In his iconic 1977 essay on migration, A Seventh Man: A Book of Images and Words about the Experience of Migrant Workers in Europe, John Berger wrote:

“To try to understand the experience of another it is necessary to dismantle the world as seen from one’s own place within it, and to reassemble it as seen from [another’s] . . . to understand a given choice another makes, one must face in imagination the lack of choices which may confront and deny [another] . . . The world has to be dismantled and re-assembled in order to be able to grasp, however clumsily, the experience of another. To talk of entering the other’s subjectivity is misleading. The subjectivity of another does not simply constitute a different interior attitude to the same exterior facts. The constellation of facts, of which [another person] is at the centre, is different.”

Amid the volume of coverage and commentary on the politics of immigration and the consequences of crackdowns and criminalization, here is a selection of recent work – analysis, personal essay, fiction, mixed-media – that can spark the moral imagination, as Berger’s work does.

To understand the constellation of facts concerning migration from Central America to the United States, Stephanie Leutert, an expert on Central American migration at the University of Texas-Austin and the lead writer for the “Beyond the Border” on Lawfare, offers a clear and thorough explanation of “who’s really crossing the border and why they’re coming.”

Drew Thompson, a doctoral candidate in philosophy at Loyola University in Chicago, analyzes the right of asylum in humanitarian law and sets out two moral objections to the “zero-tolerance” policy that has resulted in family separation and the criminalization of people with potential asylum claims. Thompson draws on Ursula LeGuin’s short story “The Ones Who Walk Away from Omelas” to help readers face in our imagination what many of us cannot see except through media documentation.

Novelist Edwidge Danticat reminds us how easy it is to forget people who have been concealed from public view. She writes that we must not forget migrant children – the fact that they, like the child in Omelas, continue to exist and to suffer – even as the news cycle inevitably moves on. Danticat’s essay, on her own experiences as a child who lived apart from her migrant parents also helps us to face in our imagination the choices, or lack of choices, that Central American parents face concerning how to ensure a future for themselves and their children. A recent conversation with Danticat also features Cristina Henriquez, whose short story “Everything is Far from Here” imagines a woman’s thoughts and experiences during migration. Novelist Valeria Luiselli uses an artifact of the immigration system – the 40 questions that unaccompanied minors are asked in immigration court to determine whether they may qualify for asylum – as the scaffolding for her 2017 essay “Tell Me How It Ends,” based on her experiences as a translator.

The Waiting Game, a new public education project of the investigative news service ProPublica and public radio station WNYC, uses game technology to dismantle the world from the viewer’s perspective and reassemble five worlds of asylum-seeking. Playing this game is an eerie experience if you have the choice to stop playing, to return from danger, or limbo, to safety.

Nancy Berlinger is a research scholar at The Hastings Center. She recently completed an academic writing residency at the Bellagio Center of the Rockefeller Foundation, for a book project on migrants as social citizens. She codirects The Hastings Center’s Undocumented Patients Project, a knowledge hub on health care access for unauthorized migrants and mixed status families in the United States that includes a searchable database.

The Russian poet Anna Akhmatova was a mother separated from her child by a state policy of terror. During the 1930s, she and other mothers would gather outside a Leningrad prison, desperate for information. One day, after 17 months of “waiting in prison queues,” another woman whispered to her, “‘Could one ever describe this?’ And I answered, ‘I can.’” Akhmatova’s poem cycle Requiem reflects on the anguish of family separation from the perspective of a parent, who “stood for three hundred hours/And no-one slid open the bolt.”

The U.S. Justice Department’s April decision to jail and criminally prosecute adult migrants apprehended after crossing the U.S.-Mexico border and separate children from parents, explainedhere, and here in visual form, has produced its own narratives of terror. The most horrifying thus far is the recording of the voices of children in a Border Patrol detention facility, pleading for their parents. In the recording obtained by ProPublica, a Salvadoran girl is determined to shape her own story, to “describe this.” She has memorized her aunt’s phone number, and begs a consular official to make a phone call. Any adult who has been responsible for a young child would recognize how this little girl’s mother has prepared her for a separation, by teaching her crucial information and explaining how to find an adult to trust.

ProPublica also spoke with the child’s aunt, who said, “‘Imagine getting a call from your 6-year-old niece. She’s crying and begging me to go get her. She says, ‘I promise I’ll behave, but please get me out of here. I’m all alone.’” The listener’s hope that this child had found a way out of her terrifying situation was dashed by the reality of her aunt and cousin, whose years-long process of seeking asylum has been jeopardized by the recent Justice Department ruling that people fleeing gang or domestic violence would no longer qualify for protection. They, too, are terrified.

In the past six weeks, 2,342 children have been separated from their parents; as yet it is unclear how the June 20 executive order ending family separation will be implemented. Journalists and immigrant rights advocates have done heroic work on the ground, describing injustice and working for justice. Attorneys have had to swiftly adapt ethics policies and related protocols designed for interviewing teenagers. As one attorney explained to a journalist: “Our duty as attorneys is to represent the child’s express wishes. Sometimes, when they are really young, it’s difficult to ascertain those wishes . . . because they can’t express as much…It is very emotional on me, and everyone else on staff. It is very hard to see very young children . . . .I feel like if we don’t do this, who else is going to? As upsetting as it is, we have to do it.”

What should the field of bioethics do, beyond lending our names, as citizens and professionals, to the outcry? Here are three recommendations for our field, reflecting the continuing importance of migration as a phenomenon shaping our world.

1. In clinical teaching and learning, frame and analyze challenges concerning care for migrants as problems of justice.

Providing good care to migrants whose legal status is uncertain or threatened is often experienced as an ethically fraught aspect of practice. While acknowledging practitioner moral distress, bioethics education should aim for a higher standard of basic knowledge concerning the situation of migrants in a society. Research insights on how a system’s leaders and administrators influence professional behavior concerning a stigmatized population should be part of this analysis.

2. In teaching and learning, organizational ethics, and public service, aim to understand and reflect the local implications of national policy.

Worldwide, most migrants live in cities; most immigrants to the U.S. live in just 20 metropolitan areas. Professionals in safety-net health care in these cities are likely to encounter patients whose lives are shaped by a nation’s immigration enforcement policies. Professionals who work near immigrant detention facilities will also encounter national issues locally. Learning from local colleagues with expertise in immigration law and immigrant health advocacy contributes new knowledge to our field. Our vocabulary can help these colleagues reflect on their own ethical challenges.

3. In ethical theory, account for the migrant and her children.

Theories of justice that specify duties of wealthier to poorer regions concerning health-related resource allocation and development may not fully account for the relationship between aid and migration, or speak to the status of migrants. Bioethicists interested in the global dimensions of public health can contribute to theory, research, and policy recommendations concerning duties to migrants, and to their children.

Nancy Berlinger is a research scholar at The Hastings Center. She recently completed an academic writing residency at the Bellagio Center of the Rockefeller Foundation for a book project on migrants as social citizens. She codirects The Hastings Center’s Undocumented Patients project, a knowledge hub on health care access for unauthorized migrants and mixed status families in the United States. Rachel Zacharias, a project manager and research assistant at The Hastings Center, provided background research.

In April, the U.S. Justice Department announced that it would criminally prosecute migrants who had been apprehended after crossing the U.S.-Mexico. border. An immediate consequence of this announcement, explained in detail here, is the separation of children from their parents.

