Executive Summary

by Nan­cy Berlinger and Michael K. Gus­mano, The Hast­ings Cen­ter

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Amid grow­ing bipar­ti­san and pub­lic sup­port for com­pre­hen­sive immi­gra­tion reform, there is a need and an oppor­tu­ni­ty to under­stand how immi­gra­tion reform will meet health care reform dur­ing the imple­men­ta­tion of the Afford­able Care Act. If as a nation we are begin­ning to think about offer­ing 11 mil­lion undoc­u­ment­ed immi­grants legal sta­tus and a path to cit­i­zen­ship, how should undoc­u­ment­ed immi­grants, new immi­grants, and future immi­grants be inte­grat­ed into our health care sys­tem at a time of change? Lack of progress on immi­gra­tion reform has placed finan­cial pres­sures on safe­ty-net health care orga­ni­za­tions and cre­at­ed eth­i­cal chal­lenges for health care pro­fes­sion­als seek­ing to pro­vide good care to their undoc­u­ment­ed patients: how should we act now to pre­vent these prob­lems going for­ward?

Begin­ning in June 2011, inves­ti­ga­tors at The Hast­ings Cen­ter, an inde­pen­dent, non­par­ti­san, and non­prof­it bioethics research insti­tute, have explored eth­i­cal, legal, and pol­i­cy­mak­ing chal­lenges in access to health care for the nation’s undoc­u­ment­ed immi­grants and their fam­i­lies. This report sum­ma­rizes key project find­ings for stake­hold­ers, includ­ing health care pro­fes­sion­als, health pol­i­cy­mak­ers, immi­grants’ rights orga­ni­za­tions, grant mak­ers, and jour­nal­ists.

Key Facts 

  • An esti­mat­ed 11.2 mil­lion undoc­u­ment­ed immi­grants live in the U.S. Most are eco­nom­ic migrants con­cen­trat­ed near labor mar­kets. Typ­i­cal jobs include food pro­duc­tion, con­struc­tion, main­te­nance, and oth­er unskilled, phys­i­cal­ly demand­ing, low-wage jobs.
  • An esti­mat­ed 4 mil­lion U.S.-born “cit­i­zen chil­dren” have undoc­u­ment­ed par­ents. Most undoc­u­ment­ed immi­grants live in “mixed-sta­tus” fam­i­lies.
  • Due to increased bor­der secu­ri­ty and the eco­nom­ic down­turn in the U.S., undoc­u­ment­ed immi­gra­tion has great­ly decreased since 2006 (to net zero from Mex­i­co).
  • Cal­i­for­nia, Texas, Flori­da, New York, and Illi­nois are home to 55.5% of undoc­u­ment­ed immi­grants liv­ing in the U.S., with grow­ing com­mu­ni­ties in many oth­er states.

Health Care Access

Undoc­u­ment­ed immi­grants are cur­rent­ly inel­i­gi­ble for the major fed­er­al­ly fund­ed pub­lic insur­ance pro­grams: Med­ic­aid, Medicare, and the Child Health Insur­ance Pro­gram (CHIP) because they are not “law­ful­ly present” in the U.S., as required by the Per­son­al Respon­si­bil­i­ty and Work Oppor­tu­ni­ty Rec­on­cil­i­a­tion Act of 1996. Some states (notably New York) have grant­ed lim­it­ed exemp­tions allow­ing some undoc­u­ment­ed immi­grants to enroll in Med­ic­aid or CHIP. Undoc­u­ment­ed immi­grants were exclud­ed from the insur­ance pro­vi­sions of the ACA. Per­ma­nent legal immi­grants have to wait five years to become eli­gi­ble for Med­ic­aid and the ACA. The pub­licly fund­ed safe­ty-net pro­vides some access to health care for undoc­u­ment­ed immi­grants, through state-lev­el Emer­gency Med­ic­aid to cov­er hos­pi­tal­iza­tion for emer­gency med­ical treat­ment and Fed­er­al­ly Qual­i­fied Health Cen­ters for pri­ma­ry care. Access to med­ical­ly appro­pri­ate diag­nos­tics, treat­ment, and care beyond the scope of these emer­gency treat­ment and pri­ma­ry care pro­vi­sions is severe­ly lim­it­ed. While health care pro­fes­sion­als may resort to using emer­gency treat­ment pro­vi­sions to help patients man­age health prob­lems, this is rec­og­nized as an expen­sive and med­ical­ly prob­lem­at­ic way to treat chron­ic dis­ease.

