Congress.gov : Noncitizens’ Access to Health Care

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This report discusses the eligibility criteria for noncitizen populations for various federal health care coverage programs, including Medicare, Medicaid, and Affordable Care Act subsidies for private health insurance.

Noncitizen eligibility for coverage through federal health care programs varies by program and immigration status category. Various restrictions in federal law prohibit certain noncitizens from receiving coverage through federal health care programs. In addition, some noncitizens who are eligible to work in the United States are employed in jobs that do not provide employer-based health insurance coverage. As such, some noncitizens may face challenges accessing health services due to their lack of health insurance coverage. These individuals may rely on parts of the health care safety net, such as health centers, that are required to provide care to individuals regardless of their ability to pay.

Recent estimates from the U.S. Census Bureau found that an estimated 47.8 million foreign-born people live in the United States, representing 14.3% of the total U.S. population. Just under half (48%) of the foreign-born population are non-U.S. citizens. Estimating the size of the noncitizen populations who may be eligible for federal health care programs is challenging because population surveys do not capture noncitizens' specific immigration statuses. Researchers have found that the immigrant population overall tends to be in better health than the U.S.-born population across a number of conditions, including cancer and cardiovascular diseases. These findings are not uniform across the immigrant population, as groups such as refugees have higher rates of chronic conditions than do other types of immigrants and the U.S.-born population. Further, researchers have found that immigrants' health status converges with that of the U.S.-born population as the length of their residency increases.

Immigrant populations may also face barriers when seeking to access health services. These include, but are not limited to, lack of health insurance coverage, health care costs, transportation, and unpredictable work schedules. Many of these barriers are similar to those faced by native-born, low-income populations. Some barriers, like fears related to immigration status, are specific to immigrant populations. Overall, researchers have found that immigrant populations use fewer health services than the native-born U.S. population. The unauthorized population (sometimes referred to as undocumented or illegal) uses fewer services and has lower annual health-related expenditures than the authorized immigrant population, while both these groups use fewer services and have lower annual expenditures than the U.S.-born population. The pattern of lower service use persists for insured immigrant populations (both authorized and unauthorized); among those who have private insurance, on average, they use less in health services than the amount paid for their coverage.

Individuals must meet general eligibility criteria for federal health care coverage programs, including applicable age and income criteria. U.S. citizens, including those who are naturalized, and legal permanent residents are generally eligible for these programs. Noncitizen eligibility varies by program and immigration status. Many programs allow specific categories of noncitizens with certain forms of legal status to access benefits, with varying restrictions. In general, unauthorized immigrants are not eligible for federal health care coverage programs.

The federal government provides direct and in-kind support for public health programs and various parts of the federal health care safety net. Facilities such as emergency departments and health centers have obligations to provide care regardless of insurance status, though they may charge for the services they provide. Federal programs also support providers that deliver family planning services and those that seek to reduce the transmission of communicable diseases. These programs generally provide services regardless of ability to pay or immigration status. Moreover, federal law provides that public health services related to communicable disease transmission be available to individuals regardless of immigration status.

Introduction

Many noncitizens may experience challenges accessing health care services because they lack access to health insurance coverage. Additionally, federal law prohibits certain noncitizens from receiving coverage through federal health care programs (e.g., Medicaid, the State Children's Health Insurance Program (CHIP), Medicare, and subsidies for private health insurance under the Affordable Care Act (P.L. 111-148, as amended)), and some noncitizens are employed in jobs that do not provide employer-based health insurance coverage.1 As such, these individuals may rely on parts of the health care safety net that are required to provide care to individuals regardless of their ability to pay.2

This report begins with a discussion of some key terms (see also the Appendix for a list of acronyms used in the report), and then provides a brief overview of immigrants' health status and use of health care. Next, it explores immigrants' eligibility for certain publicly funded health care programs, and it then provides information on types of health facilities where immigrants can access care.3 The report concludes with discussion of some of the barriers that may affect immigrants' use of health services. This report is intended to inform policymaking; it is not intended as a guide to be used by individuals to determine their eligibility for specific health care benefits.

