Immigrants’ Access
to Healthcare
May 2013
Since the founding of our nation, people have
been coming to the United States from all
corners of the world. Some have come
seeking employment, others to obtain
advanced degrees and still others
have come to escape persecution.
Recently, there has been a lot of
attention focused on immigration
reform for many of these individuals as
lawmakers in Congress have considered
the possibility of developing a pathway to citizenship for undocumented
immigrants.
Regardless of the outcome of this Congressional debate, examining the state of
healthcare for immigrants is essential. After all, it is inevitable that all people
residing in the U.S. will need medical services at some point in time, regardless
of whether they are native born or foreign born. Yet despite having higher
labor force participation rates than native-born citizens, the uninsured rate
among the immigrant population far exceeds that of native-born citizens.1 This
Policy Snapshot explores immigrants’ access to health coverage, availability of
medical services and some of the barriers that impact the availability of care.
Snapshot of the Immigrant Population
The umbrella term “immigrant” encompasses someone who migrates to
another country, often for permanent residence.2 There are a variety of terms
used to describe the immigration status that immigrants have obtained. While
not all encompassing, the following are a few of the most common categories
of immigrants:
• Naturalized citizen: a foreign-born individual who has lawfully obtained
U.S. citizenship.
• Non-citizen: a foreign-born individual who has not obtained U.S.
citizenship.
g Permanent resident: an individual who has lawfully obtained a
“green card” that allows them to reside and work permanently
in the U.S.
g Temporary visa holder: an individual who has been granted a
temporary visa, such as a student or a tourist.
g Refugee status/asylum: an individual who has been granted asylum
or refugee status because of persecution or fear of persecution due
to race, religion, nationality, political opinion, and/or membership
in a particular social group.
g Undocumented immigrant: an individual who is unlawfully residing
in the U.S. This includes people who have entered illegally and those
who have remained after their visas have expired.
In the United States, 13 percent (nearly 40 million people) of the population
is foreign-born. Over half of the U.S. foreign-born population is from Latin
America, followed by Asia, Europe, Africa, Northern America, and Oceania –
a region that includes the islands of the tropical Pacific Ocean such as those
within Polynesia and Micronesia.3
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The Center
for Health Affairs
Policy Snapshot
@NEOHospitals
the Leading Advocate for
Northeast Ohio Hospitals
Foreign-Born Population by Region of Birth: 2010
Africa
4.0%
Asia
28.2%
Europe
12.1%
Latin America and the Caribbean
53.1%
• Mexico
29.3%
• Other Central America
7.6%
• South America
6.8%
• Caribbean
9.3%
Northern America
2.0%
Oceania
0.5%
Note: Percentages do not sum to 100.0 due to rounding.
Source: U.S. Census Bureau, American Community Survey, 2010.
Ohio, and the counties that comprise Northeast Ohio, have lower rates of
foreign-born persons compared to the U.S. average. Just 3.9 percent of Ohioans
are foreign-born, and rates of foreign-born persons for Ashtabula (1.3 percent),
Geauga (3.1 percent), Lorain (2.8 percent) and Medina (3.2 percent) counties
are lower than the state average. A greater percentage of immigrants live in
both Cuyahoga (7.1 percent) and Lake (5.3 percent) counties compared to
the state average.4
Which Types of Health Insurance Can
Immigrants Obtain?
Central to the ability to access needed health services is having health
insurance. Yet for many immigrants, particularly those who have recently
arrived in the U.S., health insurance is often out of reach.
