Key takeaways:
There are over 11 million undocumented noncitizens living and working in the U.S.
Undocumented noncitizens are ineligible for most insurance programs and face barriers to obtaining healthcare.
Many organizations and programs are working to improve healthcare delivery for undocumented noncitizens.
Undocumented noncitizens have the lowest rate of healthcare coverage in the U.S. This limited access to healthcare services results in disproportionately poor health outcomes, delays in care, and increased use of emergency services.
Due to this widespread and expensive issue, many healthcare organizations are using creative alternatives in an attempt to close this coverage gap.
Here, we review the state of care for undocumented noncitizens and what’s being done to improve it.
Using healthcare as an undocumented noncitizen
Undocumented noncitizens tend to work lower-wage jobs and are less likely to receive health insurance through their workplace. They are also more likely to be of low income, making employer-sponsored coverage difficult to afford when available.
Undocumented citizens are also ineligible for comprehensive government-funded health coverage through Medicare, Medicaid, or subsidized ACA marketplace plans. This leaves only emergency Medicaid, which pays solely for healthcare services deemed true medical emergencies and perinatal services.
Public charge law
Public charge laws take into consideration the public services someone uses when considering eligibility for citizenship. Essentially, if someone utilizes multiple public services, they may be denied entry to the U.S. or be denied a green card. In 2018, the law changed to include the use of emergency Medicaid, which was previously protected and is the only accessible form of Medicaid for undocumented noncitizens.
These policies negatively affected healthcare utilization in undocumented populations, creating the fear that use of healthcare services may lead to deportation or difficulty obtaining citizenship. The changes caused 1 in 4 undocumented Hispanic adults to avoid enrolling in any publicy funded programs and 1 in 4 Asian patients to avoid participating in publicly funded community health centers.
In February 2022, the 2018 law was discontinued. However, it created lasting fear, misinformation, and a general distrust that continues to prevent many from utilizing healthcare services.
Finding and initiating care
Undocumented noncitizens have a high uninsurance rate, of about 55%, compared to 23% of lawfully present noncitizens and 8% of American citizens.
Uninsured individuals are more likely to postpone healthcare visits and preventative screenings due to the following reasons:
Distrust of government and health services
Immigration-enforcement stress and fear of deportation, including police presence in healthcare facilities
Restrictions on legal driver’s license and limited transportation
Out-of-pocket healthcare costs and the opportunity cost of missing work to receive care
Limited understanding of the healthcare system due to cultural differences and language barriers
If someone overcomes the barriers above and decides to seek out care, they then have to consider the cost. Undocumented noncitizens have very few options for comprehensive, affordable care.
Some of the available options for those who lack coverage include:
Private insurance plans: Private coverage is available outside of the ACA marketplace but is typically expensive due to a lack of subsidies.
Nonprofit health centers: Low-cost care is sometimes available from nonprofit organizations but is often limited to preventative and primary care and lacks access to specialists.
Emergency departments: Many undocumented noncitizens rely on emergency departments for routine healthcare. Hospitals are required under federal law to provide care to every person experiencing an emergency, but this does not allow for continuity of care or preventative care.
Federally qualified health centers (FQHCs): FQHCs provide affordable healthcare to anyone who financially qualifies. These centers often include community-based healthcare facilities focusing on specific populations such as migrant workers and unhoused people. They typically focus on preventative and primary care.
Despite the lack of a unified approach across the country, many local organizations are doing well to provide comprehensive care.
Bright spots: Providing healthcare to undocumented noncitizens
Managing healthcare for undocumented noncitizens has led to creative and comprehensive solutions by state and local governments, healthcare systems, and local community organizations.
Examples of such solutions include:
Sliding-scale financial assistance: In New York City’s NYC Health + Hospitals system, the Options program provides sliding-scale financial assistance regardless of immigration status. This program assesses an individual's eligibility for insurance programs, then does a financial intake to determine the ability to pay. If someone is unable to pay, they are eligible for all services — including clinic visits, emergency care, behavioral health, and prescription drugs — without charge.
Diverting resources from the emergency department: In 2017, Atlanta’s Grady Health System opened a chronic care clinic. Grady Health identifies people frequently using the emergency department to manage ongoing health issues and sends them to the chronic care clinic managed by a comprehensive team of specialists. They offer this service without attention to immigration status and regardless of ability to pay. In 2 years, the project saved 44% of what the hospital would have spent to manage the same patients.
Expanding on federally funded health centers: Los Angeles County has over 1 million undocumented citizens. They received care through the L.A. County Department of Health Services prior to the Affordable Care Act. Due to reductions in funding in the ACA, healthcare program My Health LA was developed in 2014. It offers expanded service that includes free primary care for any resident of Los Angeles, regardless of ability to pay or immigration status.
Alternative insurance programs: In Massachusetts, the Health Safety Net program reimburses providers who treat undocumented noncitizens living below 300% of the federal poverty level. It has acted as an insurance program since 2007, with copayments and a sliding-scale deductible. This state law covers comprehensive care for any citizenship status that does not qualify for Medicaid.
Creating an equitable system
Changes to the healthcare system are necessary to ensure every person living in the U.S. can access care. Until a national change occurs, local healthcare providers and systems have to find solutions that work.
Below, we explore some tips to improve care for undocumented noncitizens.
Tips for healthcare providers and organizations
Healthcare workers are integral to creating a welcoming, trusting environment that encourages people to continue receiving health services.
Healthcare workers can create a welcoming system of trust by:
Providing transportation assistance to and from healthcare appointments
Training in cultural competency
Employing native-speaking healthcare professionals
Employing interpreters when native speakers are unavailable
Connecting with local immigration organizations providing other charitable services
Staying updated on current immigration laws relating to healthcare
Healthcare systems can make institutional changes to increase healthcare use. Examples include:
Creating alternative clinics to avoid emergency room use
Implementing sliding-scale financial arrangements
Clustering services in one location to avoid transportation issues to multiple appointments
Linking patients with social workers or patient navigators who can help them navigate their care and benefits
Implementing or expand financial assistance programs
The bottom line
Why trust our experts?
Providing access to healthcare for undocumented noncitizens continues to be a challenge in the U.S. Without a national coverage option for undocumented noncitizens, many will continue to avoid receiving appropriate healthcare.
Change is starting within healthcare organizations and can continue by providing culturally competent, comprehensive care to those who need it.