Noncitizens Definition and Population Estimates

Estimating the size of various noncitizen4 populations potentially eligible for various health programs is constrained by what data are collected by federal agencies and research organizations. Using data on the foreign-born population would overestimate the noncitizen population because the foreign-born population includes naturalized citizens. (An estimated 47.8 million foreign-born people lived in the United States in 2023, representing 14.3% of the total U.S. population.5) Data are available on the total noncitizen population (estimated at 22.9 million in 2023),6 but only a subset of that population will be eligible for the programs discussed in this report.

A variety of survey and administrative data sources have been used in recent years to estimate the size of subsets of the foreign-born population. These estimates, spanning different data sources, suggest that among the foreign-born population7

25.0 million are naturalized citizens;8
12.7 million are lawful permanent residents (LPRs, or green card holders);9
3.2 million are nonimmigrant workers, students, exchange visitors, diplomats, and their relatives;10 and
11.0 million are estimated to be unauthorized immigrants.11

The data available on the noncitizen population generally do not include the granularity needed to estimate the size of this population that is eligible for a given health program. For example, as outlined in this report, subsets of the LPRs are not eligible for certain healthcare programs, while subsets of the unauthorized population are eligible for certain programs (e.g., Deferred Action for Childhood Arrivals [DACA] recipients).12 Certain nonimmigrants are eligible for certain healthcare programs discussed in this report, while others are not. Thus, CRS cannot look at these data and determine the number of noncitizens eligible for any particular program.

Immigration Categories

Noncitizen eligibility for certain federal health care programs depends on the program's criteria and the immigration status of the individual. The universe of immigration categories is vast and are not mutually exclusive; an individual can potentially belong to more than one of these categories at the same time.13 This report focuses on the categories relevant to the laws and regulations relating to federal health care programs, including the following (in alphabetical order):