Employer-sponsored insurance plays a vital role in providing health coverage for
many native-born Americans. Yet for immigrants who have recently arrived in
the U.S., employer-sponsored coverage is often unavailable. Whereas over half
(57 percent) of native-born citizens have employer-sponsored health insurance,
just over one-third (35 percent) of non-citizens have health insurance through
an employer.5 Why is this? The answer lies partly in the types of occupations
in which immigrants are typically employed. Immigrant workers are more
likely than native-born workers to be employed in low-wage industries – such
as agriculture, service, or construction – that frequently do not offer health
insurance.6
Public coverage is also often out of reach. The Medicaid program has generally
restricted undocumented immigrants and temporary visa holders from
receiving coverage since the program began, except for limited Medicaid
coverage for treatment of emergent conditions.7 Furthermore, passage of the
1996 welfare reform law barred the majority of lawful permanent residents who
immigrated after the law’s enactment from receiving Medicaid or Children’s
Health Insurance Program (CHIP) coverage for their first five years in the U.S.8
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Close to half of the states have taken advantage of an exception that allows
certain qualified low-income immigrants to obtain Medicaid/CHIP during the
five-year ban, particularly pregnant women and children, but Ohio is not among
them.9 Certain states, not including Ohio, have also opted to provide state-only
funded health coverage for certain non-qualified immigrants. Refugees and
individuals who have been granted asylum are exempt from the five-year ban
on Medicaid coverage and – if ineligible for Medicaid – may qualify for Ohio’s
Refugee Medical Assistance Program which provides access to the full Medicaid
benefit package within their first eight months in the U.S.
To qualify for Medicare Part A coverage, which covers inpatient hospital care,
native-born citizens and permanent residents need to have worked for at least
40 quarters, typically ten years, and meet other eligibility criteria. Permanent
residents 65 years of age or older who have resided in the U.S. continuously
for five years, yet haven’t met the work requirement, can buy in to Medicare.
How Many Immigrants Are Uninsured?
Given immigrants’ hampered access to health insurance, uninsured rates
among the immigrant population far exceed those among the native-born U.S.
population. In fact, the foreign-born population has uninsured rates roughly
2.5 times greater than the native-born population. Whereas 13.2 percent of
the native-born population lacked health insurance in 2011, almost one-third
(33 percent) of the foreign-born population was uninsured that same year.
Taking a closer look at the numbers, recent immigrants are more likely to be
uninsured than immigrants who have lived in the U.S. for longer periods of time.
Approximately 19.1 percent of naturalized citizens are uninsured compared to
almost half (44.2 percent) of non-citizen immigrants.10
What Healthcare Can Immigrants Access?
When emergencies happen, it is essential that all people – regardless of
their immigration status – have access to necessary, life-saving treatments.
In addition to being mandated by federal law, treating and stabilizing anyone
with an emergent condition who enters their doors is viewed by hospitals as
integral to their missions.
While providing life-saving emergency care is essential, providers understand
that healthcare is more than just emergency care. Effective healthcare
delivery must also include access to a coordinated system of primary care.
Unfortunately, many immigrants are often left to rely on a patchwork system
of healthcare providers to obtain needed services because health insurance
is frequently out of reach.
Federally qualified health centers (FQHCs) are community-based organizations
that provide primary and preventive care to patients regardless of their
immigration status, insurance status or ability to pay. For immigrants who are
also migrant or seasonal workers, migrant health centers, which serve only
migrant and seasonal workers, are another primary care option. Like an FQHC,
migrant health centers provide healthcare services regardless of immigration
status, insurance status or ability to pay.11
Recent figures show there are currently roughly 1,214 FQHCs
in operation serving more than 8,000 sites and 159 migrant
health centers serving more than 700 satellite service sites.12
not lift the five-year ban on access to Medicaid for lawful permanent residents.
The ACA also stipulates that unauthorized immigrants are unable to purchase
health insurance through health insurance exchanges, even if they use their
own money.13 Furthermore, Disproportionate Share Hospital (DSH) funding
for hospitals – which helps cover care of the uninsured under both Medicare
and Medicaid – is scheduled for significant reductions.
