1. Introduction

Until the late 19th century, wealthy people in the developed world typically received health care at home. Mass production made it more cost-effective to bring health care services together under one roof. Reimbursable care in the United States is still typically provided by doctors and other professionals working in medical settings, and insured patients receive most of their care at little cost to themselves. Employers and insurers shoulder most of the costs. Hospitals remain the most expensive places to receive care. Hospitals account for about one-third of national spending on health care services. Yet they employ only about one in every six workers in these services. Our health care system has many other inputs, including pills, needles, therapy sessions, and advice on how to create and maintain good health. Associated costs are included in the prices of the network’s products and services, which determine who is able to seek care and who is able to actually obtain care. This essay briefly describes our country’s health care system and the people served. It examines the economics of demand for care by people who are immigrants to the United States. Most of these people are characteristic of nonimmigrants who have the same legal status and individual characteristics. However, immigrants who lack authorization to reside in the country have different health care experiences from other residents. Their fear of being confronted by insurance companies or of being removed by the federal government discourages many unauthorized immigrants from seeking reimbursement for most of their health care. The federal government stands ready to support state interventions in the health care of authorized immigrants. Many of the nonelderly were eligible for past federal health insurance policies. Most of the nonelderly who were eligible for past federal health insurance policies were not authorized to reside in this country. The federal government is likely to play an increasing role in the future of health care for immigrants living in the United States, as it has in their recent past.

1.1. Background and Significance

To date, many immigrants in the United States live without health insurance coverage. In 2012, 16.4% of the native-born did not have health coverage, compared with 33.8% of all noncitizens and 56.5% of unauthorized Mexican immigrants. This issue is intimately linked to the nation’s priorities, ideals, and core values, such as equality, social justice, and the compassionate treatment of every member of society, even those who arrived irregularly. Unlike other victims of discrimination during the Great Recession and in the labor market, school children of mixed-native-immigrant status also faced challenges in using school-based free and reduced-price lunch programs. Health and health care issues that threaten the status and long-term well-being of unauthorized immigrant children include inadequate access to health care services, limited immunization coverage, incomplete health screening and follow-up, and legal and ethical issues surrounding health care services. Infants with immigrant mothers can also face blood lead levels above the guidelines.

Health outcomes of immigrants are better than expected, even though uninsured rates are highest among those without health insurance. It is estimated that nonelderly unauthorized immigrants are young and healthy, and most tend to use very few services, mainly in public hospitals in emergencies; they do not use public charging services proportionally to their inadequate insurance status. However, the literature still sheds light on the reasons why many eligible immigrants and their children fail to enroll in the health care programs for which they are entitled. Employer-sponsored insurance is limited by categories of worker qualifications, occupation, and wage level. Small businesses are less likely to offer health benefits than large businesses that employ native residents. Requirements for documentation of work eligibility are used even though requirements for direct health provision are nominal. Moreover, there are barriers to obtaining health insurance, including costs, premiums, cost-sharing obligations, language and translation barriers, large immigrant inventories, and deep fears of immigration enforcement and deportation. Prior policy changes and recent health reforms provide incentives and opportunities to reduce the number of uninsured parents and children, but the coverage of immigrants remains incomplete. In this text, related outcomes are covered, and commissions, recommendations, and future research areas are considered.

2. Legal Framework

The legal history of immigration in the United States is one of vastly different approaches and treatment for different groups arriving in the country. The Alien and Sedition Acts of 1798 were the first significant alien-related policy adopted by the United States. Decreased immigration during the U.S. Civil War and the Progressive Era gave way to a time of increased restrictions and tightening of borders. The Chinese Exclusion Act in 1882 and the 1924 Quota Act were both important milestones in our nation’s restrictive immigrant history. The 1920s also saw the Border Patrol formed as part of a new immigration policing focus, with the force reaching about 1,000 agents by 1930. The fourth phase of U.S. immigration policy, and the one which still dominates to this day, is that of current policy.

