A growing number of states are opening taxpayer-funded health insurance programs to immigrants, including those living in the U.S. without permission, even as Republicans attack President Joe Biden for a dramatic increase in illegal southern border crossings.
Eleven states and Washington, D.C., together provide full health insurance coverage to more than 1 million low-income immigrants regardless of their legal status, according to state data compiled by KFF Health News. Most do not have permission to live in the US, state authorities say.
Enrollment in these plans could nearly double by 2025 as at least seven states begin or expand coverage. In January, Republican-controlled Utah will begin covering children regardless of immigration status, while New York and California will expand eligibility to cover more adults.
“These are kids, and we have a heart,” said Utah state Rep. Jim Dunnigan, a Republican who initially opposed his state’s plan to cover undocumented children but backed down after compromises, including the enrollment cap.
There are more than 10 million people living in the US without a permit, according to Pew Research Center estimates. Immigrant advocates and academic experts point to two factors behind the growing interest of state leaders in providing health care to this population: The pandemic has highlighted the importance of insurance coverage in controlling the spread of infectious diseases. and some states are targeting people without legal status to further reduce the nation’s record-low uninsured rate.
States have also expanded coverage in response to calls from hospitals, lawmakers say, to reduce the financial burden of caring for uninsured patients.
All states pay hospitals to provide emergency services to certain unauthorized residents in emergency rooms, a program known as Emergency Medicaid. About a dozen states have extended coverage only for prenatal care to such people. Full state-provided health insurance coverage is much less common, but is increasing.
An estimated half of people living in the U.S. without a license are uninsured, according to a KFF-Los Angeles Times survey. That’s more than five times the uninsured rate for US citizens. Unauthorized immigrants are not eligible for federal health programs. But states can use their own money to provide coverage through Medicaid, the state-federal insurance program for low-income people.
California was the first state to begin covering immigrants regardless of legal status, starting with children in 2016.
“This is a real reflection of the conflict we have in the country and how states are realizing that we can’t ignore immigrant communities simply because of their immigration status,” said Adriana Cadena, director of the advocacy group Protecting Immigrant Families. Many of the millions of people without permanent legal residency have been in the United States for decades and have no path to citizenship, he said.
These state expansions of health coverage come against a backdrop of growing hostility toward immigrants among Republicans. The US Border Patrol apprehended nearly 1.5 million people in fiscal year 2023 after crossing the southern border, a record. GOP presidential candidates have portrayed the border as in crisis under Biden and the dangers of illegal immigration, such as rising crime, as the country’s top domestic concern.
Simon Hankinson, a senior immigration fellow at the conservative Heritage Foundation, said states would be sorry to extend coverage to immigrants without permanent legal residency because of the cost. Illinois, he noted, recently stopped enrolling in its program because of financial concerns.
“We need to share resources with people who are contributing to society and not have people benefiting from those who haven’t contributed, as I don’t see how the math would work in the long run,” Hankinson said. “Otherwise, you create an incentive for people to come and get free stuff.”
Most adults without a work permit account for about 5 percent of the U.S. workforce, according to the Pew Research Center. The state with the most unauthorized residents with government health insurance is California, which currently covers about 655,000 immigrants regardless of their legal status. In January, it will expand coverage to people ages 26-49, regardless of immigration status, benefiting about 700,000 additional Californians.
Connecticut, Maine, Massachusetts, New York, Rhode Island, Vermont, Washington, DC, and Washington state also provide full coverage to certain people living in the US without authorization. New York and Washington state are expanding eligibility next year.
Oregon, Colorado and New Jersey in recent years began covering more than 100,000 people combined, regardless of legal status. Minnesota will follow in 2025, covering about 40,000 people.
While states extend coverage to people living in the US potentially without permission, some impose enrollment limits to control costs.
The cost of the Utah program is capped at $4.5 million annually, limiting enrollment to about 2,000 children. Premiums will vary based on income, but cost no more than $300 per year, with preventive services fully covered.
“The pandemic has highlighted the need to have coverage for everyone,” said Ciriac Alvarez Valle, senior policy analyst for Voices for Utah Children, an advocacy group. “It’s going to have a huge impact on these kids’ lives.”
Without coverage, many children use emergency rooms for primary care and have little ability to afford drugs, specialists or hospital care, she said. “I’m not sure if this will open the door to adults having coverage, but it’s a good step forward,” Alvarez Valle said.
Colorado is also capping enrollments for subsidized coverage in its program, capping them at 10,000 people in 2023 and 11,000 in 2024. The 2024 discount slots closed within two days of enrollment, starting in November.
Adriana Miranda was able to secure coverage both years.
“You feel a lot more comfortable knowing you’re not going to owe as much to the hospitals,” said Miranda, 46, who is enrolled in a private plan through OmniSalud, a program similar to the state’s Obamacare marketplace in which the low- Colorado residents who are not legal residents can shop for plans with reduced premiums.
Miranda left Mexico in 1999 to follow her two brothers to the United States. He now works at Lamar Unidos, a non-profit immigrant rights group.
Before she got health insurance, she struggled to pay for her diabetes care and racked up thousands of dollars in debt after foot surgery, she said. Under the state program, she pays no monthly premium because of her low income, with a $40 copay for specialist visits.
“I was very happy, right? Because I was able to get it. But I know a lot of people who also have a lot of needs couldn’t get it,” she said.
OmniSalud covers only a small portion of the more than 200,000 people living in Colorado without a license, said Adam Fox, deputy director of the Colorado Consumer Health Initiative. But starting in 2025, all low-income children will be eligible for coverage under state Medicaid or the related Children’s Health Insurance Program, regardless of immigration status.
“There is a growing recognition that people regardless of their immigration status are part of the community and should have access to health care in a regular, reliable way,” Fox said. “If they don’t, it adds cost and trauma to health systems and communities.”
KFF Health News Senior Audio Producer Zach Dyer contributed to this report.
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