Rather than allowing families to stay together in an immigrant detention center while awaiting a hearing on deportation before an immigration judge, adults are being sent to federal jail to await a hearing before a federal judge, with the potential of serving time in federal prison prior to deportation. Once their parents are in the federal jail system, children are rendered “unaccompanied minors”–even though they crossed the border with their parents–and put into the custody of the Office of Refugee Resettlement, under the Department of Health and Human Services. This separates parents and children administratively as well as physically.

Professional societies such as the American Psychiatric Association and the American Academy of Pediatrics have issued statements opposing family separation, based on evidence that it risks immediate and lasting harms to children. Prior to this move by the Justice Department, public health experts and immigrant health advocates had drawn attention to other public health consequences of the Trump administration’s immigration enforcement priorities. These include the health-related dangers to children who fear a parent’s detention and deportation, adverse effects on learning, and health risks to parents who fear deportation and to families who forgo health-related public benefits to which they may be entitled out of fear of scrutiny of immigration status.

The official aim of the family separation protocol is to deter unauthorized border crossings. Its moral shock, regardless of one’s position on immigration, is that doing damage to children is central to its implementation. As journalist Masha Gessen has explained, threatening or harming children is a tactic that should have no place in a democracy’s public policy. Even if this policy is rethought and rescinded, children will have suffered avoidable harm.

In another Justice Department move with public health implications, Attorney General Jeff Sessions yesterday overturned an historic 2014 federal Immigration Court ruling that recognized the asylum claims of women subjected to violence in domestic relationships. The 2014 ruling concerned a woman from Guatemala who with her three children had fled a physically and sexually violent marriage, seeking asylum in the U.S. This ruling upheld her asylum claim in accordance with longstanding international criteria, grounded in the 1951 Convention on Refugees. It recognized the respondent’s credible fear of persecution as a member of a group– namely, women in relationships–unable to prevent or leave situations of life-threatening violence or to rely on state protection. In arguing that U.S. would no longer recognize fear of domestic violence or gang violence as grounds for asylum, the attorney general has framed domestic violence as “private behavior.” This reasoning ignores well-known structural factors, such as local violence, weak or corrupt public systems, and cultural perceptions, which often undermine the interests of less-powerful groups and make it impossible for people targeted for violence to remain free, alive, and confident of legal protection in the society where they live.

This ruling has repercussions regionally, especially for women in Central America for whom the U.S. may be the safest haven from continuing local threats and lack of protection, and internationally, as it contradicts decades-long efforts to recognize gender-based violence as a form of persecution that calls for structural responses, including refuge. It should also be troubling to American citizens, as it suggests a deeply retrogressive characterization of violence within relationships as a “private” matter.

Nancy Berlinger is a research scholar at The Hastings Center and a June 2018 resident at the Bellagio Center of the Rockefeller Foundation, where she is working on a book project on migrants as social citizens. She codirects The Hastings Center’s Undocumented Patients Project, a knowledge hub on health care access for unauthorized migrants and mixed status families in the United States. Rachel Zacharias, a project manager and research assistant at The Hastings Center, provided background research.

Updated June 8, 2017

The 11 million undocumented immigrants in the United States live in all 50 states and rely on local safety-nets and state-level provisions for health care. Launched in 2011, The Hastings Center’s Undocumented Patients project has focused on understanding ethical and policy challenges in providing health care access for this low-income population, which is excluded from key federal benefits and faces uncertain prospects.

The Undocumented Patients website is a hub for issue briefs, policy solutions, and a searchable database of research tools on this issue. The following web-based tools have been selected by project staff to help professionals who work in safety-net hospitals, clinics, and health programs learn about the demographics of the undocumented population in a state or county. These tools also provide up-to-date information on insurance, legal rights, and legal services relevant to the care of undocumented immigrants and mixed-status families. Information and links are current as of June 8, 2017.

For the basics about the undocumented population and migration trends in your state

Pew Research Center

• Annual reports and interactive maps provide reliable estimates based on U.S. Census Bureau data
• State level data sets available in report, table, and map formats
• City level maps and tables available for major metropolitan areas

For demographic detail relevant to health care access in your state

Migration Policy Institute (MPI)

• Interactive map with state-level profiles includes countries/regions of origin, insurance access, and language proficiency, with additional detail for more than 100 US counties (scroll down below map for county profiles)
• Frequently Requested Statistics on Immigrants and Immigration is a helpful quick reference

For information about state-level health insurance coverage

Henry J. Kaiser Family Foundation (KFF)

• Annual reports on Medicaid and CHIP Eligibility, Enrollment, Renewal, and Cost Sharing Policies include state-level information on eligibility for undocumented immigrants
• Table 3 of 2017 report lists states offering CHIP coverage to income-eligible undocumented children using state funds
• Table 4 of 2017 Kaiser report and 2014 Undocumented Patients Project/Hastings Center issue brief provide state-level detail on coverage for prenatal services
• 2016 Undocumented Patients Project/Hastings Center issue brief provides additional state-level detail on Medicaid access for some undocumented immigrants

For information about legal rights relevant to health care access

National Immigration Law Center (NILC)

• “Know Your Rights, Know Your Patients’ Rights” resource offers detailed information and recommendations for health care providers on organizational processes to safeguard patients’ rights and in interactions with immigration enforcement.
• “Know Your Rights” resource on health insurance and health care offers detailed information, in English and Spanish, on the health-related and Constitutional rights of undocumented immigrants.

American Academy of Pediatrics (AAP)

• Child Immigrant Health Toolkit offers guidance on ethical, legal, and social issues relevant to health care for immigrant children and families, and on medical screening and treatment recommendations for newly arrived immigrant children.

For information about hospital-based legal services for low-income patients

National Center for Medical-Legal Partnership

• Interactive map lists participating institutions in 41 states
• Search tools locate services by health care institution or legal institution as well as city or state
• Resources include a guide for legal services in farmworker health programs

Rachel Zacharias is a research assistant and project manager at The Hastings Center.

Updated February 27, 2017

Health care access is local; creating, financing, expanding, or restricting health care access for a low-income population involves local, state, and federal policies. During the Obama administration, health insurance for the estimated 11 million undocumented immigrants in the United States remained severely restricted by this population’s broad exclusion from federally financed public benefits such as Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and Affordable Care Act (ACA) insurance subsidies. This same period saw moves by some states and major cities to expand health care access for the nation’s remaining uninsured, including many undocumented immigrants. These state and local initiatives have included the creation of programs offering low-cost primary care through public and nonprofit facilities, plus care coordination, in San Francisco (Healthy San Francisco), Los Angeles (My Health LA), and New York City (ActionHealthNYC), and legislative efforts in California and New York to expand public insurance coverage, using state funds, for some undocumented immigrants.

The Obama Administration’s 2012 executive action establishing Deferred Action for Childhood Arrivals (DACA) to allow young undocumented immigrants to work legally sparked the creation of further state, local, and institutional efforts to support this group. Some of these reforms mirrored ACA initiatives targeting millennials and aimed for equity for undocumented immigrants excluded from the ACA. California enacted legislation to allow income-eligible DACA recipients to enroll in Medi-Cal using state funds; DACA recipients in New York State became eligible, under 2001 case law relevant to certain undocumented immigrants, to enroll in state-funded Medicaid. California also expanded Medi-Cal to include undocumented children. New York City’s popular community ID program, IDNYC , launched in 2014 to provide local residents with a recognized form of identification for access to city facilities and services, is being used to connect undocumented immigrants with the city’s public health and hospital system, with benefits such as pharmacy discounts, and as a membership card for the ActionHealthNYC direct-access pilot program now underway.