The Immigration and Nationality Act of 1965 abolished the national-origins quota system that had been in place since 1921 and broadened the basis for immigrant admissions. Many neoclassical economists would argue that immigrants should be selective and only those able to provide a net economic benefit to the country should be permitted to migrate. From their point of view, hence, one might capacitate only those who are not likely to be unemployed or in poverty, i.e., those able to purchase health insurance. Data presented in this report, however, indicates that immigrants have a much lower tendency to access health insurance from their employer than do natives. Only about 30% of Hispanic immigrants with and without health insurance had health insurance from their employer.

2.1. Federal Laws and Regulations

Most provisions of the U.S. Public Health Service Act do not use the term “citizens”, “national” or “legal resident” as criteria for defining eligibility. However, the substantial amount of money the federal government currently spends in those areas may result in a de facto exclusion of illegal immigrants from many programs, either because statutes or regulations affirmatively exclude certain people or because the funding is insufficient to provide services to all who may qualify for them. More importantly, Public Health Service Act funds are not spent for the direct provision of health services. Instead, the bulk of the funds are disbursed to state and local agencies or private organizations that are then supposed to use the money to carry out specified purposes. Because the PHS Act does not impose citizen or legal alien requirements on the individuals receiving services, immigration status requirements for PHS Act services do not generally exist. However, individual programs within the PHS Act do not have the same general language and are more explicit in their requirements. It is from those specific programs that many illegal immigrants currently receive services that would seem to require citizenship or legal residence. Additionally, the Department of Health and Human Services has recently issued regulations and policy guidance that directly regulate the provision of health services to illegal immigrants, as a form of social regulation. The issue before Congress is whether illegal immigrants (and other categories of immigrants, particularly legal immigrants) should be entitled to federal health programs that are funded and administered under the Federal PHS Act.

2.2. State Laws and Regulations

State laws have been enacted to replace restrictions on immigrant eligibility for various state-funded programs that were established in the Personal Responsibility Act. States were not mandated to provide benefits to most categories of lawful immigrant non-citizens, who had previously been eligible for them through TANF, Medicaid, State Children’s Health Insurance Program, and Supplemental Security Insurance Program. A number of these state laws reinstate eligibility for programs but do so by covering some or all of the losses in eligibility with state funds so the rollback in immigrant access could be undone. Other state laws choose to provide eligibility for state-funded programs for similar groups of immigrants with state funds as well, which is more generous than most of these states’ rules prior to 1996. Legal immigrants are eligible for federal Medicaid coverage in the first five years residing in the US. However, like the TANF program, several states have expanded eligibility under the state-funded program. Unlike Medicaid, the Children’s Health Insurance Programs are financed by the federal government, but each state must apply for a waiver to allow lawfully residing immigrant children to be eligible for SCHIP. It is important to know which states are applying for and receiving waivers and when, for future reference in the data, so that appropriate data are used to accurately represent state-by-state program eligibility restrictions.

3. Types of Immigrants

3.1. Lawful Permanent Residents (LPRs)

In general, LPRs (or immigrants with “green cards”) are subject to the individual mandate and subject to the same private market coverage rules as citizens. In 2009, 45.7 percent of nonelderly LPRs were insured, a rate far higher than the 22.7 percent for unauthorized immigrants. As is the case for the overall foreign born, LPRs often earn too much to qualify for Medicaid or CHIP in states that have not opted to expand their programs under the Affordable Care Act, but too little to afford private insurance. LPRs who earn less than 400 percent of the federal poverty level are eligible for subsidized premium tax credits if they do not have employer coverage and meet other requirements of the tax credit. However, unlike citizens, eligible LPRs who hold green cards must also meet a 5-year waiting period for accessing premium tax credits.

Among the most important changes to Medicaid through the Affordable Care Act was a gradual expansion, with the goal of raising Medicaid coverage rates for all low-income individuals. One category of LPRs – those who entered the U.S. as refugees, asylees, or as family of current or past refugees or asylees – have long had eligibility and an exemption under the five-year rule if the additional pathway to lawful status provision applied to them. However, weaknesses in these types of coverage limit the degree to which they benefit these immigrants, who are predominantly poor and nonwhite. In particular, premiums, the cost to cover dependents, and the ineligibility to have their premium subsidized by the marketplace may limit affordability despite the guarantee of a lower out-of-pocket limit for those under 200 percent of the federal poverty level.

