Health Reform WK-EDGE Immigrants in America: Crossing the border to better health
Wednesday, August 24, 2016

Immigrants in America: Crossing the border to better health

By Bryant Storm, J.D.

Immigrants in America face challenges accessing health care and health insurance. Because an immigrant’s ability to access health insurance depends on his or her immigration status, many individuals—depending on their status—face obstacles, if not outright prohibitions, in their ability to obtain coverage. While eligibility for some programs depends on documentation, in some cases, as illustrated by recent litigation in Arizona, administrative error can impact an immigrant’s access to care. In other cases, for example Medicaid expansion, state politics limit immigrants’ ability to get the care they need. Now, as immigration becomes a focal point in the upcoming presidential election, it has become increasing important to understand the complex relationship between immigration and health care. This Strategic Perspective examines the status quo for immigrant health care and considers some of the consequences of leaving immigrants without meaningful access to care.

Immigrant Health Coverage

Medicaid is an important source of coverage for many eligible immigrants; however, according to Cori Racela, an attorney with the National Health Law Program, “immigration status determines the scope of Medicaid benefits.” She noted Medicaid benefits can be “either full-scope or emergency-only benefits.” Racela went on to explain “citizens, nationals, and certain ‘qualified’ immigrants receive the full scope of Medicaid benefits, including inpatient and outpatient care, prescription drugs, and more.” She added, “certain qualified immigrants, such as refugees and asylees, can get full-scope Medicaid immediately.” Other immigrants, however, “including lawful permanent residents (‘green card’ holders), must have an eligible immigration status for five years before they qualify for full-scope benefits,” additionally, she said, “immigrants who do not have a qualified status, namely undocumented immigrants, can get emergency-only Medicaid services if they meet the other eligibility criteria.” Emergency Medicaid services are far more limited than full-scope benefits, covering only the care and services necessary for the treatment of an emergency medical condition. Thus, undocumented immigrants and immigrants new to the country—those with less than five years of eligible status—are often left without access to anything but the bare minimum of health coverage.

State efforts. States, however, can take steps to alter the status quo set by those general federal requirements. “There are two main ways in which state policies can impact immigrant eligibility for Medicaid,” Racela said. She explained states can rely on “a waiver for the federal requirements.” For example, she noted, “CMS allows individual states the option to lift the five-year requirement for children and pregnant women who are lawfully present.” Most states rely on an option under Section 214 of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) (P.L. 111-3) to accomplish Medicaid and CHIP coverage of children and pregnant women within their first five years of lawfully residing in the United States. However, other mechanisms are available to states. For example, Virginia relies on a demonstration under Section 1115 of the Social Security Act to cover pregnant immigrants who would not otherwise be eligible for Medicaid.

Racela explained that “the second way in which states can augment the federal Medicaid immigration rules is to use state funds to provide services.” As an example, she pointed to California that “recently implemented a program using state-only funds to provide Medi-Cal [the state’s Medicaid program] to eligible children under the age of 19 regardless of immigration status, which includes undocumented immigrants.” Beyond those efforts, Racela said “states can provide safety net programs and fund community health centers that provide medical care regardless of immigration status.” For example, California is seeking a waiver that will allow immigrants who do not meet the federal definition of lawful presence the opportunity to buy unsubsidized coverage through their state-based marketplace, Covered California. The program would allow 390,000 “illegal immigrants” the opportunity to purchase health care coverage through the state’s exchange. Without such a waiver, the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) prohibits undocumented immigrants from purchasing insurance—even without subsidies—through the ACA’s federal or state exchanges.

Medicaid expansion. Another critical component of immigrant access to health care is Medicaid expansion under the ACA. The ACA and the subsequent decision in NFIB v Sebeliusresulted in the availability, rather than mandate, of an option to expand Medicaid coverage to more low-income individuals in states. Specifically, the Medicaid expansion option allows states to provide coverage through Medicaid to individuals with incomes at or below 133 percent of the federal poverty level (FPL). While immigrants, legal and undocumented, face barriers to health coverage, access has improved in the 32 states (including D.C.) that have elected to expand their Medicaid program. Some proponents of expansion have argued that the costs of expanded Medicaid are more effective expenditures because regularly check-ups and screenings result in lower overall health costs because of earlier diagnoses, more effective treatments, and less reliance on emergency care (see Choosing or not choosing Medicaid expansion—the effects on legal and illegal immigrants, April 16, 2014). Racela called the decision to expand a “crucial factor” noting that “states that did not expand Medicaid limit their immigrant residents’ ability to access emergency services.” For example, she said, “a childless, 35-year-old undocumented immigrant who lives in a state that did not expand its Medicaid will not even be eligible for emergency-only Medicaid.” In such circumstances, an individual is forced to forego care, pay out of pocket, or rely on community health centers.

