Key Facts on Health Coverage of Immigrants | KFF (2024)

Note: This content was updated on June 26, 2024 to include updated information about state coverage for immigrants.

Summary

As of 2022, there were 45.5 million immigrants residing in the U.S., including 21.2 million noncitizen immigrants and 24.2 million naturalized citizens, who each accounted for about 7% of the total population.1 Noncitizens include lawfully present and undocumented immigrants. Many individuals live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens. One in four children has an immigrant parent, including over one in ten (12%) who are citizen children with at least one noncitizen parent.2 This fact sheet provides an overview of health coverage for immigrants based on data from The 2023 KFF/LA Times Survey of Immigrants, the largest nationally representative survey focused on immigrants.

As of 2023, half (50%) of likely undocumented immigrant adults and one in five (18%) lawfully present immigrant adults report being uninsured compared to less than one in ten naturalized citizen (6%) and U.S.-born citizen (8%) adults.3 Noncitizen immigrants are more likely to be uninsured than citizens because they have more limited access to private coverage due to working in jobs that are less likely to provide health benefits and they face eligibility restrictions for federally funded coverage options, including Medicaid, the Children’s Health Insurance Program (CHIP), Affordable Care Act (ACA) Marketplace coverage, and Medicare. Those who are eligible for coverage also face a range of enrollment barriers including fear, confusion about eligibility rules, and language and literacy challenges. Reflecting their higher uninsured rate, noncitizen immigrants are more likely than citizens to report barriers to accessing health care and skipping or postponing care. Immigrants have lower health care expenditures than their U.S.-born counterparts given their more limited access and use.

Some states have expanded access to health coverage for immigrants. At the federal level, legislation has been proposed that would expand eligibility for health coverage for immigrants, though it faces no clear path to passage in Congress. At the state level, there has been continued take up of state options to expand Medicaid and CHIP coverage for lawfully present immigrant children and pregnant people, and a small but growing number of states have expanded fully state-funded coverage to certain groups of low-income people regardless of immigration status. However, many immigrants, particularly those who are undocumented, remain ineligible for coverage options.

Many immigrants remain fearful of accessing assistance programs, including health coverage. The Biden Administration reversed prior Trump Administration changes to public charge rules, which may help reduce fears among immigrant families about participating in non-cash assistance programs, including Medicaid and CHIP. It also increased funding for Navigator programs that provide enrollment assistance to individuals, which is particularly important for helping immigrant families enroll in coverage. However, as of 2023, nearly three-quarters of immigrant adults, including nine in ten of those who are likely undocumented, report uncertainty about how use of non-cash assistance programs may impact immigration status or incorrectly believe use may reduce the chances of getting a green card in the future. About a quarter (27%) of likely undocumented immigrants and nearly one in ten (8%) lawfully present immigrants say they avoided applying for food, housing, or health care assistance in the past year due to immigration-related fears.

Overview of Immigrants

Based on federal survey data, as of 2022, there were 45.5 million immigrants residing in the U.S., including 21.2 million noncitizens and 24.2 million naturalized citizens, who each accounted for about 7% of the total population (Figure 1).4 About six in ten noncitizens were lawfully present immigrants, such as lawful permanent residents (green card holders) and those with a valid work or student visa, while the remaining four in ten were undocumented immigrants, who may include individuals who entered the country without authorization and individuals who entered the country lawfully and stayed after their visa or status expired.5 Many individuals live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens. A total of 19 million or one in four children living in the U.S. had an immigrant parent as of 2022, and the majority of these children were citizens (Figure 1).6 About 8.6 million or 12% were citizen children with at least one noncitizen parent.

Uninsured Rates by Immigration Status

The 2023 KFF/LA Times Survey of Immigrants, the largest nationally representative survey focused on immigrants, provides data on health coverage of immigrant adults and experiences accessing health care, including by immigration status.

Although the majority of uninsured people are citizens, noncitizen immigrants, particularly likely undocumented immigrants, are significantly more likely to report being uninsured than citizens. As of 2023, half (50%) of likely undocumented immigrants and one in five (18%) lawfully present immigrants say they are uninsured compared to 6% of naturalized citizens and 8% of U.S.-born citizens (Figure 2).7

Reflecting their higher uninsured rates, noncitizen immigrants, especially those who are likely undocumented, are more likely than citizens to report barriers to accessing health care and skipping or postponing care. Research shows that having insurance makes a difference in whether and when people access needed care. Those who are uninsured often delay or go without needed care, which can lead to worse health outcomes over the long-term that may ultimately be more complex and expensive to treat. Overall, likely undocumented immigrants are more likely than lawfully present immigrants and naturalized citizens to report not having a usual source of care other than an emergency room, not having a doctor’s visit in the past 12 months, and skipping or postponing care in the past 12 months (Figure 3).8 Lawfully present immigrants also are more likely than naturalized citizens to say they have not had a doctor’s visit in the past 12 months.