3.2. Undocumented Immigrants

Undocumented immigrants in the United States are less likely to have health insurance coverage than U.S.-born individuals and other immigrant groups. Because they are ineligible for Medicaid and the Children’s Health Insurance Program and have limited access to other safety net programs, coverage rates are very low among both adults and children aged 18 and younger. In 2004, 33.9 percent of the adult undocumented immigrant population and 69.7 percent of undocumented children aged 18 and younger were uninsured. Granting unauthorized access to Medicaid and CHIP can expand their ability to purchase health insurance through the subsidies provided by these programs. For those unauthorized immigrants who continue to be uninsured, access to health care services will improve as a result of their ability to pay for services. Program expenditures will increase as some health care utilization by the uninsured is shifted to encounters for which Medicaid and CHIP are the payer.

In 2008, the estimated federal and state spending for coverage expansions for nondisabled, childless adults under a broadened Medicaid program for unauthorized immigrants would have been $2.1 billion. Undocumented individuals who apply for and receive health insurance through general subsidy programs may also be paying less for health insurance coverage than would their legally present counterparts. Due to cross-subsidization across an insurance pool, a lower-than-usual effective price for coverage exists, particularly in cases where an offset for private insurer risk is not constructed in the public financing mechanism.

3.3. Refugees and Asylees

Refugees and asylees are eligible for public health insurance programs under the same terms as other low-income residents after they have been in the country for a year. They enter with some visa and income documentation. Not only do they get public health insurance coverage, they can also jump right into publicly funded language training and, if they do not already have employment, job search assistance, basic welfare benefits, and food stamps. This immediate and generous array of services is facilitated by an agency that is separate from and more independent than the agency that oversees the legal immigration process.

Refugees (and their dependents) are aliens eligible for long-term residency and citizenship in the United States who entered the United States after being persecuted on account of certain characteristics or who were authorized to enter the United States from abroad under the annual ceiling for refugee admissions. Asylees, like the aliens whose applications were denied and who chose to remain in the United States, are authorized to enter the United States from other countries while having claims processed. U.S. law doesn’t specify an absolute limit for the number of aliens the Attorney General may grant asylum, but the number of aliens who may be granted asylum status within any given year is capped. The cap specifically prevents asylees from being granted permission to work or receive federal benefits at any time.

4. Public Health Insurance Programs

Following the welfare reform law, Congress allowed states the option to expand Medicaid and/or the Children’s Health Insurance Program to children who otherwise would have been ineligible due to their non-immigrant status. Most states have taken advantage of this option, and children in families with incomes below 200% of the federal poverty level are eligible if they arrived in the United States before the welfare reform law was signed. The CHIP reauthorization law also created a new federal block grant to help states provide services to legal immigrant children with funds. Since 2003, states have also had the option to expand Medicaid and/or CHIP to pregnant women and/or parents, grandparents, and other adults. Most states have not chosen this option, although immigrants who are “qualified” under the law are already eligible even if they have legal permanent residence in the United States.

Since the reauthorization of the Trade Adjustment Act, “qualified” immigrants have become eligible for Medicaid beginning five years after entry, without regard to their age. This means all individuals who are 65 years old and over, pregnant women, children, parents, and individuals with a disability are eligible beginning five years after their entry date. However, it is important to note that these individuals are only eligible to receive “emergency” Medicaid services before this time (except for the “qualified” immigrant children who are eligible under the state option). This important policy shift means that only the legal immigrants may be in the United States five years after entry and still not have any coverage for the acute and chronic health conditions likely to develop over time. Furthermore, the five-year residency requirement does not consider the length of one’s status as a “qualified” individual and also does not include any benefits received during a prior five-year period.

4.1. Medicaid

Barriers to Medicaid coverage for immigrants have grown substantially with the enactment of welfare reform and the numerous other restrictions related to immigrant eligibility for social service programs. For most, it will be five years before they are eligible for Medicaid. There are a number of categories of noncitizens who are going to have significant problems obtaining comprehensive private health insurance or maintaining it after their term of employment ends. This situation will not only leave many immigrants in desperate medical straits, but also create incentives for healthy noncitizens, especially those who have no intention of settling permanently in the United States, to forego health insurance, leading to an adverse selection problem that could hike premiums and make insurance even less attractive to low-income immigrants. Nonetheless, even eligible immigrants and their U.S.-born children receive proportionately fewer benefits from Medicaid and from the State Children’s Health Insurance Program than members of their own households. It is an open question whether this differential participation is going to continue as card-based eligibility systems, initiatives, and other enrollment simplification policies are more fully adopted to rectify the problem of low rates of take-up of benefits that have plagued these programs since their inception.

