Uninsured Immigrants Face Significant Regulatory Barriers to Coverage

Regulatory barriers present significant hurdles for uninsured immigrants seeking healthcare coverage, a report from the Urban Institute and the Robert Wood Johnson Foundation (RWJF) found.

The researchers used the Urban Institute’s Health Insurance Policy Simulation Model (HIPSM) and state-level Affordable Care Act marketplace enrollment data from the CMS 2022 open enrollment period snapshot.

Nonelderly noncitizens—including lawfully present and undocumented immigrants—make up only eight percent of the US population but account for nearly a third of the nation’s uninsured population (31 percent). The report indicated that in 2024 around 8.7 million out of 22 million noncitizens—or 39.2 percent—are uninsured.

Common characteristics among uninsured noncitizens include that they may be Hispanic, nonelderly adults, males, have no or low education, are in families without naturalized members, are in families that have at least one employed member, or lack English proficiency. Over eight out of ten uninsured noncitizens are in families with one or more employed family members.

Only around 16.5 percent of uninsured noncitizens are eligible for coverage through a state or federal health insurance marketplace or public payer. Immigration status is the top barrier to healthcare coverage for most US noncitizens.

Legally present immigrants have more coverage options available to them than undocumented immigrants. Adults gain Medicaid eligibility after five years of residency and some states have expanded coverage for legally present children and pregnant immigrants. Also, they are immediately eligible for Affordable Care Act marketplace premium tax credits.

The Basic Health Program could help lower costs and improve access to coverage, the researchers mentioned. However, the program has only been tried in two states so far, and the results will vary based on the state, separate research demonstrated.

Medicaid and the Children’s Health Insurance Program (CHIP) eligibility is higher among noncitizens who live in states that have adopted Medicaid expansion. In Medicaid expansion states, 16 percent of uninsured noncitizens are eligible for these programs. In nonexpansion states, that share is 6.8 percent. However, expansion does not significantly affect premium tax credit eligibility.

For undocumented immigrants, coverage opportunities vary on a state-by-state basis. California, Colorado, and Washington have taken steps to extend coverage to undocumented immigrants.

California allows undocumented immigrants younger than 26 and older than 50 to apply for Medicaid and has plans to expand the age range. Colorado offers premium subsidies for undocumented immigrants in a certain income bracket, and Washington plans to extend eligibility for state qualified health plans to undocumented immigrants in 2024.

However, regulatory barriers are not the only factor barring noncitizens from gaining coverage. Many noncitizens work in low-wage positions in which they do not qualify for employer-sponsored health plans or they work for employers who do not offer health insurance. A little over a third of noncitizens (36 percent) have employer-sponsored health plans, compared to more than half of nonelderly individuals nationwide (54.4 percent).

Undocumented immigrants and legally present immigrants have demonstrated lower utilization than documented citizens, which could mean that the cost of expanding coverage is a less viable barrier for states.

“To achieve nearly universal coverage in the US, it will be necessary to extend coverage to noncitizens including undocumented immigrants. Federal and state governments could enact policies that remove the immigration-specific barriers and qualify noncitizens, especially undocumented immigrants, to be eligible for state-funded programs and Marketplace PTCs,” the researchers concluded.

The report outlined the continuing trends identified in a Kaiser Family Foundation issue brief, which found that 24 percent of nonelderly uninsured individuals were lawfully present and undocumented immigrants. The RWJF report was published on the heels of an HHS proposal to improve health insurance coverage for Deferred Action for Childhood Arrivals (DACA) recipients.