What will be the fate of these state and local efforts under the new administration? Three sets of issues in health care financing for low-income people in the U.S. are important to watch during a period of uncertainty and apprehension for immigrants, and in the context of the continuing challenge of providing medically appropriate health care to low-income populations lacking access to public insurance. These issues overlap with health care access for specific undocumented populations, such as immigrants in detention centers and victims of trafficking and with access to types of health care, such as prenatal care, that are likely to be used by the undocumented population due to its demographics. They also overlap with efforts to protect the basic civil rights of undocumented immigrants, other immigrants, and members of minority groups as persons entitled to equal protection under the law.

Cities as sanctuary and safety-net: Public policy at federal, state, and local levels, even if not directly related to health, can affect local health care access for immigrants if it reinforces civil rights, or, by contrast, reinforces undocumented immigrants’ avoidance of situations in which they fear being asked for identifying information or confronted by authorities. One question following the February 21, 2017 release of new Department of Homeland Security rules expanding criteria for deportation is whether this policy will affect health care access.  Two public health studies from Arizona suggest that crackdowns change health-seeking behavior.

During and following the 2010 enactment of Arizona SB 1070, a highly controversial law reflecting state lawmakers’ goal of “attrition through enforcement,” public health researchers conducting an unrelated study  of childhood obesity among residents of a Latino neighborhood in Flagstaff noticed that the new law was creating “a generalized climate of fear . . . In a neighborhood with no major grocery store and several fast food and gas station markets, fear of travel in public could severely skew food purchasing and consumption behaviors . . . Residents also reported reluctance to allow their children to engage in physical exercise outside the home.” Community health professionals interviewed “noted dramatic changes in clinic intake and service use, suggesting rapid behavioral change” among neighborhood residents. A later study that focused on the impact of SB 1070 on health-seeking behavior among families of Mexican origin found that parents were less likely to take babies to the doctor, and adolescents were less likely to seek routine health care. These effects were not limited to immigrants; U.S.-born citizens were also reluctant to use public assistance.  The study’s authors concluded that “this law is likely associated with heightened perceptions of fear and lack of community safety, even among . . . US citizens.”

In 2012, the U.S. Supreme Court struck down certain provisions of Arizona’s law, and decisions by lower courts weakened similar laws in other states.

The passage in October 2015 of North Carolina HB 318 (“Protect North Carolina Workers Act”) suggested the continuing appeal of state-level immigration policymaking. In addition to prioritizing cooperation with federal immigration authorities, HB 318 prohibited local “sanctuary city” policies and the issuance of “community IDs” to help city residents without other identification to gain access to public facilities, including hospitals and clinics. In the immediate aftermath of the 2016 presidential election, the mayors of many major cities affirmed “sanctuary city” policies limiting cooperation with federal authorities in efforts to enforce federal immigration law. The consequences of these actions remain to be seen, and could include cutoffs of federal aid. New York City’s mayor has further affirmed that he will delete the IDNYC database if ordered to disclose these records to federal authorities. Sanctuary cities (also states and institutions such as campuses and hospitals) may serve as important sources of civic identity, values, and action; the need for cities to make this declaration underscores the gravity of the national problem.

DACA, immigration policy, and the states: Immigrants and their advocates are bracing for the possibility that DACA, as a process of the Department of Homeland Security, could be eliminated. This action would imperil the immigration status of the 740,000 individuals who have qualified for this program (and who, along with their parents, are now on record as undocumented), and also call into question whether state-level Medicaid access, financial aid, eligibility for licensures, and other programs tied to DACA status will survive. Advocates are reporting an increased demand for health services among the DACA population that reflects the high stress over their uncertain status and future prospects.

Obamacare and Medicaid: Even though undocumented immigrants were formally excluded from the insurance provisions of the ACA – namely, Medicaid expansion in 31 states, and federally subsidized insurance policies – this population benefits indirectly from Medicaid block grants to states that finance safety-net health care programs, such as primary care clinics. This population may also have benefited indirectly from expanded Medicaid criteria, which reduce hospitals’ unreimbursed expenses and in theory free up funds for services to the remaining uninsured. Medicaid spending is a likely early target of the Republican-led Congress, despite the crucial role of Congress in the financing of hospitals, nursing homes, and clinics. If the current federal Medicaid program, which matches eligible state expenditures, is replaced by block grants to states, waivers of state-level requirements for participation, or a mix of both, the  result will certainly be reduced safety-net services coupled with more demand for existing services. As people who are currently covered by Medicaid become ineligible, or underinsured relative to their health care needs, they will turn to the same safety-net services – namely, emergency departments and community health centers – that the undocumented and other uninsured populations already rely on.

See Also: Quick Guide to State and County-Level Data and Resources: Undocumented Patients in the Local Safety-Net

This issue brief was drafted by Rachel Fabi with research assistance from Mohini Banerjee, edited by Michael K. Gusmano and Nancy Berlinger, and designed by Mohini Banerjee. Special thanks to expert reviewers Evan A. Ashkin, MD, Associate Professor of Family Medicine, University of North Carolina at Chapel Hill; Kate Bicego, Consumer Assistance Program Manager, Health Care For All, Boston, MA; Caroline Rath, physician assistant, Gouverneur Healthcare Services, New York City; and Eva Turbiner, President and CEO, Zufall Health Center, Dover, NJ. Information about policy mechanisms was compiled using publicly available documents, including Medicaid Provider Manuals for each state; see References. All information is current as of September 12, 2014.

Click Here for Slideset Version

On undocumented immigrants’ general use of health care, see here. On relevant U.S. health policy, see here. On relevant demographics, see here.

Access to prenatal care for women who are undocumented immigrants varies widely across the United States due to differences in state policies and differing state-level interpretations of federal policies that fund health services for pregnant women. This issue brief provides an overview of this access problem and the consequences of policy-related uncertainty or variation for undocumented patients, their families, and the health care safety-net.

Why is access to prenatal care for undocumented immigrants important?

There is long-established medical consensus that prenatal care is fundamental to reproductive and infant health; however, undocumented immigrants living in the U.S. are significantly less likely to have “adequate” prenatal care, compared to other immigrants and to U.S. born citizens. [1-4] The reasons for this gap include lack of means to pay for prenatal care, lack of access to sources of prenatal care, and mistrust of the health care system. [5] Other barriers to health care that undocumented immigrants face include difficulties navigating the health care system; linguistic, literacy, and other challenges in communicating about health care needs; inability to take time off from work; misinformation about the immigration-related consequences of using health care services; and perceived and actual risks of encountering immigration authorities or local law enforcement in the course of seeking health care.

The Emergency Medical Treatment and Active Labor Act (EMTALA), which prevents hospitals from turning away uninsured patients in need of emergency treatment, encompasses labor and delivery, and most “emergency” health care services used by undocumented immigrants are related to childbirth. [6-8] State-level Emergency Medicaid programs provide some reimbursement to hospitals for treatment provided under EMTALA. In some states, undocumented immigrants may account for as much as 99% of Emergency Medicaid expenditures; approximately 80% of these costs are related to childbirth or to complications of pregnancy and labor. [8] Because access under EMTALA is restricted to emergent conditions, it is not a mechanism for access to routine prenatal care that could prevent or monitor pregnancy-related complications.

Lack of access to prenatal care increases the risk of premature birth and low birth-weight, and may be a factor in a range of poor health outcomes experienced by undocumented pregnant women and their babies, including higher rates of labor and delivery complications such as precipitous labor, excessive bleeding, breech presentation, cord prolapse, and fetal distress. [9, 10] These risks and outcomes have consequences for the viability and health of newborns, infant and child development, and the health of mothers, and for costs associated with treating medical conditions that could have be prevented or managed before birth.

