Public debates and media coverage about health care for undocumented immigrants often focus on individual cases in which undocumented patients are seriously ill and require expensive treatment. While such cases do occur, studies have repeatedly shown that undocumented immigrants consume less health care than U.S. citizens or legal immigrants.1
There is also considerable evidence that many undocumented immigrants live with unmet health care needs. Undocumented immigrants are much less likely than U.S. citizens or legal immigrants to have private health insurance. They are ineligible for Medicare and their access to Medicaid is usually restricted to emergency provisions, which means that they lack access to the two major public insurance programs in the U.S. Their access to health care may also be hampered by factors ranging from language, to lack of transportation, to fear of deportation, to the inability to leave work to attend to health care needs.2 In this issue brief, we summarize evidence regarding the use of health care services by undocumented immigrants and the existing barriers to their use of health care.
How does the use of health care services among undocumented immigrants compare with U.S. citizens and legal residents?
As noted, comparisons of health care spending consistently find that total per capita spending on undocumented immigrants is lower than spending on legal immigrants and citizens. A 2010 study based on data from last decade concluded that spending on health care for all immigrants is lower than for U.S. born citizens, and that “immigrants are not contributing disproportionately to high health care costs in public programs such as Medicaid.”3 This study found that national health expenditures for immigrant adults were 55% lower than for U.S. born adults. A 2006 study that looked specifically at undocumented immigrants found that health expenditures were 39% lower for undocumented men and 54% lower for undocumented women when compared to U.S. born men and women.4 In Los Angeles County, where the undocumented population represents 12% of the total population, undocumented immigrants consume only 6% of medical expenditures.5
Use of health care services is lower among undocumented adults and their children – regardless of the immigration status of those children – than it is among adult U.S. citizens and their children. Undocumented adults and their children are less likely than U.S. citizens to use emergency department care, visit a physician or nurse on an outpatient basis, or use mental health or dental services.6 A 2007 survey of undocumented Latinos reported that they are less likely than U.S. born citizens to have a usual source of care (58% vs. 79%) or to have their blood pressure (67% vs. 87%) and cholesterol (56% vs. 83%) checked annually.7 When undocumented immigrants do use health care services, they are more likely than U.S. citizens to pay out of pocket for this care.8
Which health care services are used most frequently by undocumented immigrants?
Most of the health care services used by undocumented immigrants are for childbirth. A study of emergency Medicaid expenditures for undocumented and recent immigrants in North Carolina between 2001 and 2004 found that between 82.2% and 86.4% of health care spending was related to childbirth. These findings reflect the fact that almost half (47%) of undocumented immigrants live in households comprised of couples with children.9 Of the remaining health care expenditures in North Carolina, about one third was spent on the treatment of injuries and poisoning (which may be a consequence of, for example, exposure to pesticides or other toxins in the workplace). These uses of health care services reflect not only the relatively young age of most undocumented immigrants but also the type of work that they do (See the Hastings Center Issue Brief: Undocumented Immigrants in the United States: Demographics and Socioeconomic Status for additional detail).
Why do undocumented immigrants use fewer health care services than citizens or legal residents?
While age may help to explain why undocumented immigrants, on average, use less health care than U.S. citizens and legal immigrants, there is significant evidence that undocumented immigrants face barriers to care.10 As noted, undocumented immigrants are less likely to have a usual source of care, and they are more likely to report having a negative experience when then do access health care services.11 While some undocumented immigrants are able to obtain private insurance (whether through an employer or on the open market), as noted, most are uninsured (Figure 2).12,13,14 The Patient Protection and Affordable Care Act (PPACA) of 2010 prohibits undocumented immigrants from purchasing private health insurance with their own money through the new insurance exchanges established by the health care reform law.15 This means that a significant percentage of the U.S. population, consisting of 11.2 million individuals, will be left without health care coverage even as a primary aim of the law is to reduce this very problem.