4.2. Children’s Health Insurance Program (CHIP)

Implemented in 1997, the Children’s Health Insurance Program (CHIP) provides funds to states to expand health coverage and lower costs for uninsured children. This program was authorized for $20.4 billion over 10 years, to be in place through September 2007. National CHIP’s features include funding to states, matching funds to help states provide health insurance to uninsured children in families who are not poor enough to qualify for Medicaid, and allotment of some federal tobacco revenues to fund the program. CHIP targets uninsured children in families with incomes above the publicly insured eligibility thresholds. Subsequent to passing this authorization law, states formed insurance partnerships to propose access and coverage proposals. With approval by the Secretary of HHS, states developed separate child health programs after writing a State Health Insurance Programs plan that identified the target population, benefits, networks, contract process, and other information on the intended program.

The most recent CHIP legislation includes an overall national spending cap on federal funding, creating potential access limitations on projected funding gaps in the program. States currently are developing cost-containment strategies to address these potential capped issues. Unauthorized immigrant children are ineligible for the federally administered Medicaid and CHIP programs. State involvement is also a deterrent to connecting unauthorized immigrants with public health services because of emerging state requirements for proof of legal residence. Under the federal Children’s Health Insurance Program Reauthorization Act of 2009, all legal immigrant children and pregnant women meeting specific eligibility criteria will either be able to gain eligibility for Medicaid/CHIP or retain it. However, states have the option to offer or eliminate optional coverage for pregnant women under CHIP. Optional coverage ending can occur when states are unable to afford the increased costs of covering the new mandatory Medicaid population.

4.3. Emergency Medicaid

In the event that they are emergency Medicaid eligible, states are required to cover only those medical services that are necessary for treating an emergency medical condition. States are not required to cover care for the underlying medical issues that produce the emergency medical condition. As of August 2018, 16 states did not extend coverage to emergency Medicaid eligible individuals. Furthermore, coverage policies vary from state to state, and coverage policies are not uniform across various states within the same region.

The criteria for EMTALA emergency medical condition vary from state to state, and the methodology and calculation for emergency medical services are not specified in federal law or guidance. In determining coverage, the scope, duration, or intensity of services may not be used as a basis for determining whether the service is related to the emergency medical condition. However, states are prohibited from providing a level of benefits that is less than the emergency services provided to pregnant women, which must include treatment of psychiatric or substance use disorders, regardless of whether an emergency medical condition is present.

5. Affordable Care Act (ACA)

The Affordable Care Act (ACA) was a fundamental structural shift in health insurance coverage in the United States, with the explicit goal of reducing the number of uninsured people through a combination of subsidies, regulations, and mandates. As of December 2013, the ACA also enabled states to extend eligibility for Medicaid to childless adults. The ACA, along with revenue enhancements from changes to the tax code and efforts to improve government management of health care programs, was financed in a manner consistent with its goals of reducing the federal budget deficit. Through its incentives and penalties, the ACA was projected to have varied fiscal impacts, including potential behavioral responses. Although it was initially anticipated that some immigrants might be made newly eligible for Medicaid expansion if all states chose to participate, the US Supreme Court ruling found the Medicaid expansion to be voluntary for states, with several states opting against participation.

The Affordable Care Act (ACA) represented a major change in how immigrant access to health insurance would be regulated. It favors those who are lawfully present in the United States by allowing them, regardless of time as a legal resident, access to health insurance affordability principles and care through the government marketplace, newly authorized state health insurance marketplaces developed for individuals and small businesses with 50 or fewer employees. People who do not meet the definition of lawfully present, however, are restricted from seeing what the new marketplace has to offer, regardless of the years lived in the United States. Because of the nature of the restricted access to private insurance found in the ACA, the latter is unlikely to be the whole solution to the problem of covering the uninsured, including the uninsured who are undocumented.