What policy provisions may offer access to prenatal care for undocumented immigrants?

1. CHIP Unborn Child Option

As of September 2014, 16 states have implemented a State Plan Amendment (SPA) to the Children’s Health Insurance Program (CHIP), which is jointly supported by federal and state funds. An unborn child may be considered a “targeted low-income child” who is eligible for this program. [11] This provision would enable an undocumented immigrant to enroll her unborn child in the program so she can obtain coverage for prenatal care and labor and delivery services, in the interest of protecting the child’s future health. Under this provision, services such as prenatal vitamins and ultrasounds may be covered but services perceived as unrelated to pregnancy may not be covered.

2. Presumptive Eligibility for Medicaid (PE)

Presumptive eligibility (PE) is a state-level mechanism that enables pregnant women to obtain immediate temporary Medicaid coverage without having to wait for a Medicaid application to be processed. As of September 12, 2014, PE was available in 30 states, 13 of which explicitly restrict access to women with legal immigration status. Physicians who are “qualified providers” of Medicaid services and eligible to determine PE based on a patient’s self-reported income can provide Medicaid-funded care to any pregnant woman whose self-reported income meets that state’s eligibility threshold. During the time-limited PE period, the woman is expected but not required to submit an application for regular Medicaid coverage. PE coverage typically lasts two months, or until a decision approving the applicant for Medicaid is made. The scope of services covered under PE differs by state; some states cover only ambulatory prenatal care, while others cover the full Medicaid scope of services.

For information on the Hospital Presumptive Eligibility provision of the Patient Protection and Affordable Care Act (ACA), which enables qualified hospitals to determine PE, see References.

3. Other Policy Mechanisms

Expanding eligibility for safety-net health insurance programs to include coverage for low-income pregnant women regardless of immigration status is another way that undocumented women in some jurisdictions can obtain coverage for prenatal care. Three states (New York, Massachusetts, and New Jersey) offer public insurance for the duration of a pregnancy and for two months after delivery. In New York, this coverage is offered as an entitlement program through a state-funded expansion of Medicaid. In Massachusetts, coverage is provided through a state-funded Medicaid expansion, supplemented by the CHIP Unborn Child Option (see above) to cover ambulatory prenatal care services. In New Jersey, Medicaid coverage for prenatal care only is funded through the state budget and offered through community health centers and hospitals subject to the availability of grant funds.

In some cities, undocumented immigrants are eligible for coverage for prenatal care and other health care services through locally-funded programs. In Washington D.C, for example, the D.C. Healthcare Alliance provides insurance coverage for low-income city residents who do not have Medicaid or other insurance.

Beyond these publicly-funded insurance mechanisms, access to prenatal care for undocumented immigrants may also be provided directly by public health clinics and nonprofit organizations (such as Federally Qualified Health Centers) that offer health services for patients without insurance that are available for free or at a sliding-scale fee based on a patient’s ability to pay.

References

1. American Academy of Pediatrics, Guidelines for Perinatal Care, 7th ed. 2012.
2. ACOG Committee Opinion No. 425: health care for undocumented immigrants. Obstet Gynecol, 2009. 113(1): 251-4.
3. Cohen, G.J., The prenatal visit. Pediatrics, 2009. 124(4): 1227-32.
4. Korinek, K. and K.R. Smith, Prenatal care among immigrant and racial-ethnic minority women in a new immigrant destination: exploring the impact of immigrant legal status. Soc Sci Med, 2011. 72(10): 1695-703.
5. Frisbie, W.P., S. Echevarria, and R.A. Hummer, Prenatal care utilization among non-Hispanic Whites, African Americans, and Mexican Americans. Matern Child Health J, 2001. 5(1): 21-33.
6. Federal Funding for Unauthorized Aliens’ Emergency Medical Expenses, in CRS Report For Congress. 2004.
7. United States Congressional Budget Office, The Impact of Unauthorized Immigrants on the Budgets of State and Local Governments. 2007.
8. DuBard, C.A. and M.W. Massing, Trends in emergency Medicaid expenditures for recent and undocumented immigrants. Jama, 2007. 297(10):1085-92.
9. Lu, M.C., et al., Elimination of public funding of prenatal care for undocumented immigrants in California: a cost/benefit analysis. Am J Obstet Gynecol, 2000. 182 (1 Pt 1): 233-9.
10. Reed, M.M., et al., Birth outcomes in Colorado’s undocumented immigrant population. BMC Public Health, 2005. 5: 100.
11. State Children’s Health Insurance Program; Eligility for Prenatal Care and Other Health Services for Unborn Children, F. Register, Editor. 2002: 61956-61974.

CHART–Prenatal Care: State-Level Policy Provisions

SLIDESET–Access to Prenatal Care Teaching Tool

State-Level and Local-Level Programs

On immigrants’ eligibility provisions for public benefits, including Medicaid and CHIP, see Overview of Immigrants’ Eligibility for SNAP, TANF, Medicaid, and CHIP, Office of the Assistant Secretary for Planning and Evaluation (March 2012): http://aspe.hhs.gov/hsp/11/ImmigrantAccess/Eligibility/ib.shtml (accessed on August 27, 2014).

Medicaid Provider Manuals for presumptive eligibility in many states are available on the website of Enroll America, a nonprofit, nonpartisan organization (March 2014): http://www.enrollamerica.org/toolkits/pe/states.html
(accessed on August 20, 2014). See also links below.

For a list of states that had Presumptive Eligibility as of January 2013, see the Kaiser Family Foundation state indicator: http://kff.org/medicaid/state-indicator/presumptive-eligibility/ (accessed on August 27, 2014).
(The chart that accompanies this Issue Brief reflects subsequent changes to this list current as of September 1, 2014)
See also: Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 2012-2013, Kaiser Commission on Medicaid and the Uninsured (January 2013): http://kaiserfamilyfoundation.files.wordpress.com/2013/05/8401.pdf (accessed on August 27, 2014)

On Hospital Presumptive Eligibility, see Implementation of the Affordable Care Act’s Hospital Presumptive Eligibility Option: Considerations for States, Center for Medicare and Medicaid Services (November 2013): http://www.medicaid.gov/State-Resource-Center/MAC-Learning-Collaboratives/Learning-Collaborative-State-Toolbox/Downloads/State-Network-CHCS-Implementation-of-the-Affordable-Care-Acts-Hospital-P.pdf (accessed on August 27, 2014); see also The New Hospital Presumptive Eligibility Opportunity. Enroll America. March 10, 2014. http://www.enrollamerica.org/toolkits/pe/home.html (accessed on August 26, 2014).

State Medicaid Provider Manuals and Related State-level Documents

Alabama:

Alabama Medicaid Agency. Provider Manual – Maternity Care – Chapter 24. July 2014.
http://medicaid.alabama.gov/documents/6.0_Providers/6.7_Manuals/6.7.8_Provider_Manuals_2014/6.7.8.3_July_2014/Jul14_24.pdf (accessed 20 August 2014).

Alaska:

Alaska Department of Health and Social Services. Medicaid. 2012. http://dhss.alaska.gov/dpa/pages/medicaid/default.aspx (accessed 26 August 2014).

Arizona:

Arizona Health Care Cost Containment System. AHCCCS Health Plans. 2014. http://www.azahcccs.gov/applicants/healthplans/healthplans.aspx (accessed 26 August 2014)

Arkansas:

Arkansas Department of Human Services. Medical Services Policy Manual, Section B. January 2014. https://ardhs.sharepointsite.net/DHSPolicy/DCOPublishedPolicy/Section%20B-200%20Families%20and%20Individuals%20Group%20(MAGI).pdf (accessed on August 20, 2014).