Arizona Lawsuit

The immigrant health care debate came under the public eye in Arizona where thousands of immigrants are receiving emergency-only Medicaid coverage despite being eligible for full medical benefits, according to a complaint filed in July 2016 in a federal court in Arizona. The lawsuit, filed by the William E. Morris Institute for Justice in Phoenix, together with attorneys from the National Health Law Program in Los Angeles, alleges that the state’s Medicaid program—The Arizona Health Care Cost Containment System (AHCCCS)—improperly reduced medical benefits for immigrants, in many cases without providing beneficiaries with adequate notice of the change in eligibility. The complaint alleges that as a result of the improper eligibility transfers, “AHCCCS participants with significant medical conditions, including persons with diabetes, mental health conditions, asthma, and high blood pressure, have been left without needed medical care.”

Class action. The lawsuit is a class action brought on behalf of a statewide class of immigrant Medicaid beneficiaries. The class includes immigrant residents of Arizona who were eligible for full-scope Medicaid benefits but whose eligibility was improperly reduced. The complaint asserts that, in response to an October 2015 letter, AHCCCS identified 3,500 immigrants who had been improperly transferred from full-scope to emergency-only benefits. Even though the benefits of those immigrants subsequently were reinstated, the complaint alleges that the improper reductions continued. The lawsuit seeks a declaratory judgment and a preliminary injunction to prevent Arizona from continuing to reduce immigrant Medicaid benefits.

Consequences of Being Uninsured

The restriction of Medicaid benefits to immigrants—whether through administrative error or policy—results in negative health and socioeconomic consequences. According to Racela, while many of those consequences are also present for members of the general population, some of the consequences are unique to immigrants. Racela noted that “while restricted-scope Medicaid benefits will work in the event of an emergency, they do not cover regular and routine care and medications or chronic condition management.” Thus, she explained, “although an immigrant with emergency-only Medicaid would get emergency services if she were in a car accident, she would not be able to access preventive care or services to treat diabetes, cancer, or a simple cold.” Another way a lack of coverage can negatively impact immigrants is a result of some immigrant family structures. Racela pointed to “a correlation between a parents’ health insurance status and whether and how often their children seek and receive medical care, even if the child has health coverage.” In other words, when immigrant parents are uninsured, their children are more likely to forego health care. She said this is particularly important with families that have members with various immigration statuses—such as citizen children and immigrant parents.”

Health and cost. A report from the National Immigration Law Center suggests still greater risks of being uninsured. For example, the report notes that uninsured adults are more than 25 percent more likely to die prematurely than adults with health insurance. Uninsured individuals are also less likely to be diagnosed early, more likely to suffer complications, and less likely to pursue effective remedies. Apart from the negative health consequences, the report noted that high rates of uninsurance destabilize local health care systems and force unnecessary utilization of emergency resources when less costly care mechanisms would have sufficed.


Immigrant health care is complex. Access and coverage issues depend on multiple variables, including state policies, immigration status, and federal law. Because of the complexity and myriad requirements, many immigrants do not have meaningful access to health care or have limited access in the form of emergency-only benefits. Additionally, a lack of health care coverage among immigrants is a significant contributor to the high rates of uninsured individuals that have persisted since the ACA’s enactment. Notably, the Commonwealth Fund listed “the ACA’s exclusion of undocumented immigrants from the coverage expansions” as one of six factors primary contributing to the 24 million individuals that remain uninsured in the country. Thus, as the nation increases its focus on issues like immigration, stakeholders, policymakers, and voters must be mindful of the status and scope of immigrant health care. With current policies that restrict immigrants’ and immigrant families’ ability to access care and coverage, policymakers should ask whether we—a nation of immigrants—are providing adequate access to care for all those that call our country home.

Attorneys: Cori Racela (National Health Law Program)

MainStory: StrategicPerspectives AccessNews AgencyNews CHIPNews IndividualMandateNews MedicaidNews MedicaidExpansionNews

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