5.1. Eligibility

The restriction: Most immigrants are severely restricted by federal policy from enrollment in public insurance programs. Undocumented immigrants are primarily excluded from federally funded programs. Lawful permanent residents generally face a five-year wait after entry to become eligible for public programs. Refugees and asylees are exempt from the waiting period. Some other lawfully present immigrants are also exempt from the waiting period, such as lawful permanent residents who worked in the United States for at least 40 quarters. Background: Despite the restrictions, immigrants have federal eligibility for a number of key public health insurance programs. A significant share of the immigrants’ U.S.-born children are also entitled to public insurance. The four main categories with some federal eligibility are (1) Medicaid-SCHIP: Medicaid provides health insurance for the poor; SCHIP is a related program that targets insurance coverage for uninsured children with family incomes too high to qualify for Medicaid. (2) Ryan White HIV: The Ryan White programs provide treatment and care for low-income people with HIV/AIDS, including immigrants. (3) Section 101: Some immigrants who are not eligible for Medicaid-SCHIP, but are otherwise lawfully present in the United States and have incomes up to 200 percent of the federal poverty level, can get insurance through a federal program known as Section 101. (4) Poverty Level SSI: Supplemental Security Income / State Supplementary Payment programs provide monthly payments to people with low income and limited resources who are aged, blind, or disabled. Under most circumstances, applicants must reside in the U.S. to receive SSI/SSP. However, some categories of U.S. citizens and qualified aliens who are not residing in the U.S. might be eligible for SSI/SSP.

5.2. Marketplace Plans

Undocumented immigrants are ineligible to participate in the health insurance marketplaces or to purchase coverage through the marketplaces, even at full premium price. The three major federal health insurance programs are organized under the Social Security Act, and only certain non-citizens qualify for benefits under these programs. Non-citizens who are not qualified for health care benefits by these programs are barred from using their own resources to buy health insurance for basic and essential health care. This has placed undocumented non-citizen immigrants in a vulnerable position because they are ineligible for subsidies and credits from the health insurance marketplaces. The ACA is enacted with the supporting goal of legal immigration, and it may not solve the immigration problem; therefore, the health insurance problem fully.

The ACA rules allow legal immigrants to access the health insurance marketplace’s tax credits and subsidies to purchase a plan. Legal immigrants who have been in the country for less than five years are not permitted to receive Medicare benefits, even if qualified. Subsidies for purchasing marketplace insurance and other publicly authorized coverage are available to all legal non-citizens who are ineligible for Medicaid and CHIP. However, many prohibitions on buying subsidies and health insurance for non-citizen immigrant groups remain. Individual and family subsidies and market plan coverage eligibility are limited based on income ranges, and the non-citizen immigrant must have Qualified Non-Citizen Social Security status, which can be proven with a special qualified non-citizen certification. Subsidies do not apply to non-citizens who hold a different status. They could be very small; hence, the ACA’s merits are not fully applied to non-citizen immigrant beneficiaries. Family members are authorized to apply for benefits that are deemed eligible, and similar rules are applicable for tax credit eligibility. With the exception of only a single member of the family, a Form 1095-A is provided for each of the family members. Low-earning non-citizen immigrants, who have a financial disadvantage, are not authorized to use any advance payment tax credit. Their insurance will be operating in niche markets.

6. Barriers to Access

Many immigrants are unfamiliar with insurance procedures due to a lack of previous exposure to health insurance. In many instances, obtaining coverage can be facilitated through individual contacts and orientations available through several immigrant-serving community organizations, especially in the case of recent immigrant arrivals. Many such organizations also conduct seminars providing assistance in completing applications for publicly owned health care programs. Nevertheless, stand-alone assistance in filling out the application may not ensure ongoing insurance coverage or access to needed services, especially in the cases of the many foreign-born migrants who live in continuous fear of deportation. Many immigrants are afraid that they will be found living in areas of the city where unauthorized persons should not be living.