California:

Access for Infants and Mothers (AIM). AIM Handbook. April 2014. http://www.aim.ca.gov/Publications/AIM_Handbook_en.pdf (accessed on August 20, 2014).

Colorado:

Colorado Department of Health Care Policy & Financing. Medicaid Provider Information Billing Manual. February 2014. 19-20. https://www.colorado.gov/pacific/sites/default/files/GENERAL_PROVIDER_INFORMATIO_0.PDF (accessed on August 20, 2014).

Connecticut:

Connecticut Department of Social Services. U.S. Citizenship: What you need to know for your benefits in Medicaid, HUSKY A and HUSKY B. February 2010. http://www.ct.gov/dss/lib/dss/pdfs/0606citizenshiprevised02.10.pdf (accessed on August 20, 2014).

Delaware:

Delaware Department of Health and Social Services, Division of Medicaid and Medical Assistance. 31 Del.C. §512: Delaware Medicaid Modified Adjusted Gross Income (MAGI) Eligibility and Benefits State Plan Amendments MAGI-Based Eligibility Groups. December 2013. http://regulations.delaware.gov/register/december2013/final/17%20DE%20Reg%20612%2012-01-13.pdf and http://regulations.delaware.gov/register/december2013/final/Benefits.pdf (accessed on August 20, 2014).

Florida:

State of Florida Department of Children and Families. Presumptive Medicaid Eligibility for Pregnant Women. January 2014. http://www.dcf.state.fl.us/admin/publications/cfops/165%20Economic%20Self-Sufficiency%20Services%20(CFOP%20165-XX)/CFOP%20165-09,%20Presumptive%20Medicaid%20Eligibility%20for%20Pregnant%20Women.pdf (accessed on August 20, 2014).

Georgia:

Georgia Department of Community Health, Division of Medical Assistance Plans. Part II: Policies and Procedures Affordable Care Act For Presumptive Eligibility Pregnant Women Medicaid. July 2014. https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/PE%20ACA%20Pregnant%20Women%20Medicaid%2002-07-2014%20145016.pdf (accessed on August 20, 2014).

Hawaii:

State of Hawaii. My Benefits. 2014, http://mybenefits.hawaii.gov/. (accessed 26 August 2014).

Idaho:

Idaho Department of Health and Welfare. Presumptive Eligibility for Medicaid: Provider Training. January 2014. http://healthandwelfare.idaho.gov/Portals/0/Providers/PresumptiveMedicaid/PresumptiveEligibilityProvidersTraining.pdf (accessed on August 20, 2014).

Illinois:

State of Illinois All Kids. Moms & Babies Programs for Pregnant Women. 2014. http://www.allkids.com/pregnant.html#momsbabies (accessed on August 20, 2014).

Indiana:

State of Indiana Family and Social Services Administration. Presumptive Eligibility for Pregnant Women. 2014. http://member.indianamedicaid.com/media/15344/pe%20brochure_v2.pdf (accessed on August 20, 2014).

Iowa:

Iowa Department of Human Services. All Providers II Member Eligibility. August 2014. https://dhs.iowa.gov/sites/default/files/All-II.pdf (accessed on August 20, 2014).

Kansas:

Kansas Department of Health and Environment. KanCare. 2012-2014. http://www.kancare.ks.gov/ (accessed 26 August 2014).

Kentucky:

Kentucky Cabinet for Health and Family Services. Presumptive Eligibility (PE) for Pregnant Women. April 2014. http://chfs.ky.gov/dms/peservice.htm#eligible (accessed on August 20, 2014).

Louisiana:

Louisiana Department of Health and Hospitals. Louisiana Medicaid Eligibility Manual (MEM). May 2014. http://new.dhh.louisiana.gov/assets/medicaid/MedicaidEligibilityPolicy/H-3050m.pdf (accessed on August 20, 2014).

Maine:

Maine Department of Health and Human Services. Mainecare Eligibility Manual. June 2014. http://www.maine.gov/sos/cec/rules/10/144/ch332/144c332-sans-extras.doc (accessed on August 20, 2014).

Maryland:

Maryland Department of Health and Mental Hygiene. Maryland Medical Assistance Programs. February 2014, https://mmcp.dhmh.maryland.gov/SitePages/Home.aspx (accessed 26 August 2014).

Massachusetts:

Massachusetts Executive Office of Health and Human Services. Member Booklet for Health Coverage and Help Paying Costs. March 2014. http://www.mass.gov/eohhs/docs/masshealth/membappforms/aca-1-english-mb.pdf (accessed on August 20, 2014).

Massachusetts Executive Office of Health and Human Services. MassHealth Regulations, 130 CMR 505.002(D). January 2014.
http://www.lawlib.state.ma.us/source/mass/cmr/cmrtext/130CMR505.pdf (Accessed on August 27, 2014).

Michigan:

Michigan Department of Community Health. Health Care Programs Eligibility. 2014. http://www.michigan.gov/mdch/0,4612,7-132-2943_4860-35199–,00.html (accessed on August 20, 2014).

Minnesota:

Minnesota Department of Human Services. People Who Are Not U.S. Citizens. December 2013. http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_144099# (accessed on August 20, 2014).

Mississippi:

Mississippi Division of Medicaid. Medicaid. 2014. http://www.medicaid.ms.gov/ (accessed on August 27, 2014).

Missouri:

Missouri Department of Social Services. TEMP Eligibility Determination. 2008. http://manuals.momed.com/forms/temp_eligibility_determination.pdf (accessed on August 21, 2014).

See also : Lieb, D. Missouri governor signs health care expansion. St. Louis Post-Dispatch. July 10, 2014.
http://www.stltoday.com/news/special-reports/mohealth/updates/missouri-governor-signs-health-care-expansion/article_035eec6f-1bd0-5b9d-97b6-1d1363b127e4.html (accessed on August 21, 2014).

Montana:

Montana Department of Health and Human Services. Presumptive Eligibility 2014 Qualified Entity Reference Guide. 2014. http://medicaidprovider.hhs.mt.gov/pdf/presumptive_eligibility/presumptiveEeigibilityreferenceguide%202014.pdf (accessed on August 21, 2014).

Nebraska:

Nebraska Department of Health and Human Services. New Adjunct Eligible Program. July 2012. http://dhhs.ne.gov/publichealth/Documents/I-6-2012_New_Adjunct_Eligible_Program.pdf (accessed on August 21, 2014).

The Undocumented and the Unborn. April 23, 2013. The New York Times. http://www.nytimes.com/2012/04/24/opinion/undocumented-immigrants-and-the-unborn.html (accessed on August 21, 2014).

Nevada:

Nevada Department of Health and Human Services. Division of Health Care Financing and Policy. https://dhcfp.nv.gov/index.htm (accessed 26 August 2014).

New Hampshire:

New Hampshire Department of Health and Human Services. Application for Medicaid Presumptive Eligibility (PE). 2014. http://www.dhhs.nh.gov/dfa/presumptive/documents/dfa-821.pdf (accessed on August 21, 2014).

New Jersey:

New Jersey Department of Human Services. Medicaid Communication No. 11-07: New Jersey Supplemental Prenatal Care Program (NJSPCP). July 2011. http://www.state.nj.us/humanservices/dmahs/info/resources/medicaid/2011/11-07_New_Jersey_Supplemental_Prenatal_Care_Program_NJSPCP.pdf (accessed on August 21, 2014).