On the plus side, the ACA authorized $11 billion in dedicated funding for FQHCs
over a five-year period. This funding aims to support the operation, expansion
and construction of health centers and is expected to double the capacity of
health centers by 2015.14
Factors Impacting Immigrants’ Ability to
Access Healthcare
The struggles faced by uninsured immigrants are similar to those faced by
uninsured native-born citizens. Uninsured individuals face higher out-of-pocket
costs than those who are insured. Given the high proportion of immigrants
who lack health insurance, many immigrants have a difficult time paying
their healthcare bills. Furthermore, for immigrants – who often work in more
physically strenuous jobs and jobs with higher occupational health hazards
than their native-born counterparts – having unmet health needs can have
serious consequences.
While many of the struggles faced by uninsured immigrants mirror those faced
by uninsured native-born citizens, some barriers to care are more prevalent
among the immigrant population. For example, language and literacy barriers,
lack of knowledge about community resources, confusion about eligibility
requirements, complex application requirements, transportation barriers, and
fear of adverse immigration consequences all play a role in immigrants’ ability
and perceived ability to access healthcare services.
Perhaps it is not surprising that these factors result in immigrants being less
likely than their native-born counterparts to use emergency medical services,
hospital services, dental care, and primary and preventive care services. These
findings hold true even after controlling for the effects of income, insurance
status, race/ethnicity and health status.15
Conclusion
Immigrants face multiple barriers that can prevent them from accessing needed
healthcare services. As implementation of the federal healthcare reform law
moves forward, hospitals and other healthcare providers will continue focusing
on culturally competent care to meet the needs of the increasingly diverse and
ever-changing patient population. In the future, sufficient funding to support
hospitals and other healthcare providers that care for the uninsured population,
including immigrants, will be essential to ensuring a healthy population and a
well-functioning healthcare system.
Endnotes
1.
2.
3.
4.
5.
6.
Will Federal Healthcare Reform Improve
Immigrants’ Access to Healthcare?
How the recently passed federal healthcare reform law, commonly referred to
as the Affordable Care Act (ACA), will impact immigrants’ access to healthcare
depends on the circumstances. The law’s Medicaid expansion and creation of
health insurance exchanges will likely decrease the ranks of uninsured nativeborn citizens, naturalized citizens and permanent residents.
However, the ACA did not extend health coverage through public programs
such as Medicare and Medicaid to undocumented immigrants and it also did
7.
8.
9.
10.
11.
12.
13.
14.
15.
Grieco, E.M. et al. “The Foreign-Born Population in the United States: 2010.” U.S. Census Bureau. May
2012. http://www.census.gov/prod/2012pubs/acs-19.pdf
Dictionary.com, http://dictionary.reference.com/browse/immigrant?s=t&path=/
Grieco, E.M. et al. “The Foreign-Born Population in the United States: 2010.”
U.S. Census Bureau, 2007-2011 American Community Survey.
Author’s calculation based on Current Population Survey: http://www.census.gov/hhes/www/
cpstables/032012/health/h09_000.xls
Ku, L. “Why Immigrants Lack Access to Health Care and Health Insurance.” Center on Budget and Policy
Priorities. September 2006. http://www.migrationinformation.org/usfocus/display.cfm?ID=417
Ibid.
Ibid.
Urban Institute. “Overview of Immigrants’ Eligibility for SNAP, TANF, Medicaid, and CHIP.” March 2012.
http://aspe.hhs.gov/hsp/11/ImmigrantAccess/Eligibility/ib.shtml#Medicaid
DeNavas-Walt, C. et al. “Income, Poverty, and Health Insurance Coverage in the United States: 2011.”
U.S. Census Bureau. September 2012. http://www.census.gov/prod/2012pubs/p60-243.pdf
Gusmano, M.K. “Undocumented Immigrants in the United States: U.S. Health Policy and Access to
Care.” The Hastings Center. October 3, 2012. http://www.undocumentedpatients.org/issuebrief/healthpolicy-and-access-to-care/ prod/2012pubs/p60-243.pdf
Ibid.
Ibid.
National Association of Community Health Centers. “Expanding Health Centers Under Health Care
Reform.” June 2010. http://www.nachc.com/client/HCR_New_Patients_Final.pdf
Ku, L. “Why Immigrants Lack Access to Health Care and Health Insurance.”
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