Young undoc­u­ment­ed immi­grants (the “dream­ers”) eli­gi­ble for work per­mits under the Deferred Action on Child­hood Arrivals (DACA) pro­gram are cur­rent­ly exclud­ed from Med­ic­aid and CHIP and from ACA insur­ance ben­e­fits.

Health Con­se­quences of Undoc­u­ment­ed Sta­tus

Eighty per­cent of undoc­u­ment­ed immi­grants in the U.S. are His­pan­ic. The Depart­ment of Health and Human Ser­vices (HHS) report­ed in 2012 that His­pan­ics are more like­ly to be unin­sured, more like­ly to have chron­ic dis­eases, and less like­ly to receive pre­ven­tive care, com­pared with the gen­er­al pop­u­la­tion. Efforts to improve the health of the U.S. His­pan­ic pop­u­la­tion are like­ly to be stymied if undoc­u­ment­ed immi­grants are unable or reluc­tant to be includ­ed in these ini­tia­tives.

Cit­i­zen chil­dren of undoc­u­ment­ed par­ents lag both in health insur­ance enroll­ment and in access to health care despite their eli­gi­bil­i­ty for CHIP. Pub­lic health research sug­gests that anti-immi­grant poli­cies (such as Ari­zona S.B. 1070) have devel­op­men­tal con­se­quences for chil­dren with undoc­u­ment­ed par­ents. Even when these poli­cies do not explic­it­ly restrict access to health care, undoc­u­ment­ed par­ents may be reluc­tant to par­tic­i­pate in pre­ven­tive-health and oth­er activ­i­ties in which their sta­tus could be revealed or ques­tioned. Sim­i­lar find­ings have been report­ed in edu­ca­tion research.

Immi­gra­tion Reform, Health insur­ance, and the Safe­ty-Net

Undoc­u­ment­ed immi­grants are like­ly to con­tin­ue to rely on safe­ty-net health care for years to come. Immi­gra­tion reform pro­pos­als cur­rent­ly under dis­cus­sion describe numer­ous steps that undoc­u­ment­ed immi­grants will need to com­plete to gain pro­vi­sion­al legal sta­tus. As out­lined in these pro­pos­als, undoc­u­ment­ed immi­grants with pro­vi­sion­al legal sta­tus will con­tin­ue to be inel­i­gi­ble for fed­er­al ben­e­fits such as Med­ic­aid and Medicare. Their appli­ca­tions for per­ma­nent legal res­i­dence will be processed only after green card appli­ca­tions from legal­ly present immi­grants have been reviewed; as not­ed, per­ma­nent legal res­i­dents cur­rent­ly must wait five years before enrolling in Med­ic­aid.

It is as yet unclear whether immi­gra­tion reform will expand access to ACA pro­vi­sions for new immi­grants or if the short­er path to cit­i­zen­ship for young undoc­u­ment­ed immi­grants pro­posed in the Sen­ate plan will expand access to health care for this group. Because most undoc­u­ment­ed immi­grants are low-income work­ers, Med­ic­aid may be their most like­ly future source of health insur­ance. Greater eco­nom­ic oppor­tu­ni­ties result­ing from legal sta­tus, includ­ing bet­ter jobs and access to cred­it, may even­tu­al­ly make afford­able pri­vate health insur­ance more avail­able to them.

Undoc­u­ment­ed Immi­grants and the Ethics of Access: Fair­ness, Pru­dence, Benef­i­cence

The “dirty” jobs that undoc­u­ment­ed immi­grants and oth­er unskilled immi­grants often fill are part of the econ­o­my of devel­oped nations. Fair­ness would seem to require that undoc­u­ment­ed immi­grants “go to the end of the line,” behind cur­rent appli­cants for per­ma­nent res­i­den­cy. How­ev­er, there has been no real queue for unskilled work­ers from Mex­i­co and oth­er devel­op­ing coun­tries to join to fill a range of avail­able jobs in the U.S. The route to these jobs has instead involved unau­tho­rized entry and tac­it accep­tance of this sta­tus quo. As immi­gra­tion reform attempts to fix this prob­lem, fair­ness also requires atten­tion to the health, wel­fare, and safe­ty of all mem­bers of our soci­ety as equal per­sons and social cit­i­zens. One low-income population’s access to med­ical­ly appro­pri­ate health care should not wait on the res­o­lu­tion of the immi­gra­tion back­log.