New Jersey Administrative Code. 10:72-3.10: New Jersey Care Special Medicaid Programs Manual. 18 August 2014.
https://web.lexisnexis.com/research/retrieve?_m=fa48f5c6040d70cb38009b6c3e923ada&csvc=toc2doc&cform=tocslim&_fmtstr=FULL&docnum=1&_startdoc=1&wchp=dGLzVzB-zSkAb&_md5=b1be9ccbb51b271b7fb8183803b176eb (accessed on August 26, 2014).

New Mexico:

New Mexico Administrative Code. 8.291.400: Eligibility Requirements. 2014. http://www.nmcpr.state.nm.us/nmac/parts/title08/08.291.0400.htm (accessed on August 21, 2014).

New Mexico Human Services Department. Presumptive Eligibility (PE) Applicant Information Form. May 2014. https://nmmedicaid.acs-inc.com/static/PDFs/PE%20Forms/MAD011.pdf (accessed on August 21, 2014).

New York:

New York State Department of Health. New York State Medicaid Update, Prenatal Care Special Edition. February 2010. https://www.health.ny.gov/health_care/medicaid/program/update/2010/2010-02_special_edition.htm (accessed on August 21, 2014).

North Carolina:

North Carolina Department of Health and Human Services. Family and Children’s Medicaid MA-3245 Presumptive Eligibility for Pregnant Women. March 2012. http://info.dhhs.state.nc.us/olm/manuals/dma/fcm/man/ma3245-01.htm (accessed on August 21, 2014).

North Carolina Department of Health and Human Services. Presumptive Eligibility Determination Form for Pregnancy-Related Care. July 2014. http://info.dhhs.state.nc.us/olm/forms/dma/dma-5032-ia.pdf (accessed on August 21, 2014).

North Dakota:

North Dakota Department of Human Services. North Dakota Medicaid. 2010. http://www.nd.gov/dhs/services/medicalserv/medicaid/ (accessed 26 August 2014).

Ohio:

Ohio Department of Job and Family Services. 5160:1-2-50 Medicaid: Presumptive Eligibility for Pregnant Women. March 2014. http://emanuals.odjfs.state.oh.us/emanuals/GetDocument.do?docId=Document(storage%3DREPOSITORY%2CdocID%3D%24REP_ROOT%24%23node-id(1631364))&locSource=input&docLoc=%24REP_ROOT%24%23node-id(1631364)&version=8.0.0 (accessed on August 21, 2014).

Oklahoma:

Oklahoma Health Care Authority. What is SoonerCare?. http://www.okhca.org/individuals.aspx?id=52&menu=40&parts=11601_7453 (accessed 26 August 2014).

Oregon:

Oregon Health Authority. Oregon’s Medicaid State Plan. http://www.oregon.gov/oha/healthplan/Pages/stateplan.aspx (accessed 26 August 2014).

Pennsylvania:

Pennsylvania Department of Public Welfare. Provider Instructions Presumptive Eligibility Application. May 2006. http://www.dpw.state.pa.us/cs/groups/webcontent/documents/form/s_002592.pdf (accessed on August 21, 2014).

Rhode Island:

Rhode Island KIDS COUNT. RIte Care Coverage for Immigrant Children and Families. October 2010. http://www.rikidscount.org/matriarch/documents/Q%20and%20A%20For%20Helpers.pdf (accessed on August 21, 2014).

South Carolina:

South Carolina Department of Health and Human Services. Health Connections Medicaid. https://www.scdhhs.gov/ (accessed 26 August 2014).

South Dakota:

South Dakota Department of Social Services. Medical Services. 2011. http://dss.sd.gov/medicalservices/ (accessed 26 August 2014).

Tennessee:

Tennessee Department of Finance and Administration Division of Insurance Administration. Chapter 0620-05-01 Cover Kids Rules. June 2014. http://www.tn.gov/sos/rules/0620/0620-05/0620-05-01.20140615.pdf (accessed on August 21, 2014).

Texas:

Texas Health and Human Services Commission. CHIP State Plan. March 2012. http://www.hhsc.state.tx.us/medicaid/about/state-plan/docs/CHIPStatePlan.pdf (accessed on August 27, 2014).

Texas Department of State Health Services. Title V MCH Fee For Service Policy Manual. September 2013. http://www.dshs.state.tx.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=8589980232 (accessed on August 21, 2014).

Utah:

Utah Department of Health. Baby Your Baby Eligibility Chart. 2014. http://www.babyyourbaby.org/financial-help/eligibility.php (accessed on August 21, 2014).

Vermont:

Green Mountain Care. Medicaid. 2014, http://www.greenmountaincare.org/vermont-health-insurance-plans/medicaid (accessed 26 August 2014).

Virginia:

Virginia’s Medicaid Program. Department of Medical Assistance Services. 2009. http://www.dmas.virginia.gov/ (accessed 26 August 2014).

Washington:

Washington State Department of Social and Health Services. Pregnancy and Women’s Health – Medical Programs. November 2013. http://www.dshs.wa.gov/manuals/eaz/sections/medicalassistance/PREGmedicalprogs.shtml (accessed on August 21, 2014).

Washington D.C.:

DC Department of Human Services. Chapter 4 – DC Healthcare Alliance. (2011) http://dhs.dc.gov/page/chapter-4-dc-healthcare-alliance-program (accessed on August 21, 2014).

West Virginia:

West Virginia Department of Health and Human Resources. West Virginia Bureau for Medical Services. 2011. http://www.dhhr.wv.gov/bms/Pages/default.aspx (accessed 26 August 2014).

Wisconsin:

Wisconsin Department of Health Services. BadgerCare+ Prenatal Services. February 2014. http://www.dhs.wisconsin.gov/publications/p1/p10026.pdf (accessed on August 21, 2014).

Wyoming:

Wyoming Department of Health. Presumptive Eligibility (PE). 2013. http://www.health.wyo.gov/healthcarefin/medicaideligibility/PresumptiveEligibilityPE.html (accessed on August 21, 2014).

Rachel Fabi is a PhD student in the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, and in the Johns Hopkins Berman Institute of Bioethics. She is a 2014 intern on the Undocumented Patients Project.

Access to health care for undocumented immigrants in the U.S. is shaped by several policies and programs at the federal state and local level. This issue brief provides an overview of key federal and state policies.

Are undocumented immigrants eligible for public insurance programs?

With the exception of emergency medical care, undocumented immigrants are not eligible for federally funded public health insurance programs, including Medicare, Medicaid and the Child Health Insurance Program (CHIP).{{1}}Medicare is a social insurance program that provides health insurance to people age 65 and over, as well as people with permanent disabilities and end-stage renal disease. Medicaid is a means-tested social welfare program that provides health insurance to certain categories of poor people. CHIP, created in 1997, is a block grant program to expand coverage to children in families with incomes that exceed Medicaid eligibility.{{2}} There is no organized, national program to provide health care for undocumented children. U.S.-born children in mixed-status families may be eligible for Medicaid or CHIP if they qualify on the basis of income and age.