Figure 2: Percent without health insurance by residency status
Most children (73%) born to undocumented immigrants in the U.S. were born in this country and so are U.S. citizens, while the remainder (27%) are undocumented.16 Overall, 45% of children born to undocumented immigrant parents do not have health insurance. This figure includes U.S. born children, of whom 25% lack health insurance even though they are likely to qualify for Medicaid or the State Child Health Insurance Program (SCHIP).17 By contrast, only 8% of U.S.-born children with U.S.-born parents lack health insurance. In other words, children born in the U.S. whose parents are undocumented are three times more likely to be uninsured than are other children born in the U.S. Undocumented immigrants may have difficulty enrolling their U.S. born children in Medicaid or SCHIP due to language or literacy barriers, or may avoid insurance enrollment and other activities that, they fear, will bring them to the attention of authorities.18
Low levels of insurance often discourage people from seeking appropriate care in a timely fashion, resulting in higher rates of hospital admission for avoidable conditions.19 A 2007 study of immigrant families concluded that immigrant children make fewer visits to the Emergency Department compared to U.S. born children, but are sicker when they are brought to the ED.20
In addition to lack of insurance coverage, individual and local-level barriers may limit access to health care services among undocumented immigrants as well as other immigrants.21,22 The first language of most undocumented residents is a language other than English. A California study found that children whose parents do not speak English fluently experience poorer access to health care.23 As noted, undocumented immigrants may avoid seeking care because they fear deportation, a and this fear may create an additional barrier to health care beyond those that may be experienced both by undocumented immigrants and by other low income, uninsured people in the U.S.24
- 1. Sabin, Jim. “Tragic Choices at Grady Hospital.” Healthcare Organizational Ethics. December 29, 2009. Available at: http://healthcareorganizationalethics.blogspot.com/2009/12/tragic-choices-at-grady-hospital.html↵
- 2. Medicaid eligibility varies by state. We review Medicaid, Medicare and other relevant health policies that influence access to health care for undocumented immigrants in another issue brief.↵
- 3. Stimpson, Jim P., Fernando A. Wilson, and Karl Eschbach. “Trends in Health Care Spending for Immigrants in the United States.” Health Affairs 2010; 29(3): 544-50.↵
- 4. DuBard, C. Annette and Mark W. Massing. “Trends in Emergency Medicaid Expenditures for Recent and Undocumented Immigrants.” JAMA 2007; 297(10): 1085-92.↵
- 5. Goldman, Dana P., James P. Smith, and Neeraj Sood. “Immigrants and the Cost of Medical Care.” Health Affairs 2006; 25(6): 1700–11.↵
- 6. Derose, Kathryn Pitkin, Benjamin W. Bahney, Nicole Lurie, and José J. Escarce. “Review: Immigrants and Health Care Access, Quality, and Cost.” Medical Care Research and Review 2009; 66(4): 355-408.↵
- 7. Rodríguez, Michael A., Arturo Vargas Bustamante, and Alfonso Ang. “Perceived Quality of Care, Receipt of Preventive Care, and Usual Source of Health Care Among Undocumented and Other Latinos.” Journal of General Internal Medicine 2009; 24(Suppl 3): 508–13.↵
- 8. Derose, Kathryn Pitkin, Benjamin W. Bahney, Nicole Lurie, and José J. Escarce. “Review: Immigrants and Health Care Access, Quality, and Cost.” Medical Care Research and Review 2009; 66(4): 355-408.↵
- 9. Passel, Jeffrey S. and D’Vera Cohn. A Portrait of Unauthorized Immigrants in the United States. Pew Hispanic Center, April 2009. Available at: http://pewhispanic.org/files/reports/107.pdf↵
