Federal and State Policies Affecting Immigrant Access to Health Care

Immigration continues to be the focus of much public debate at both the state and federal levels in the US.¹ Recent debate has focused on litigation surrounding the Trump administration’s new interpretation and planned enforcement of the public charge rule for current or former immigrants who apply for permanent residency (ie, green cards). The public charge rule states that immigrants are ineligible for green cards if they are “likely at any time to become a public charge,”^2(p41292) which means receiving public assistance for longer than 12 months. In addition to receipt of cash-based public assistance, the administration will include receipt of noncash assistance, including Medicaid, the Supplemental Nutrition Assistance Program (SNAP), housing vouchers, or other subsidies, when US Citizenship and Immigration Services officers determine whether an applicant for a green card is likely to become a public charge. Immigrants falling within the public charge rule will be ineligible for changes in immigration status or extensions of their stay.² Until recently, the revised public charge rule was delayed by litigation. However, on January 27, 2020, the US Supreme Court lifted injunctions against the new rule, and it is expected to be implemented in the near future.³

Many immigrants already face longstanding federal barriers to accessing federally funded benefits programs, such as Medicaid and Medicare. Under the Personal Responsibility and Work Opportunity Act of 1996, unauthorized immigrants and most authorized immigrants with less than 5 years of US residency are excluded from receiving federally funded benefits.⁴ The federal legal barriers to accessing care have been linked to high rates of uninsured status and poverty for immigrant populations. Immigrants, particularly those who are noncitizens, have substantially lower rates of health care utilization and lower mean health care expenditures than citizens who are naturalized or native born.^5,6

Unauthorized immigrants have also been excluded from participation in the Affordable Care Act (ACA).⁴ The expansion of state Medicaid programs under the ACA excluded large numbers of immigrants because of the Personal Responsibility and Work Opportunity Act, further exacerbating disparities in access to care between communities of immigrants with socioeconomic disadvantages and nonimmigrants.⁴ A recent national study⁵ of people who would qualify for Medicaid based on their low income reported that fully two-thirds of noncitizen immigrants live below the federal poverty line and more than half are uninsured. Immigrants without authorization also are prohibited from accessing the health insurance marketplaces under the ACA, even if they receive no insurance premium subsidies.^4,5

Following the lead of federal policies, few states provide any health care coverage or assistance to immigrants who are unauthorized.⁴ California and Massachusetts are exceptions to this and have instituted policies to help immigrants obtain access to health care. California’s Health for All Kids Act expanded state-funded Medi-Cal coverage to all children, regardless of immigration status.⁷ Using funding from both state appropriations and hospital service providers, Massachusetts provides health care coverage to all immigrants who are without authorization, if they are income eligible for the state’s Health Safety Net program.⁸ There is also evidence that state immigration policies have had a chilling effect on health-seeking behaviors. For example, the enactment of Arizona Senate Bill 1070, which empowered law enforcement to verify immigration status if a person was suspected to lack authorization, resulted in decreased likelihood of using preventive health care and public assistance by pregnant women and girls and mothers of Mexican origin, even if they were born in the US.⁹

Although the policy environment in the US is likely to contribute to lower rates of preventive care and worse long-term health outcomes for immigrants, data on immigrants are largely not collected or are incomplete or available only after a multiyear lag. Thus, the implications of recent federal policies on immigrant health outcomes may remain unknown for many years. Few health services research databases record citizenship status of respondents. Reasons for this paucity of data are unclear and may be a combination of well-meaning but misguided protection of immigrant respondents and efforts to avoid any perceived political issues associated with reporting these data. As a result, immigrant communities in the US are difficult to identify in health care data and consequently often ignored by health services researchers. Without data, the full scope of immigrants’ vulnerability associated with legal and economic barriers to care is uncertain, thus inhibiting identification of immigrants’ health care needs and advocacy for effective policies and interventions to address these needs.

Although lower health care utilization and expenditures by immigrants may be viewed as desirable among some policy makers, the implications of immigrants’ poor access to health care are concerning for public health. For example, an often-cited public health concern is the need to monitor and treat infectious diseases in migrant and refugee populations.¹ At a time when coronavirus disease 2019 (COVID-19) has become an emerging global health threat, legal and economic barriers to care and concerns over arrest and deportation may burden immigrant communities with a disproportionate share of risk from COVID-19 and other public health threats, despite having the fewest economic and health care resources to deal with these threats.

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