Although federal funds may not be used to provide non-emergency health care to undocumented immigrants, some states and local governments use their own funds to offer coverage to undocumented children.{{3}} For example, the Healthy Kids program in San Francisco covers uninsured children under the age of 19, including undocumented children.{{4}} Similarly, the All Kids program Illinois covers all children under the age of 19 who meet program income requirements, regardless of immigration status.{{5}}

PRUCOL (Permanent Residence Under Color of Law) is a public benefits eligibility category that refers to individuals who are in the U.S. with the knowledge of immigration services and are not likely to be deported.Before the adoption of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996,{{6}} people with PRUCOL status were eligible for Medicaid, but PRWORA eliminated their eligibility with the exception of emergency services. In New York, the State Court of Appeals (Aliessa et al. v. Novello) concluded that denying access to Medicaid violated the equal protection clauses of the New York and U.S. constitutions. As a result, New York provides Medicaid to this population using state funds only.

In about half of the U.S. states, immigrant children under the age of 21 and pregnant woman who have been granted deferred action on their immigration status are allowed to apply for Medicaid and the CHIP or enroll in their state’s high risk insurance pool. An exception to this, however, are the so-called “dreamers” – the estimated 1.7 million undocumented teenagers and young adults granted deferred action by the Obama Administration on June 15, 2012.{{7}} President Obama announced that undocumented immigrants who were brought to the U.S. before they turned 16 and are younger than 30, have been in the country for at least five continuous years, have no criminal history, graduated from a U.S. high school or earned their GED, or honorably discharged from the military will be immune from deportation and can apply for a work permit that will be good for two years with no limits on renewal.On August 28, 2012, the Obama Administration announced that the young people affected by this directive would not meet the definition of being “lawfully present”and would therefore be ineligible for Medicaid, the CHIP and the insurance benefits of the ACA.{{8}}

How is emergency medical care available to undocumented immigrants?

In 1986 the Congress enacted the Emergency Medical Treatment and Active Labor Act (EMTALA) as part of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) (Pub. L. 99-272). The law was designed to provide patients with access to emergency medical care and to prevent hospitals from “dumping” unstable patients that could not afford to pay for their care.”{{9}} Under the law, “any patient arriving at an Emergency Department (ED) in a hospital that participates in the Medicare program must be given an initial screening, and if found to be in need of emergency treatment (or in active labor), must be treated until stable.”{{10}} The law defines an emergency medical condition as a “medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in – (i) [p]lacing the health of the individual . . . in serious jeopardy; (ii) [s]erious impairment to bodily functions; or (iii) [s]erious dysfunction of any bodily organ part[.]” It requires hospitals covered by the law to provide patients with an emergency medical condition with “an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (EMC) exists.” (42 C.F.R 489.24(a)(1)(i)). the medical screening examination “must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations” (42 C.F.R. § 489.24(a)(1)(i)).

Although the law refers specifically to hospitals with an ED, the guidelines from the federal government have applied EMTALA requirements to all facilities that participate in the Medicare program and offer emergency services.{{11}} Met, while EMTALA requires covered hospitals to stabilize patients with emergency medical conditions, it does not require these facilities to provide additional treatment. There is a legal dispute over whether the stabilization requirement in EMTALA continues to apply if a patient has been admitted to the hospital.{{12}} Decisions by the Fourth, Ninth and Eleventh Circuit Courts held that hospitals have no stabilization duties once patients are admitted,{{13}} but the Sixth Circuit held the opposite.{{14}}

In addition to EMTALA, it is also possible for undocumented immigrants to qualify for Medicaid coverage for emergency care. The definition of emergency care and the scope of services available through the Medicaid programs vary by state. For example, in New York State Medicaid for Emergency Care may be used to provide chemotherapy and radiation therapy to undocumented patients with cancer. In New York State, California, and North Carolina, it may be used to provide outpatient dialysis to undocumented patients.{{15}}

Do undocumented immigrants have access to care through the health care safety net?

To care for the lower income residents, including undocumented immigrants, the U.S. relies on a patchwork “system” of safety-net providers, including public and not-for-profit hospitals, federally qualified community health centers (FQHCs), and migrant health centers. Since the Omnibus Budget Reconciliation Act of 1981, a hospital recognized as “disproportionate share hospital” (DSH) with respect to the percentages of low-income and uninsured patients it treats receives additional payments from Medicaid to support uncompensated care. Congress also required Medicare to allocate DSH funds to hospitals. The DSH programs fund hospital care for uninsured patients. Together, the Medicare and Medicaid DSH programs provide more than $20 billion to qualified hospitals annually, but these programs are scheduled to be reduced significantly under health care reform.{{16}}

Federally Qualified Health Centers (FQHCs) and Migrant Health Centers are not-for-profit organizations{{17}} funded by the federal Health Resources and Services Administration (HRSA). Both offer comprehensive primary care to vulnerable populations that include Medicaid patients, uninsured patients, and patients in underserved urban, suburban, and rural areas. They provide care regardless of ability to pay, insurance status or immigration status. Both are required to have a board of directors with a majority (at least 51%) of the members from the community served by the center. In addition, both types of health centers are required to use a sliding fee scale. The main difference between them is that migrant health centers are only allowed to serve migrant and seasonal farm workers and their families.{{*}}

Federal support for FQHCs increased significantly under the George W. Bush administration and they have received continued support from the Obama administration.{{18}} Between 1996 and 2010, direct federal funding for FQHCs increased from $750 million to $2.2 billion. As of 2010, there were 1,214 FQHCs operating more than 8,000 service sites.{{19}} In addition, there were 159 federally funded migrant health center sites, operating more than 700 service sites.{{20}}

How will the Patient Protection and Affordable Care Act influence access to health care for undocumented immigrants?

The PPACA does not provide undocumented immigrants with eligibility for public insurance programs. Because undocumented immigrants are not regarded as “qualified individuals” under the law, it also does not allow undocumented immigrants to purchase health insurance through the new state health exchanges even if they are able to do so with their own money.{{21}} Section 1312 of the Act states, “If an individual is not, or is not reasonably expected to be for the entire period for which enrollment is sought, a citizen or national of the United States or an alien lawfully present in the United States, the individual shall not be treated as a qualified individual and may not be covered under a qualified health plan in the individual market that is offered through an Exchange.”{{22}}

Despite these restrictions, the law does include additional funding for the health care safety-net, including an $11 billion increase for FQHCs and the law’s expansion of the Medicaid program may provide additional revenue to many FQHCs and other safety-net providers. Yet, the PPACA also calls for an $18 billion dollar reduction in Medicaid DSH payments and a $22 billion reduction in Medicare DSH payments through 2020. The DSH cuts are based on the assumption that hospitals will not need to provide as much charity care once the health reform is implemented. Because undocumented immigrants will not receive public or private insurance coverage under health reform, they are likely to represent a larger percentage of the nation’s uninsured population. This raises important question about future political support for the health care safety-net.{{23}}

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

{{Figure 2 source}}

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]]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[[1]]

[[2]]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.[[2]]

[[3]]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.[[3]]

[[4]]4. DuBard, C. Annette and Mark W. Massing. “Trends in Emergency Medicaid Expenditures for Recent and Undocumented Immigrants.” JAMA 2007; 297(10): 1085-92.[[4]]

[[5]]5. Goldman, Dana P., James P. Smith, and Neeraj Sood. “Immigrants and the Cost of Medical Care.” Health Affairs 2006; 25(6): 1700–11.[[5]]

[[6]]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.[[6]]

[[7]]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.[[7]]

[[8]]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.[[8]]

[[9]]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[[9]]

[[10]]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[[10]]

[[11]]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.[[11]]

[[12]]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.[[12]]

[[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.[[13]]

[[14]]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.[[14]]

[[15]]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[[15]]

[[16]]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[[16]]

[[17]]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.[[17]]

[[18]]18. “Five Questions for Karina Fortuny on Children of Immigrants.” Urban Institute, October 2011. Available at: http://www.urban.org/toolkit/fivequestions/fortuny.cfm[[18]]

[[19]]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).[[19]]

[[20]]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[[20]]

[[21]]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.[[21]]

[[22]]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.[[22]]

[[23]]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.[[23]]

[[24]]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.[[24]]

[[Figure 2 source]]Source: Pew Hispanic Center tabulations based on 2008 Current Population Survey.[[Figure 2 source]]

How many undocumented immigrants live in the United States?