The immigrant population is characterized by high levels of poverty, which can act as an impediment to their accessing basic nutrition before and after obtaining legal resident status. The welfare rules disqualify immigrant non-citizens from Medicaid and federal nutritional programs, such as food stamps, unless they belong to one of the specified categories. Hospitals and health clinics have then turned to different sources of funding for the provision of the same. Some organizations have built or renovated several shelters and service centers across the United States in support of more affordable health care for residents who are shut out from the mainstream for economic or legal reasons. They argued that the legal restrictions trade costs to programs that provide services to these individuals. They noted that increased pressure on state governments to provide what the federal government will not might cause dislocations in those state financing formulas unless state legislatures expand the classification of ‘new’ immigrants to those who may be eligible for Medicaid within the Medicaid program.

6.1. Language and Cultural Barriers

The large number of immigrants, including refugees, asylees, and those who are undocumented, who have settled in the United States has contributed substantially to a need for health information and services in languages other than English. Research findings demonstrate the importance of language in decreasing access barriers. People who are not proficient in English can have difficulty understanding the need for and obtaining non-English resources, including health clinics, insurance, and services for which they may be eligible. There are numerous compelling reasons for the healthcare community to provide services at the non-English speaking patient’s level of understanding, preferences, and needs. However, with few exceptions, limited English proficiency has not yet been embraced as a priority for healthcare delivery and policy making. Indeed, linguistic competence is increasingly being recognized as a central component of affordable access to quality health care. The financial and legal implications of providing optimal interpretation and translation services make addressing language and cultural barriers a complex endeavor. However, it should be noted that non-English speakers, whether immigrants or citizens, have a right to healthcare access and services regardless of their socioeconomic background or health insurance status.

6.2. Lack of Information and Awareness

Another reason that eligible immigrant families do not participate in public programs is that they simply do not know they are eligible. Focus group participants frequently expressed amazement at the prospect of qualifying for Medicaid coverage for children despite not having a “green card” or not being able to prove that their child is a citizen. Tenants who do not have legal status in the U.S. are also often unaware of how to access health coverage, including information on open enrollment periods and implications of the public charge rule. A growing concern is that disinformation or a “chilling effect” has been created by news about more stringent immigration policies and restrictions and potential anti-immigrant sentiment. Although the public charge rule does not consider non-benefit use as negative factors, some individuals without legal status may be hesitant about accessing health care because they are not fully aware of the complex regulations or the nuances of any adverse effects, particularly a loss of financial security if penalized.

Correcting misinformation is difficult but important. A program in California has been addressing this challenge and helping residents learn about existing rights and eligibility for health insurance and other benefits. Specific program goals include making sure that individuals learn about benefits for which they are eligible, such as food or housing support, regardless of immigration status. Promising strategies involve using a multi-disciplinary approach to improve programs, identifying practical recommendations for disjointed information sharing, and highlighting potential opportunities for integrating best practices across different social service programs. Furthermore, community-based networks, representative of target populations, can provide the most effective outreach and promotion. They should serve as trusted resources of information that connect immigrant communities to reliable sources of correct information. Digital tools and printed materials for multiple languages and literacy levels should be used, and school and community events, jobsite outreach, and trusted volunteer programs should be organized as well. Given the evolving nature of immigration policy and public health programs and the potential “chilling effect” on those who are in need of but may be reticent to use certain public resources, outreach and information activities should be continually updated and modified. Additionally, immigrants often have positive social ties, so engaging families with questions and concerns about service use through their own community may be effective.

6.3. Financial Barriers

Most of the reported financial barriers that limited access to health care among foreign-born Latinos in our New Growth Communities study were strongly influenced by health insurance status. “Poor” or “uninsured” were the reasons given for why participants (1) did not have regular health care providers, (2) had not visited any doctor within the previous year, and (3) had not followed up with recommended diagnostic and treatment medical care resulting from a doctor visit. Over and over, we heard examples of immigrants delaying or going without recommended medical care because of the cost. These financial barriers meant that most immigrant adults in our focus groups were more likely to rely on home remedies and over-the-counter medication rather than visit a doctor. Moreover, since the cost of medical care is unplanned, unanticipated problems such as injury or severe illness could quickly place these immigrants in a financial hole, particularly if the breadwinner were too sick to work or had a long-term disability.