Adjustment of status applicants are those applying for LPR status through U.S. Citizenship and Immigration Services (USCIS) because they are already in the United States (in contrast to those residing abroad, who apply for an immigrant visa from the Department of State).14
Asylees are foreign nationals who fled their countries because of persecution, or a well-founded fear of persecution on account of race, religion, nationality, membership in a particular social group, or political opinion.15 Asylees meet the definition of a refugee (see below) in terms of persecution or a well-founded fear of persecution but are present in the United States or at a land border or port of entry to the United States. This term refers to those granted asylum; it does not include asylum applicants.
Asylum applicants are those that have submitted an application for asylum and are awaiting a final decision on their application.
Certain noncitizens who entered the United States before January 1, 1982,16 which refers to noncitizens who were granted temporary legal status and were then able to adjust to LPR status pursuant to the Immigration Reform and Control Act of 1986 (IRCA; P.L. 93-603).
Compacts of Free Association (COFA) migrants are citizens of the Marshall Islands, Micronesia, or Palau permitted to live in the United States indefinitely under the terms of those nations' COFA with the United States.17
Refugee-like noncitizens who arrived before 1980 and were granted conditional entry pursuant to the Immigration and Nationality Act (INA), Section 203(a)(7).18
Cuban-Haitian Entrants are nationals of Cuba or Haiti who have been paroled into the United States at any time, are in removal proceedings,19 or have a pending asylum application and do not have a final, nonappealable order of removal.20
Noncitizens with deferred action are those who are inadmissible21 or deportable but DHS granted them a discretionary reprieve from removal.22
Deferred Action for Childhood Arrivals (DACA) recipients are unauthorized childhood arrivals who DHS granted renewable two-year protection from removal.23
Deferred Enforced Departure (DED) recipients are foreign nationals from countries who have been granted a temporary administrative stay of removal at the President's discretion, usually in response to war, civil unrest, or natural disasters.24
Family Unity Beneficiaries are spouses and unmarried children of legalization applicants who have resided in the United States since May 5, 1988, pursuant to the Immigration Act of 1990 (§301 of P.L. 101-649, as amended).
Iraqi and Afghan special immigrants are certain Iraqi and Afghan nationals who worked as translators or interpreters, or who were employed by, or on behalf of, the U.S. government in Iraq or Afghanistan and were eligible for a special immigrant visa (SIV), which enables them to become LPRs.25
LPRs are foreign nationals permitted to live in the United States permanently.26
The INA does not define lawfully present noncitizens. Various health care programs utilize this term, but it has different meanings depending on the statutory or regulatory definition used for each program. (If applicable, the definition utilized by the programs discussed in this report is explained in the relevant section.)
Noncitizens admitted to the United States, which can refer to any noncitizen who was lawfully admitted (e.g., as a nonimmigrant or refugee).27
Nonimmigrants are foreign nationals admitted to the United States on a temporary basis and for a specific purpose (e.g., tourists, students, diplomats, temporary workers).28
Parolees are foreign nationals granted permission to enter or remain temporarily in the United States for urgent humanitarian reasons or significant public benefit. Immigration parole is granted on a case-by-case basis.29 Since 2021, the Biden Administration has used discretionary parole authority to enable persons with particular nationalities to lawfully enter and reside in the United States.30 These initiatives are distinct from the standard process through which persons outside the United States can apply to DHS's USCIS for immigration parole.31
Afghan parolees refers to Afghans32 paroled into the United States between July 31, 2021, and September 30, 2023.33
Cuban, Nicaraguan, Haitian, and Venezuelan (CNHV) parolees refers to individuals from those countries who were paroled into the United States since January 2023.34
Ukrainian parolees refers to Ukrainians35 paroled into the United States between February 24, 2022, and September 30, 2024.36
Refugees are foreign nationals fleeing their countries because of persecution, or a well-founded fear of persecution, on account of race, religion, nationality, membership in a particular social group, or political opinion.37
Special Agricultural Workers are certain individuals granted legal status through the IRCA (P.L. 93-603). The law granted eligible individuals temporary residence; they could later apply for permanent residence.38
Special Immigrant Juveniles (SIJs) are children under age 21 who were born in a foreign country; live without legal authorization in the United States; have experienced abuse, neglect, or abandonment; and meet other specified eligibility criteria.39
Temporary Protected Status (TPS) holders are foreign nationals from designated countries granted temporary relief from removal due to armed conflict, natural disaster, or other extraordinary circumstances in their home countries that prevent their safe return.40
Victims of human trafficking and their families who have received a T nonimmigrant status are foreign nationals who can live in the United States for up to four years; they may apply for LPR status after three years.41
Noncitizens who have violated the terms of their status42 (e.g., a nonimmigrant who worked without authorization or overstayed their visa).
Violence Against Women Act (VAWA) Self-Petitioners refers to certain foreign nationals who have been subject to battery or extreme cruelty in the United States by a spouse or other household member, foreign nationals whose children have been subject to battery or extreme cruelty, and noncitizen children of foreign nationals who have been subject to battery or extreme cruelty. In these cases, the foreign national must have been approved for, or have pending, an application with a prima facie case for immigration preference as a spouse or child or for cancellation of removal.43
Certain foreign nationals present in the United States who do not qualify for asylum may be granted withholding of removal based on persecution on account of race, religion, nationality, membership in a particular social group, or political opinion. Withholding of removal provides protection from removal. Noncitizens can also be granted withholding of removal under the Convention Against Torture (CAT) due to the prohibition against removing noncitizens to any country in which there is substantial reason to believe they could be tortured.44

Health Status of Immigrants

Health status "[r]efers to your medical conditions (both physical and mental health), claims experience, receipt of health care, medical history, genetic information, evidence of insurability, and disability."45 Research on immigrant populations generally looks at country of birth. As such, some studies may include individuals who have immigrated to the United States but are naturalized citizens or LPRs and therefore eligible for the programs discussed in this report. Studies show that, at a population level, immigrants living in the U.S. tend to have better health status than native-born U.S. citizens.46

The National Academies of Sciences, Engineering, and Medicine (NASEM), reviewed the existing literature on immigrants in the United States and their health status in 2015 and found the following:

Comprehensive analyses on immigrant health status using eight federal national datasets show that immigrants have better infant, child, and adult health outcomes than the native-born in general and the native-born members of the same ethnoracial groups (Singh et al., 2013). Immigrants, compared to the native-born, are less likely to die from cardiovascular disease and all cancers combined and have a lower incidence of all cancers combined, fewer chronic health conditions, lower infant mortality rates, lower rates of obesity, lower percentages who are overweight, fewer functional limitations, and fewer learning disabilities.47

These health advantages might decrease the longer immigrants reside in the United States. According to NASEM, "Research has documented higher rates of different health problems including hypertension, chronic illness, smoking, diabetes, and heavy alcohol use as length of residency increases."48 Other studies have also demonstrated that immigrants' health status converges with the rest of the U.S. population the longer they reside in the United States. 49 More recent studies are less comprehensive, but have similar findings where most immigrant populations rate their health as excellent and had lower rates of certain chronic conditions.50 The health status of immigrants is not uniform and may vary, for example, by immigration pathway. For examples, researchers found that refugees have higher rates of chronic conditions compared to other types of immigrant populations and the U.S.-born population.51

