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September 3, 2021

Undocumented Immigrants and COVID-19: A Call for Federally Funded Health Care

Author Affiliations
  • 1Center for Bioethics and Humanities, State University of New York Upstate Medical University, Syracuse
  • 2Department of Medicine and Office of Research, Denver Health, Denver, Colorado
  • 3Division of General Internal Medicine and Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora
JAMA Health Forum. 2021;2(9):e212252. doi:10.1001/jamahealthforum.2021.2252

As the COVID-19 pandemic has torn through communities around the country and around the world, one searing lesson learned has been the danger of a health care system that leaves some members of society out. In the US, immigrants are often excluded from care. This is both by design, as with the exclusion of undocumented immigrants and some legal immigrants from Medicaid, Medicare, and the Patient Protection and Affordable Care Act, and as a consequence of immigration policies. For example, the Trump administration’s change to the public charge rule penalized the use of public benefits by immigrants seeking to become lawful permanent residents. Although this rule has since been revoked by the Biden administration, it had a chilling effect on some immigrants who chose to avoid using even those public benefits to which they were entitled.1 This is particularly true for undocumented immigrants; although some states provide coverage for some of this group (including pregnant people and people with end-stage kidney disease), most undocumented immigrants are unable to receive publicly funded health insurance. Undocumented immigrants are therefore among the most likely people in the country to be uninsured, including 45% of the nonelderly undocumented population and 33% of undocumented children in 2018.2

During the COVID-19 pandemic, lack of health insurance has left some undocumented patients unable or unwilling to seek care, a potentially fatal decision.3 For many immigrants, this patchwork system creates insurmountable barriers to care, which can be deadly in the face of a dangerous communicable disease. To address the patchwork (and often threadbare) insurance options available to undocumented immigrants across the US, policy changes are warranted during the ongoing pandemic and its aftermath.

Because of the communicable nature of COVID-19, the US Congress included funding for the treatment of uninsured patients with COVID-19 as part of the 2020 Coronavirus Aid, Relief, and Economic Security (CARES) Act, including $175 billion in the Provider Relief Fund. However, this model does not actually offer insurance to the patients, who may be unaware that hospital care for COVID-19 might be reimbursed and that the funding is tied to a primary diagnosis of COVID-19. The inadequacy of this option has led several states to adopt emergency Medicaid authorizations to cover uninsured patients with COVID-19.4

Under the Emergency Medical Treatment and Active Labor Act (EMTALA), hospitals must assess and stabilize all patients who present to their emergency departments without regard to their insurance status. As a result, patients with COVID-19 who require emergency department services or an inpatient hospital admission can receive treatment in all 50 states, and that treatment can generally be covered by Emergency Medicaid for emergency department services (and, in some states, for inpatient services). However, once a patient is stabilized, EMTALA no longer applies. It also does not apply for uninsured patients who do not require emergency services and instead receive outpatient primary care services for the treatment of COVID-19, and it does not preclude hospitals from issuing potentially ruinous bills to patients for the treatment of conditions not covered by Emergency Medicaid. Several states have therefore amended their Emergency Medicaid–qualifying conditions to include outpatient prevention, testing, and treatment of COVID-19; as of March 2021, 12 states (California, Colorado, Connecticut, Delaware, Illinois, Massachusetts, Maine, Michigan, New York, Oregon, Pennsylvania, and Washington) have done so.4 In New York, for example, the state’s Department of Health issued guidance in March 2020 that emergency services could be reimbursed for COVID-19 testing, evaluation, and treatment of undocumented individuals without copays.5

Following the lead of these 12 states, 47 members of Congress wrote a letter to the Centers for Medicare & Medicaid Services urging the agency to clarify that Emergency Medicaid will cover treatment for COVID-19 as an emergency condition in all states.6 Although this policy would be a helpful step toward ensuring that undocumented immigrants can access timely care for COVID-19 in the short term, it leaves open the question of whether care for long-term sequelae of COVID-19 will also be considered “emergency services” or whether chronically ill patients, such as those with “long COVID,” will have ongoing access once their immediate respiratory symptoms are resolved. If not, many undocumented patients may be forced to rely on Emergency Medicaid only when their chronic symptoms reach crisis status, such as many undocumented immigrants with end-stage kidney disease must do in states that do not cover scheduled outpatient hemodialysis.7

For many reasons, this system is unsustainable. The COVID-19 pandemic has repeatedly demonstrated that infectious diseases affect undocumented immigrants and citizens alike. While immigrants are more likely to hold high-risk essential jobs than many citizens,8 they still move within the same public spaces as those who can afford to stay home. Grocery stores, health care settings, and gas stations are all public places where people in close contact are susceptible to infection. Only by providing care to the population as a whole can a communicable infection such as COVID-19 be controlled.

But if this argument alone is not sufficient to justify access to care for undocumented immigrants with chronic conditions that result from COVID-19, consider instead an economic argument. For many people with COVID-19, the condition undermines their ability to fully participate in the social and economic activity of their communities. Many may be unable to return to work or will incur substantial out-of-pocket costs for necessary care, creating extreme financial instability, which is dangerous for individual families and also hinders their ability to participate in the local economy.

The patchwork system currently in place, which provides coverage to some groups of immigrants in some states, must be changed. At the periphery of debates on the US health care system, a policy has been proposed to include all US residents in the programs that provide publicly funded health care. At a Democratic presidential debate in June 2019, all candidates, including now-President Biden, endorsed the inclusion of undocumented immigrants in their visions of universal health care.9 We urge President Biden and members of Congress to include all US residents, regardless of immigration status, in plans for a universal health care system, as some of the proposed Medicare-for-all plans do. COVID-19 has underscored the necessity of such a policy decision to create a more just and equitable health care system that can withstand the next pandemic.

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Article Information

Published: September 3, 2021. doi:10.1001/jamahealthforum.2021.2252

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Fabi R et al. JAMA Health Forum.

Corresponding Author: Rachel Fabi, PhD, Center for Bioethics and Humanities, State University of New York Upstate Medical University, 618 Irving Ave, Syracuse, NY 13210 (fabir@upstate.edu).

Conflict of Interest Disclosures: None reported.

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Cervantes  L, Johnson  T, Hill  A, Earnest  M.  Offering Better Standards of Dialysis Care for Immigrants: The Colorado Example.   Clin J Am Soc Nephrol. 2020;15(10):1516-1518. doi:10.2215/CJN.01190120PubMedGoogle ScholarCrossref
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All democratic candidates support health care for undocumented immigrants: ‘we do ourselves no favors’ when millions can’t access care. Kaiser Health News. June 28, 2019. Accessed June 22, 2021. https://khn.org/morning-breakout/all-democratic-candidates-support-health-care-for-undocumented-immigrants-we-do-ourselves-no-favors-when-millions-cant-access-care
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    1 Comment for this article
    Excellent Article
    Fernando Wilson, PhD | University of Utah
    I want to commend the authors for their article. Undocumented immigrants have largely been overlooked or ignored by state and federal policymakers throughout the course of the pandemic despite their particularly vulnerable social and economic status, in my opinion. The authors highlight an important issue that urgently needs consideration. At a minimum, the 1996 Personal Responsibility and Work Opportunity Reconciliation Act, which created substantial barriers to accessing care by undocumented and many documented immigrants, must be re-examined.