To do so is pru­dent as well as fair. As a soci­ety, we aim to make progress on health and health care for all. Leav­ing the undoc­u­ment­ed behind now, while health care reform is being imple­ment­ed, may increase the suf­fer­ing of the sick, under­mine the health-relat­ed rights of cit­i­zen chil­dren whose access to health care depends on their par­ents, and work against the goals of reduc­ing health dis­par­i­ties affect­ing vul­ner­a­ble pop­u­la­tions. Think­ing about how to inte­grate undoc­u­ment­ed immi­grants and oth­er new immi­grants into our com­pre­hen­sive efforts to improve our health care sys­tem is a chal­leng­ing prob­lem. It requires fresh think­ing about the cost of pro­vid­ing health insur­ance to 11 mil­lion undoc­u­ment­ed immi­grants and also to legal res­i­dents cur­rent­ly exclud­ed, and to the cost of exclu­sion.

Health care pro­fes­sion­als seek to do good (benef­i­cence) and be effec­tive advo­cates for their patients. As long as a large group of low-income patients is exclud­ed from health insur­ance cov­er­age and from pub­lic pro­grams that cov­er dial­y­sis, hos­pice care, and oth­er ser­vices, this sit­u­a­tion will con­tin­ue to cre­ate dis­pro­por­tion­ate dilem­mas and eco­nom­ic bur­dens for safe­ty-net providers in com­mu­ni­ties and states where undoc­u­ment­ed immi­grants find work. Tack­ling the prob­lem of access to health care as part of immi­gra­tion reform is good for the nation’s health care work­force and for the integri­ty of our safe­ty-net.

Recommendations for integrating access to health care into immigration reform 

  • Pol­i­cy­mak­ers and oth­er stake­hold­ers in immi­gra­tion reform should explic­it­ly address access to health care for low-income immi­grants, who may include undoc­u­ment­ed immi­grants, guest work­ers, per­ma­nent legal res­i­dents, refugees, and new­ly nat­u­ral­ized cit­i­zens, in the details of reform pro­pos­als. The health and health care needs of future cit­i­zens should be on the table at all lev­els of pol­i­cy­mak­ing, with atten­tion to the costs of inclu­sion and of exclu­sion. At a time of reform in immi­gra­tion and health care, it is pru­dent to assess whether exist­ing bar­ri­ers to health care (such as wait­ing peri­ods for Med­ic­aid enroll­ment with­in the larg­er immi­grant pop­u­la­tion) are appro­pri­ate, or are undu­ly bur­den­some to safe­ty-net providers and to per­sons in need of med­ical treat­ment.
  • The HHS Sec­re­tary should direct safe­ty-net fund­ing to states with large infor­mal labor mar­kets, where undoc­u­ment­ed immi­grants and oth­er low-income immi­grants are like­ly to live and seek health care, to mit­i­gate known uncom­pen­sat­ed-care prob­lems.
  • State pol­i­cy­mak­ers should, sim­i­lar­ly, sup­port safe­ty-net fund­ing for orga­ni­za­tions serv­ing undoc­u­ment­ed immi­grants, oth­er low-income immi­grants, and mixed-sta­tus fam­i­lies.
  • Health pol­i­cy ana­lysts should study and share find­ings on local-lev­el inno­va­tions, such as union-spon­sored low-cost health insur­ance, aimed at improv­ingthe health, wel­fare, and safe­ty of undoc­u­ment­ed immi­grants and their inte­gra­tion into main­stream soci­ety.



The project’s web­site (www.undocumentedpatients.org) was designed by Jacob Moses. It fea­tures an inter­ac­tive data­base of lit­er­a­ture on undoc­u­ment­ed immi­grants and access to health care.

Project publications include:

Issue briefs writ­ten by Michael K. Gus­mano and edit­ed by Nan­cy Berlinger, avail­able at: http://undocumentedpatients.org/issuebrief/

Commentaries, available at: http://undocumentedpatients.org/commentary/

Selected other publications:

  • Berlinger, Nan­cy, and Michael K. Gus­mano, “Immi­grant Health Care,” New York Times, August 6, 2012 <http://www.nytimes.com/2012/08/07/opinion/immigrant-health-care.html>
  • Berlinger, Nan­cy, and Michael K. Gus­mano, “Undoc­u­ment­ed Immi­grants and Access to Health Care,” Ency­clo­pe­dia of Bioethics, fourth edi­tion, 2013 (forth­com­ing)
  • Gus­mano, Michael K. and Nan­cy Berlinger, “Undoc­u­ment­ed Immi­grants and Child Health: What Are the Issues?” Com­mu­ni­ties and Bank­ing (the Jour­nal of the Fed­er­al Reserve of Boston) 24, no. 3 (June 2013):14–15

The Undoc­u­ment­ed Patients project was cre­at­ed through a gen­er­ous grant from the Human Rights pro­gram of the Over­brook Foun­da­tion.