Immigrants' Health Care Use

Though immigrant populations have access to some types of health services, researchers have found that both authorized and unauthorized immigrants use less health care than the U.S.-born population. For example, in a study published in 2020 of national health care use, the authors found that unauthorized immigrants had fewer visits and lower annual per person expenditures compared to authorized immigrants, and that the U.S.-born population had the highest number of visits and per person expenditures compared to both authorized and unauthorized immigration populations.52 In a more recent study published in 2024, researchers also found that expenditures were lower for immigrant populations (both authorized and unauthorized). They also found no significant differences in emergency room or Medicaid expenditures between immigrants and U.S.-born citizens, but found that immigrant populations use the emergency room more than the U.S.-born population.53 Other studies have found that immigrants paid more in out-of-pocket expenses than U.S.-born individuals. The higher out-of-pocket expenditures are due to lower rates of insurance coverage among immigrant populations.54 Other researchers have found that immigrants who do have private insurance coverage, on average, use less in health services than the amount they paid for their coverage.55 Researchers have also found that some (approximately one-quarter) of immigrants report being treated unfairly by the health providers they do see, such as perceptions of being treated differently because of race or ethnicity and challenges accessing timely translation services.56

Public and Private Health Insurance Coverage

Comprehensive studies of insurance coverage generally do not include information on immigration status57 as such, estimates of the insurance status of the immigrant population are rare. However, one recent study, estimated that as of 2023 18% of lawfully present adult immigrants were uninsured, as were 50% of unauthorized adult immigrants.58 In comparison, 8% of U.S.-born adults were uninsured in 2023.59

There are multiple reasons why the uninsured rate among noncitizens is disproportionally high. First, private health insurance is the predominant source of health insurance coverage in the United States. Private health insurance is provided through both the group market (i.e., health insurance coverage that is mostly sponsored by employers) and through the non-group or individual market. Group market coverage is the source of health insurance coverage for more than half of the U.S. population.60 Certain noncitizens may have limited access to employer-sponsored coverage because they are over-represented in low-skilled occupations,61 where they are less likely to be offered subsidized health coverage. Second, because of their low pay, they may have difficulty affording private, unsubsidized health insurance.62 Third, noncitizens may have limited access to public health care coverage depending on their immigration status. As explained in the sections below, many noncitizens are excluded from non-emergency63 Medicaid.64 They may also be excluded from using health care subsidies through the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended).65 Finally, they may not be eligible to purchase unsubsidized health care on ACA exchanges.66

Health Coverage Eligibility

This section reviews noncitizen eligibility for federally funded health insurance programs.67 It also includes a discussion of noncitizen eligibility for financial subsidies made available through the ACA.

Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA)

Title IV of PRWORA created a "national policy with respect to welfare and immigration."68 Enacted on August 22, 1996, PRWORA amended immigration law to establish an overarching set of noncitizen eligibility requirements for most federal public benefits. Subsequent amendments from 1996 through 1998 modified PRWORA's requirements to form the basic framework that applies today.69 While PRWORA created blanket noncitizen eligibility requirements, noncitizen eligibility is not uniform across federal public benefit programs because PRWORA interacts with other laws, regulations, and guidance that govern each individual program.70

PRWORA defines "federal public benefit" to include "any retirement, welfare, health, disability ... or any other similar benefit for which payments or assistance are provided to an individual, household, or family eligibility unit by an agency of the United States or by appropriated funds of the United States."71 PRWORA exempts certain types of programs, usually thought of as emergency programs, from its noncitizen eligibility requirements.72 In addition, PRWORA makes an exception "for immunizations with respect to immunizable diseases and for testing and treatment of symptoms of communicable diseases."73

PRWORA states that aliens, unless they are qualified aliens (see the "Qualified Alien" section), are ineligible for federal public benefits. In addition, PRWORA places a number of restrictions on qualified aliens' eligibility for certain federal means-tested public benefits (FMTPBs), including Medicaid.74

Source : https://www.congress.gov/crs-product/R47351