7. Community Health Centers

ARTICLE September 2014 Health Insurance Access and Coverage for Immigrants in the United States Key Findings: • Eighty percent of community health center patients are members of racial or ethnic minority populations. • There are approximately 1,200 unique community health center sites that provide language services, serve a disproportionate percentage of immigrant and limited English proficient populations, and have expertise in working with the immigrant population. • Community health centers are required to offer interpretation as a complement to their services, used in 81 different interpreted languages. The top seven spoken languages were Spanish, French, Portuguese, Arabic, Cantonese, Russian, and Vietnamese. • Disproportionately more immigrants use these safety net community health centers for care than any other health care insurance access point. • Forty-five percent of immigrants who are Medicaid recipients use a community health center for care. • A report found that more than two-thirds of health centers served Medicare recipients, immigrants, and renally disabled and dual-eligible patients, which indicates that many health center patients have low incomes. Community health centers applying to the federal Office of State, Tribal, Local, and Territorial Support and Office of Special Health Affairs were surveyed on the services they provided to the limited English proficient population. Based on the presented abstract, “all grantee profiles include information on interpreting as it relates to patient services.” The Office of Special Health Affairs report and profile many languages that funded community health centers “demonstrated this year as interpreters were available to assist patients in 81 different languages. These health centers use multiple language lines, bilingual staff, trained staff, and telephone-based interpretation to meet the needs of their patients.” The top seven languages for interpreting services were Spanish, French, Portuguese, Arabic, Cantonese, Russian, and Vietnamese. Forty other languages accounted for interpretation hours across more than contacts.

8. Immigrant Health and Well-being

Immigrants make up a significant share of the labor force providing low-wage workers in health and patient care support. A large share of physicians and surgeons in the United States are foreign-born, as are over 20% of other health diagnosing and treating practitioners. In 2017, the immigrant share of direct care workers (nursing, psychiatric, and one-on-one aides; medical assistants; and personal care aides) was 40%, and 28% of that year’s newly employed direct care workers were immigrants. Immigrants also make up a large share of health support specific occupation categories. Approximately 23% of the employed labor force is comprised of workers providing health and patient care support, particularly those found within the office and administrative support, service and cultural, and extraction and building/specialty trades categories.

Sixty-one percent of non-citizen immigrants are no longer eligible for federally funded assistance for children, including those programs that provide nutritional assistance to low-income families, state-funded maternal and child health assistance programs, and the state’s Children’s Health Insurance Program. These are critical areas of support for low-income and poorer individuals in communities under financial duress. Because of their economic vulnerability as working poor individuals and families, as well as being overwhelmingly uninsured, there are few options for non-citizen children to receive free or affordable health care. The objective is to explore the individual access and experiences described by non-citizen immigrants when dealing with the requirements, models, and limitations of medical visits, information, and help systems in the community. The focus is on health service access for undocumented and documented immigrants. This is the first study to explore uninsured immigrants’ experiences discussing and receiving advice about capitalizing on medical visits, and to examine their related perceived needs and help system information sources. The study explores documented immigrants concerning first-time offered aid, including state-sponsored financial healthcare resources and a one-of-a-kind charity care program now available at one community hospital. Data was obtained via ethnographic passport realization contacts with 54 exhausted immigrants and their families.

9. Policy Recommendations

The following policy recommendations reflect both the symposium interventions and the discussion and suggestions that participants offered at the meeting. The discussion was explicitly concerned with the issue of health insurance coverage for immigrants, rather than with broader or more general issues of welfare or societal responsibility. Only the first two recommendations contain much specific attention to issues of immigration status, while the others are more general and apply to the U.S. population overall, not merely to the treatment of newcomers. The policy recommendations thus reflect the research focus of the symposium, although the symbolism of the research projects is that immigration status cannot be ignored, even when the topic seems confined to health insurance access and coverage.

The recommendations are roughly divided into two types: those that maintain immigrants as separate within the existing system, and those that seek to reduce or eliminate entitlement distinctions based on immigration status. Recommendations 1-8 reflect the first approach; recommendations 9-11 are more comprehensive in scope.