Research also shows that immigrants have lower health care expenditures than their U.S.-born counterparts as a result of lower health care access and use, although their out-of-pocket payments tend to be higher due to higher uninsured rates. Recent research further finds that, because immigrants, especially undocumented immigrants, have lower health care use despite contributing billions of dollars in insurance premiums and taxes, they help subsidize the U.S. health care system and offset the costs of care incurred by U.S.-born citizens.

Access to Health Coverage Among Immigrants

Private Coverage

Despite high rates of employment, noncitizen immigrants have limited access to employer-sponsored coverage. Although most noncitizen immigrant adults say they are employed, they are significantly more likely than citizens to report being lower income (household income less than $40,000) (Figure 4).9 This pattern reflects disproportionate employment of noncitizen immigrants in low-wage jobs and industries that are less likely to offer employer-sponsored coverage. Given their lower incomes, noncitizen immigrants also face challenges affording employer-sponsored coverage when it is available or through the individual market.

Federally Funded Coverage

Lawfully present immigrants may qualify for Medicaid and CHIP but are subject to certain eligibility restrictions. In general, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP, and many, including most lawful permanent residents or “green card” holders, must wait five years after obtaining qualified status before they may enroll. Some immigrants with qualified status, such as refugees and asylees, as well as citizens of Compact of Free Association (COFA) communities, do not have to wait five years before enrolling. Some immigrants, such as those with temporary protected status, are lawfully present but do not have a qualified status and are not eligible to enroll in Medicaid or CHIP regardless of their length of time in the country (Appendix A). For children and pregnant people, states can eliminate the five-year wait and extend coverage to lawfully present immigrants without a qualified status. As of March 2024, 37 states plus D.C. have taken up this option for children and 30 states plus D.C. have elected the option for pregnant individuals.

In December 2020, Congress restored Medicaid eligibility for citizens of COFA communities and inMarch 2024, eligibility was restored for additional federally funded programs including CHIP. The U.S. government has COFA agreements with the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau. Certain citizens of these nations can lawfully work, study, and reside in the U.S., but they had been excluded from federally funded Medicaid since 1996, under the Personal Responsibility and Work Opportunity Reconciliation Act. As part of a COVID-relief package, Congress restored Medicaid eligibility for COFA citizens who meet other eligibility requirements for the program effective December 27, 2020. On March 9, 2024, Congress further extended eligibilityforCOFAcitizens to newly include other federally funded programs such as CHIP, the Supplemental Nutrition Assistance Program (SNAP), and Temporary Assistance for Needy Families (TANF), among others.

A total of 22 states have also extended coverage to pregnant people regardless of immigration status through the CHIPFrom-Conception-to-End-of-Pregnancy(FCEP) option.Coloradoplans to implement this coverage by January 2025. While other pregnancy-related coverage in Medicaid and CHIP requires 60 days of postpartum coverage, the CHIP FCEP option does not include this coverage. However, some states that took up this option provide postpartum coverage regardless of immigration status either through a CHIP state plan amendment or using state-only funding. Additionally, ten states (California, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New York, Oregon, Rhode Island, and Washington) have used state funding or CHIP health services initiatives to extend postpartum coverage to 12 months to individuals regardless of immigration status to align with theMedicaid extensionestablished by the American Rescue Plan Act, and Marylandextends coveragefor four months postpartum through its health services initiative.

Lawfully present immigrants can purchase coverage through the ACA Marketplaces and, like citizens, may receive tax credits to help pay for premiums and cost sharing that vary on a sliding scale based on income. Generally, these tax credits are available to people with incomes starting from 100% of the federal poverty level (FPL) who are not eligible for other affordable coverage. In addition, lawfully present immigrants with incomes below 100% FPL may receive tax credits if they are ineligible for Medicaid based on immigration status. This group includes lawfully present immigrants who are not eligible for Medicaid or CHIP because they are in the five-year waiting period or do not have a “qualified” status.

Lawfully present immigrants also can qualify for Medicare subject to certain restrictions. Specifically, they must have sufficient work history to qualify for premium-free Medicare Part A. If they do not have sufficient work history, they may qualify if they are lawful permanent residents and have resided in the U.S. for five years immediately prior to enrolling in Medicare, although they must pay premiums to enroll in Part A.

