The Status of Uninsurance Among Immigrants, Barriers to Coverage

Noncitizens are more likely to be uninsured, including immigrants who are lawfully present in the US, a Kaiser Family Foundation (KFF) issue brief determined.

In 2020, 24 percent of the nonelderly uninsured population consisted of noncitizens, which includes both lawfully present and undocumented immigrants. The remaining three-quarters of the uninsured population were either citizens or naturalized citizens.

When researchers broke down the uninsured noncitizen population they found that 42 percent of undocumented immigrants and 26 percent of legally present immigrants were uninsured. In contrast, eight percent of US citizens are uninsured.

Children with at least one noncitizen parent were more likely to be uninsured. Among children with one noncitizen parent, ten percent were uninsured. For the rest of the population without a noncitizen parent the uninsurance rate was four percent.

Noncitizens were less likely to have access to financial support for healthcare coverage. 

The issue brief found that eight percent of lawfully present immigrants fall in the coverage gap between Medicaid eligibility and eligibility for tax credits under the American Rescue Plan Act. Half of all lawfully present immigrants were tax credit eligible. And about three in ten lawful immigrants were eligible for Medicaid.

All undocumented immigrants were ineligible for any kind of financial assistance through Medicaid coverage or tax credits due to their immigration status.

Lawfully present immigrants have access to public healthcare coverage, the issue brief noted. They can access Medicaid coverage or Children’s Health Insurance Plan (CHIP) coverage. 

But in order to qualify for coverage under these programs, they must have obtained a certain immigration status and then waited approximately five years before they can enroll.

Undocumented immigrants, however, are not eligible for any public payer coverage, with narrow exceptions. 

States have some flexibility to cover certain services such as pregnancy-related coverage for undocumented immigrants. But not all states have adopted this option. Undocumented immigrants can also receive coverage for emergency services but only if they meet the criteria for public payer coverage eligibility.

“Uninsured undocumented immigrants are ineligible for coverage options due to their immigration status. In the absence of coverage, they remain reliant on safety net clinics and hospitals for care and often go without needed care,” the issue brief explained.

After assessing the state of uninsurance among noncitizens, the researchers investigated why uninsurance was so prevalent among this population.

The issue brief found that most nonelderly noncitizen families included at least one individual who is employed full-time. 

The rate of living with a full-time worker was about equal with the likelihood that citizens would be living with a fully-employed individual: 83 percent of citizens lived with an individual who was employed full-time compared to 83 percent of lawfully present immigrants and 84 percent of undocumented immigrants.

While employment might not be a rarity in the noncitizen population, income levels remained low. Around a quarter of all citizens are low-income (26 percent)—living on less than 200 percent of the federal poverty level. Meanwhile, 39 percent of lawfully present immigrants and 44 percent of undocumented immigrants have low incomes.

When employment is not a barrier to healthcare coverage, noncitizens face a couple of other challenges in accessing coverage. There is still confusion in the immigrant population about changes to the public charge rule, which are now defunct. Separate research has established strategies that public payers can adopt to reduce misinformation about the public charge rule.

Additionally, noncitizen may face language and literacy barriers and challenges in navigating public payer coverage enrollment.

Moreover, the coronavirus pandemic may have posed a particularly high risk for noncitizens who often live and work in geographies and positions with the potential for coronavirus exposure and who were more likely to experience job loss. They were less likely to have access to coronavirus relief and vaccines.

The researchers noted that lawmakers had taken certain steps to improve the status of immigrant healthcare coverage. 

For example, citizens are now eligible for Medicaid in the Compact of Free Association communities. Policymakers in Congress are considering a couple of immigrant healthcare coverage eligibility proposals. Some states have expanded access to coverage for immigrant children and pregnant persons while others are expanding state-funded immigrant healthcare coverage overall.

Additionally, the Biden administration has boosted outreach and enrollment assistance funding generally, which may increase enrollment among immigrants.