1. De-link Medicaid from welfare eligibility. Immigrants tend to be in poor health, and they tend to be poor; they should not also be disqualified from Medicaid coverage by the linkage of welfare and Medicaid eligibility. Immigrant eligibility requirements for Medicaid coverage should parallel those for other people living in poverty, so that they do not unfairly exclude immigrants who contribute via taxes and social security.

9.1. Enhancing Outreach and Education Programs

Enabling persons to learn about public and private health insurance programs may increase their families’ access to care. Increasing the knowledge of immigrants, native-born minorities, and the general population about benefit program availability will be important. Programs illustrate how tailored outreach, education, and enrollment services can be targeted at Hispanic immigrant families. In the first year, only about one-third of the funded allotment was spent, indicative of the need for states to develop information and family-sensitive systems, and of the climate of fear that many Hispanic immigrant families report.

In general, improvements in coverage and access to insurance programs cannot be effectively carried out due to the lack of full immigrant rights in the United States. However, good programs can help pave the way for fuller participation when reforms of the laws are undertaken. This will be particularly true for children, whose health care needs are the least controversial. It is possible that health program successes will also generate grassroots support for expanding immigrant rights.

9.2. Addressing Legal Barriers

There is no single way to navigate the complexities of the legal barriers that restrict access and coverage for lawfully present immigrants. Two strategies are likely to be particularly helpful. One involves relatively modest modifications to immigration status options, especially focusing on expanding the number of legally present immigrants who may be eligible to reside in the U.S. and become U.S. citizens. The second involves consideration of ways to extend full access and coverage to certain key subgroups of the immigrant population facing particularly acute access and coverage problems beyond what would be achieved through more modest modifications of immigration status options.

A number of policy measures could be adopted to reduce the length of time that qualified immigrants in the U.S. remain without legal immigration status after they have applied and been found admissible for permanent residency. Such measures include increasing the number of visas and reducing the number of unauthorized immigrants who enter annually; extending employment authorization to applicants for temporary resident status; and extending automatic benefits eligibility and direct subsidies to applicants for temporary residence while excluding receipt of other federal benefits and local government provided benefits.

10. Conclusion

The U.S. health care system covers some legal immigrants, predominantly those with employer-sponsored health insurance coverage or Medicaid eligibility. However, the system leaves many immigrants without coverage, potentially resulting in delayed care, decreased productivity, negative health outcomes, and uncompensated care costs to providers. Notably, the remaining uninsured immigrant population is more socio-economically disadvantaged and has more limited access to affordable health care. Solutions to improve access to affordable health care for uninsured immigrants could lead to better health outcomes, prevent uncompensated care costs, and reduce the spillover effects associated with an insured population. As the debates continue at the federal level, several proposals seek to provide or limit access to health insurance for specific immigrant populations. Advocates should keep in mind that maintaining and improving access to affordable coverage for immigrants may lead to better health, economic, and social outcomes, including reducing spillover costs related to the uninsured. Given the need for further research into the effects of specific policies on immigrant health services use, costs, access, and public health, additional work should explore and monitor specifically how immigrant populations use safety-net health care facilities, their related health outcomes, and funding sources.

10.1. Key Findings and Implications

Our analysis details the health insurance dynamics that immigrants in the United States have experienced between 1998 and 2010 and the particular importance of native and employer-provided health insurance coverage for immigrant populations that are least likely to have it. We show that during the Great Recession and subsequent protracted labor market slump, U.S.-born individuals and immigrants alike have experienced health insurance losses, but immigrants have faced much larger coverage declines. Documenting health insurance dynamics over the past decade for U.S.-born individuals and immigrants and paying particular attention to the lesser health insurance protection available for some immigrant subpopulations is particularly important given ongoing and planned future health insurance coverage expansions. If specific immigrant subpopulations remain particularly unprotected, expansion coverage gains will likely fall short of their potential to reduce disparities in health insurance coverage and reflect continued low public program participation rates, particularly for employer-provided group health insurance. This research is also particularly enlightening in light of current economic conditions and increasing enforcement stringency and expansions for federal and state policies that influence health insurance access and coverage for immigrants. The establishment of state-based health insurance distribution exchanges offers a novel platform through which state governments may craft specific immigrant health insurance coverage policies.