Undocumented immigrants are not eligible to enroll in federally funded coverage including Medicaid, CHIP, or Medicare or to purchase coverage through the ACA Marketplaces. Previously, individuals with Deferred Action for Childhood Arrivals (DACA) status were not considered lawfully present for purposes of health coverage eligibility and remained ineligible for these coverage options despite having a deferred action status, which otherwise qualified for Marketplace coverage. On May 3, 2024, the Biden Administration published new regulations that will change the definition of lawfully present to include DACA recipients for purposes of eligibility to purchase coverage through the ACA Marketplaces and to receive tax credits to help pay for premiums and cost sharing. The rule will become effective on November 1, 2024. Medicaid payments for emergency services may be made on behalf of individuals who are otherwise eligible for Medicaid but for their immigration status. These payments cover costs for emergency care for lawfully present immigrants who remain ineligible for Medicaid as well as for undocumented immigrants.

State Funded Coverage

As of June 2024, 12 states plus D.C. provide comprehensive state-funded coverage for children regardless of immigration status (Figure 5). These states include California, Connecticut, Illinois, Maine, Massachusetts, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and D.C. By 2025,ColoradoandMinnesotaplan to offer state-funded Medicaid-like coverage to income-eligible children regardless of immigration status. Additionally, two of these states (New Jersey and Vermont) also provide state-funded coverage to income-eligible pregnant people regardless of immigration status, with Vermont extending this coverage for 12 months postpartum.

As of June 2024, six states(California, Colorado, Illinois, New York, Oregon, Washington) plus D.C. have also expanded fully state-funded coverage to some income-eligible adults regardless of immigration status (Figure 6). Some additional statescoversome income-eligible adults who are not otherwise eligible due to immigration status using state-only funds but limit coverage to specific groups, such as lawfully present immigrants who are in the five-year waiting period for Medicaid coverage, or provide more limited benefits. Maryland and Minnesota have also indicated plans to extend coverage to adults.

Data suggest that state coverage options for immigrants make a difference in their health coverage and health care access and use. The 2023 KFF/LA TimesSurvey of Immigrantsshows that immigrants residing in states with more expansive coverage policies for immigrants are less likely to be uninsured compared to their counterparts living in states with less expansive coverage policies. California’s 2016 expansion to cover low-income children regardless of immigration status was associated with a34%decline in uninsurance rates. Similarly, adecline in uninsurance rates. Similarly, astudyfound that children who reside in states that have expanded coverage to all children regardless of immigration status were less likely to be uninsured, to forgo medical or dental care, and to go without a preventive health visit than children residing in states that have not expanded coverage. Other research has found that expanding Medicaid coverage to pregnant people regardless of immigration status was associated with higher rates of prenatal care andimproved outcomesincluding increases in average gestation length and birth weight among newborns, while more restrictive state coverage policies were associated withreduced postpartum careutilization. The cost of providing insurance to immigrant adults through Medicaid expansion was also found to beless than halfthe per person cost of doing so for U.S-born adults. Recent estimates also suggest that the state-funded expansion to all immigrants regardless of status in California couldreduce povertyamong noncitizen immigrants and their families.

Enrollment Barriers

Among immigrants who are eligible for coverage, many remain uninsured because of a range of enrollment barriers, including fear, confusion about eligibility policies, difficulty navigating the enrollment process, and language and literacy challenges. Research suggests that changes to immigration policy made by the Trump Administration contributed to growing fears among immigrant families about enrolling themselves and/or their children in Medicaid and CHIP even if they were eligible. In particular, changes to the public charge policy likely contributed to decreases in participation in Medicaid among immigrant families and their primarily U.S.-born children. The Biden Administration reversed many of these changes, including the changes to public charge policy, and has increased funding for Navigator programs that provide enrollment assistance to individuals, which is particularly important for helping immigrant families enroll in coverage. However, as of 2023, nearly three-quarters of immigrant adults, including nine in ten of those who are likely undocumented, report uncertainty or an incorrect understanding about how use of non-cash assistance programs may impact immigration status or incorrectly believe use may reduce the chances of getting a green card in the future. About a quarter (27%) of likely undocumented immigrants and nearly one in ten (8%) lawfully present immigrants say they avoided applying for food, housing, or health care assistance in the past year due to immigration-related fears.

Conclusion

Although the majority of immigrants are working, noncitizen immigrants, particularly those who are likely undocumented, have high uninsured rates due to more limited access to both public and private coverage. Federal legislation has been proposed that would expand immigrant eligibility for health coverage, though there is no clear path to passage in Congress. In the absence of federal action, some states are filling gaps in access to coverage for immigrants. However, many remain ineligible for any coverage options, contributing to barriers to access and use of care. Those eligible for coverage also face an array of barriers to enrollment, including fear and confusion about eligibility. The Biden Administration has made changes to public charge policies that are intended to reduce fears of enrolling in health coverage and accessing care and increased funding for outreach and enrollment assistance, which may help eligible immigrant families enroll and stay enrolled in coverage. However, immigrants continue to have significant confusion around public charge rules highlighting the importance of outreach and enrollment assistance, including community-led efforts, to rebuild trust and reduce fears among immigrant families about accessing health coverage and care.