- 10. Wolf, Richard. “Rising Health Care Costs Put Focus on Illegal Immigrants.” USA Today. January 22, 2008. Available at: http://www.usatoday.com/news/washington/2008-01-21-immigrant-healthcare_N.htm↵
- 11. Ortega, Alexander N., Hai Fang, Victor H. Perez, John A. Rizzo, Olivia Carter-Pokras, Steven P. Wallace, and Lillian Gelberg. “Health Care Access, Use of Services, and Experiences Among Undocumented Mexicans and Other Latinos.” Archives of Internal Medicine 2007; 167(21): 2354-2360.↵
- 12. Rodríguez, Michael A., Arturo Vargas Bustamante, and Alfonso Ang. “Perceived Quality of Care, Receipt of Preventive Care, and Usual Source of Health Care Among Undocumented and Other Latinos.” Journal of General Internal Medicine 2009; 24(Suppl 3): 508–13.↵
- 13. Zuckerman, Stephen, Timothy A. Waidmann, and Emily Lawton. “Undocumented Immigrants, Left Out Of Health Reform, Likely To Continue To Grow as a Share of the Uninsured.” Health Affairs 2011; 30(10): 1997-2004.↵
- 14. Undocumented immigrants who qualify as Permanent Residence Under Color of Law (PRUCOL) may qualify for emergency Medicaid services. We will review policies that influence access to care in a subsequent brief.↵
- 15. Stewart, Kristen. “Illegal Immigrants to Face New Barriers to Health Insurance.” Salt Lake Tribune. January 12, 2011. Available at: http://www.eastvalleytribune.com/arizona/immigration/article_db1debda-1e9f-11e0-88a5-001cc4c002e0.html↵
- Source: Pew Hispanic Center tabulations based on 2008 Current Population Survey.↵
- 16. Passel, Jeffrey S. and D’Vera Cohn. A Portrait of Unauthorized Immigrants in the United States. Pew Hispanic Center, April 2009. Available at: http://pewhispanic.org/files/reports/107.pdf↵
- 17. Medicaid, enacted along with Medicare in 1965, is the largest health insurance program in the U.S. It is a jointly financed, jointly administered, federal-state health insurance program for low-income people. Within overall guidelines established by the federal government, each state has great flexibility with regard to the size and scope of its Medicaid program. SCHIP, enacted in 1997, is public health insurance coverage that provides coverage to uninsured, low income children who do not qualify for Medicaid. The Patient Protection and Affordable Care Act of 2010 calls for expanding eligibility to these programs as a strategy for reducing the uninsured.↵
- 18. “Five Questions for Karina Fortuny on Children of Immigrants.” Urban Institute, October 2011. Available at: http://www.urban.org/toolkit/fivequestions/fortuny.cfm↵
- 19. Gusmano, Michael K., Victor G. Rodwin, and Daniel Weisz. Health Care in World Cities: London, New York and Paris (Baltimore: Johns Hopkins University Press, 2010).↵
- 20. Ledford, Meredith King. Immigrants and the U.S. Health Care System: Five Myths that Misinform the American Public. Center for American Progress, June 2007. Available at: http://www.americanprogress.org/issues/2007/06/pdf/immigrant_health_report.pdf↵
- 21. Kirby, James B. and Toshiko Kaneda. “Neighborhood Socioeconomic Disadvantage and Access to Health Care,” Journal of Health and Social Behavior 2005; 46(1): 15-31.↵
- 22. Blewett, Lynn A., Pamela Jo Johnson, and Annie L. Mach. “Immigrant Children’s Access to Health Care: Differences by Global Region of Birth.” Journal of Health Care for the Poor and Underserved 2010; 21: 13–31.↵
- 23. Yu, Stella M., Zhihuan J. Huang, and Michael D. Kogan. “State-Level Health Care Access and Use Among Children in US Immigrant Families.” American Journal of Public Health 2008; 98(11): 1996-2003.↵
- 24. The Health of Immigrants in New York City: A Report from the New York City Department of Health and Mental Hygiene. New York City Department of Health and Mental Hygiene, June 2006.↵