What States Can Do to Fill the Gap in Health Care Access for Immigrant Communities
April 11, 2025
Overview
Immigration status is a social determinant of health and the structural factor with the most direct impact on the health outcomes of immigrants is access to health care. Refugee, immigrant, and migrant communities in the United States, on average, have lower rates of health insurance, face increased barriers to care, and receive lower quality of care than U.S.-born populations. However, there are actions that states can take through federal programs, but also outside of federally funded programs, to improve access to care.
According to the Centers for Disease Control and Prevention (CDC), more than 1 billion people globally are immigrants, refugees, and/or migrants. An individual’s status is determined by the specific conditions that led them to leave their place of origin and the length of time they plan to stay in their new destination. It is estimated that more than 47 million immigrants live in the United States, including approximately 24 million noncitizen immigrants (both lawfully present and unauthorized immigrants) and 23 million naturalized citizens. Further, 4.7 million households are made up of mixed immigration status families, i.e., families that include lawfully present immigrants, undocumented immigrants, and/or citizens.
Immigration status is a social determinant of health. Migration and immigration status affect health care access and utilization; creates added stress related to fear of law enforcement; often results in challenging or even hazardous working conditions; and makes individuals vulnerable to the harmful impacts of anti-immigrant prejudice. The structural factor with the most direct impact on the health outcomes of immigrants is access to health care. Refugee, immigrant, and migrant communities in the United States, on average, have lower rates of health insurance, face increased barriers to care (such as language access challenges), and receive lower quality of care than U.S.-born populations.
The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, in addition to restructuring the primary federal cash assistance program into Temporary Assistance for Needy Families (TANF), also details immigrant eligibility for public benefits. The law restricts access to public benefits for noncitizens by categorizing individuals as either qualified or non-qualified. To qualify for public benefits, including health insurance through Medicaid, individuals must be green card holders, asylees, refugees, or lawful residents for at least five years. All other lawfully present and undocumented immigrants are ineligible for Medicaid coverage. It is estimated that PRWORA excludes between 11 and 14 million noncitizens from federal health insurance programs.
When not eligible for Medicaid, there are alternative ways that immigrants in the United States may access coverage for health services. Individuals may still receive emergency services, i.e., immediate attention to prevent death, serious harm, or disability in hospitals through Emergency Medicaid. Emergency Medicaid reimbursement is available to hospitals that provide required emergency care to individuals who meet other Medicaid eligibility requirements (such as income) but who do not have an eligible immigration status. However, there is wide latitude among states as to what services qualify for Emergency Medicaid.
Noncitizens may also access care through community clinics and Federally Qualified Health Centers (FQHCs), which typically offer income-based or free primary care and preventive services regardless of immigration status. States may also establish state-funded programs to meet the health care needs of immigrants and refugees. Some options that states may consider when seeking to improve access to health care for immigrants, include:
Expand public health insurance for children and pregnant people through the Section 214 Option.
The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA[KK3] ) provides states the option to provide affordable health coverage to “lawfully residing” immigrant children and pregnant women through Medicaid and the Children’s Health Insurance Program (CHIP). This law, known as the Section 214 option, essentially removes the mandatory federal five-year waiting period for children and pregnant people who are lawfully-present immigrants. Under this option, a state can elect to cover both or only one of these groups. As of 2023, 35 states, three territories, and the District of Columbia have adopted the option to cover children, and 27 states, three territories, and the District of Columbia have adopted the option to cover lawfully residing pregnant people.
Establish health coverage programs outside of federally funded options.
States can, and many do, provide public health insurance to individuals who are nonqualified under PRWORA through state-funded substitute Medicaid programs. According to KFF, seven states (California, Colorado, Illinois, Minnesota, New York, Oregon, Washington) and the District of Columbia have expanded fully state-funded coverage to some income-eligible adults regardless of immigration status as of January 2025. Although each state-funded program is unique, research suggests that state coverage expansions for immigrants can reduce uninsurance rates, increase health care use, lower costs, and improve health outcomes.
Provide up-to-date education about health care options and legal protections.
Before January 2025, hospitals and other health care sites were considered protected areas, which were locations that were protected from immigration and Customs and Border Patrol’s enforcement because they provide essential services. However, a January 20, 2025 Department of Homeland Security directive rescinded this protection at medical and mental health care facilities, schools, social services organizations, and places of worship, among other settings.
As policies rapidly change, states can keep residents and health care providers informed about the rights and protections of patients in their states and offer telehealth alternatives when possible. In addition to keeping community members informed, Physicians for Human Rights recommends that providers avoid asking about or documenting patient immigration status unless required by law and ensure that health facilities develop clear, written protocols and trainings to respond to immigration enforcement.
This article was developed by Marisa London, Student Legal Researcher, Network for Public Health Law – Mid-States Region and J.D./M.P.H. Candidate, University of Michigan (2025). The post was reviewed by Susan Fleurant, Staff Attorney, and Meghan Mead, Deputy Director, Network for Public Health Law – Mid-States Region.
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