties in access, many undocumented immigrants go without access to needed healthcare, or they delay access to such care. This leads to worse health outcomes and greater healthcare costs in the long run.
Federal law requires all emergency healthcare centers to screen and stabilize all patients who seek emergency care at their establishments. Medicaid provides funds to offset costs incurred by these healthcare centers when treating patients who are ineligible for Medicaid due to their immigration status. Because of this, many undocumented immigrants see few other options than seeking healthcare in an emergency facility, even when a less intensive form of healthcare would be acceptable if the individual had access to health insurance.
Emergency Medicaid is available for individuals who would otherwise be eligible for Medicaid were it not for their immigration status. Those who are ineligible for Medicaid include undocumented immigrants as well as lawfully present individuals such as those under Temporary Protected Status (TPS), Delayed Action for Childhood Arrivals (DACA), or those with lawful permanent resident status who have had this status for less than five years. The types of care covered include medical conditions manifesting themselves by acute symptoms of sufficient severity, such that in the absence of medical attention, one of the following could result: 1) placing the patient's health in serious jeopardy; 2) serious impairment to bodily functions; 3) serious dysfunction of any bodily organ or part.
Affordable Care Act Marketplace Enrollment for Lawfully Present Immigrants
Lawfully present individuals may enroll in a health insurance plan through the ACA's Health Care Marketplace in their state of residence. However, enrollment must be completed during an annual open enrollment period, unless the individual qualifies as having a special life change that makes them eligible for a special enrollment period outside of the standard period. These life changes include losing health coverage (such as losing a job and subsequently losing employer-provided health coverage), or gaining lawful presence or US citizenship.
Immigrant Healthcare during the COVID-19 Pandemic
Questions of immigrant access to healthcare have become more pressing than ever during the COVID-19 pandemic. This is due in part to the need for testing and treatment in case of COVID-19 infection and also due to the changing nature of immigration policies under the Trump administration that have led to increasing fears and apprehension among immigrant communities in relation to accessing healthcare services. While eligibility for Medicaid, Medicare, and CHIP have not changed, there are some resources available to immigrants regardless of immigration status during this time. For example, the Families First Coronavirus Response (Families First) Act, the Coronavirus Aid, Relief, and Economic Security (CARES) Act, and the Paycheck Protection Program and Health Care Enhancement (Paycheck Protection) Act have all provided funds to healthcare providers that have resulted in expanded availability of free COVID-19 testing. The CARES Act has also made additional funding available to community health centers.
Additionally, states have the option to cover COVID-19 testing, treatment, and vaccines when they become available as emergency Medicaid. US Citizenship and Immigration Services (USCIS) has declared that it will not consider use of such care in a public charge inadmissibility determination, even if the care has been provided under Medicaid.
Aritga, S. & Diaz, M. (2019). Health Coverage and Care of Undocumented Immigrants. Kaiser Family Foundation. Available: https://www.kff.org/disparities-policy/issue-brief/health-coverage-and-care-of-undocumented-immigrants/
National Immigration Law Center (NILC). (2020). Update on Access to Healthcare for Immigrants and their Families. Available: https://www.nilc.org/issues/health-care/update-on-access-to-health-care-for-immigrants-and-their-families/