As of March 2010, an estimated 11.2 million undocumented immigrants were living in the United States, a figure equivalent to 3.7% of the nation’s population.{{1}} This estimate includes persons who entered the U.S. without valid documents and persons who are living outside the terms of their entry visas. This estimate does not include U.S. citizens or legal residents who are members of “mixed-status” families that include undocumented immigrants.

The size of the undocumented immigrant population has become relatively stable in recent years. From 2000 to 2007 the estimated number of undocumented immigrants in the US had steadily increased from 8.4 million to 12.0 million, then declined slightly, reaching its current level by 2009. The decline in new immigration has been attributed to a variety of factors, including tighter border control, increased deportations, and decreased opportunities for employment due to the recession.{{2}}^,{{3}}

The undocumented immigrant population in the US is disproportionately male. Men between the ages of 18 and 39 make up 35% of the undocumented immigrant population in the US, compared with 14% of the US-born population and 18% of the legal immigrant population. Compared with the US-born population, the undocumented immigrant population includes few older people and children, excluding citizens or legal residents who are members of mixed-status families.

Where do undocumented immigrants live?

Undocumented immigrants live in every state and are concentrated in a relatively small number of states, reflecting the availability of work and social networks. About half of this population lives in one of four states: California, Texas, Florida or New York. Nearly a quarter (23%) lives in California alone. Some states, such as Georgia and North Carolina, where relatively few undocumented immigrants resided two decades ago, have seen significant increases in the number of undocumented immigrant residents in recent years.{{4}} 

Where are undocumented immigrants from?

Most (80%) of the undocumented immigrants in the U.S. emigrated from Latin American countries.{{5}} In 2007, the leading countries of birth for undocumented immigrants were Mexico (6,980,000), El Salvador (540,000), Guatemala (500,000), the Philippines (290,000) and China (290,000).{{6}}

Why do undocumented immigrants come to the U.S.?

Most undocumented immigrants came to the U.S. to find work.{{7}} Among undocumented immigrants who are men aged 18-64, 98% were part of the paid work force in 2008. Undocumented immigrants make up 25% of farm workers, 19% of building, grounds-keeping, and maintenance workers, 17% of construction workers, and 12% of food preparation and service workers and make up 5.2% of the paid work force in the U.S.{{8}} A smaller percentage (58%) of female undocumented immigrants in the same age range participate in the paid work force. This discrepancy may reflect women’s unpaid role in childcare, as many undocumented immigrants have children at home.{{9}}

What is the household income of undocumented immigrants in the U.S.?

Undocumented immigrants have lower median household incomes than legal immigrants and U.S.-born citizens, despite having more workers per household on average (1.75) than U.S.-born households (1.23).{{10}} In 2007, the median annual household income of undocumented immigrants was $36,000, compared with $50,000 for people born in the U.S. The median household income of undocumented immigrants remains largely unchanged even after they have been in the U.S. for more than a decade.{{11}}

What is the typical household structure for undocumented immigrants in the U.S.?

The majority of undocumented immigrants live with their families. Nearly half of undocumented immigrant households (47%) consist of a couple with children, while 15% consist of couples without children. Single-person households make up 13% of undocumented immigrant households.{{12}}

The establishment of family households by undocumented immigrants is reflected in the fact that by 2008, 73% of children of undocumented immigrants were U.S. citizens by birth. From 2004 to 2008, the number of U.S.-born children of undocumented immigrants increased from 2.7 million to 4 million. Some mixed-status families include both U.S.-born children and undocumented immigrant children. From 2004 to 2008, the number of children who are undocumented immigrants themselves remained at roughly 1.5 million and, according to some estimates, may have even declined slightly since 2005, reflecting the general trend toward declining new immigration and the establishment of households in which most children are born in the U.S.{{13}}

What is the education level of undocumented immigrants?

Undocumented immigrants have lower levels of education than U.S. born residents in the same age range. Among all undocumented immigrants ages 25-64, 47% have not completed high school (compared with 8% of U.S. born adults in the same age range) and of these, more than half (29% of total) have less than a ninth grade education.

Among adults age 25-64, 29% of undocumented immigrants have less than a 9^th grade education compared with only 2% among U.S. born adults in this age cohort. A total of 47% of undocumented immigrants age 25-64 have less than a high school education, compared with only 8% among US-born population adults in this age cohort (See Figure 1).

Figure 1: Education Levels Among Undocumented Immigrants and U.S. Born Citizens

[gdoc key=”https://docs.google.com/spreadsheets/d/1RrcBpeTMsX6P3NQxHfb4Dq4Vn_DIS3z6RJTyCKzpWJE/edit#gid=0″ title=”” http_opts='{}’ chart=”column” class=”columnchart”]

{{Figure 1 source}}

[[1]]1. Passel, Jeffrey S. Unauthorized Immigrant Population: National and State Trends, 2010. Pew Hispanic Center, February 2011. Estimates are based on the U.S. Census Bureau’s Current Population Surveys, March 2010 Supplement. The Pew Hispanic Center’s report is available at: http://pewhispanic.org/files/reports/133.pdf[[1]]

[[2]]2. Camarota, Steven A. and Karen Jensenius. A Shifting Tide: Recent Trends in the Illegal Immigrant Population. Center for Immigration Studies, July 2009. Available at: www.cis.org/IllegalImmigration-ShiftingTide[[2]]

[[3]]3. Another contributing factor may be the decline in the birth rate in Mexico (the birthplace of most undocumented immigrants to the U.S.) from an average of 7 children per family in the 1960s to 2.2 children per family, or just over replacement rate, today. See Raúl Hinojosa-Ojeda. Raising the Floor for American Workers: The Economic Benefits of Comprehensive Immigration Reform. Center for American Progress and the Immigration Policy Center, American Immigration Council, January 2010. Available at: www.americanprogress.org/issues/2010/01/pdf/immigrationeconreport.pdf[[3]]

[[4]]4. Passel, Unauthorized Immigrant Population: National and State Trends, 2010.[[4]]

[[5]]5. Passel, Jeffrey S. and D’Vera Cohn. Trends in Unauthorized Immigration: Undocumented Inflow Now Trails Legal Inflow. Pew Hispanic Center. 2008. Available at: http://pewhispanic.org/files/reports/94.pdf.[[5]]

[[6]]6. Hoefer, Michael, Nancy Rytina, and Bryan C. Baker. Estimates of the Unauthorized Immigrant Population Residing in the United States. Office of Immigration Statistics, September 2008. Available at: www.dhs.gov/xlibrary/assets/statistics/publications/ois_ill_pe_2007.pdf[[6]]

[[7]]7. 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[[7]]

[[8]]8. Passel, Unauthorized Immigrant Population: National and State Trends, 2010.[[8]]

[[9]]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[[9]]

[[10]]10. 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]]

[[11]]11. 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[[11]]

[[12]]12. 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[[12]]

[[13]]13. 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[[13]]

[[Figure 1 source]]Source: Pew Hispanic Center tabulations based on 2008 Current Population Survey.[[Figure 1 source]]