• ISSUE BRIEF

    Last updated: March 27, 2012

Undocumented Immigrants in the United States: Use of Health Care

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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

Ref­er­ences    (↵ returns to text)
  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
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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
  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
  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.
  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.
  13. 13. Zuck­er­man, Stephen, Tim­o­thy A. Waid­mann, and Emily Law­ton. “Undoc­u­mented Immi­grants, Left Out Of Health Reform, Likely To Con­tinue To Grow as a Share of the Unin­sured.” Health Affairs 2011; 30(10): 1997–2004.
  14. 14. Undoc­u­mented immi­grants who qual­ify as Per­ma­nent Res­i­dence Under Color of Law (PRUCOL) may qual­ify for emer­gency Med­ic­aid ser­vices. We will review poli­cies that influ­ence access to care in a sub­se­quent brief.
  15. 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
  16. Source: Pew His­panic Cen­ter tab­u­la­tions based on 2008 Cur­rent Pop­u­la­tion Sur­vey.
  17. 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
  18. 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.
  19. 18. “Five Ques­tions for Karina For­tuny on Chil­dren of Immi­grants.” Urban Insti­tute, Octo­ber 2011. Avail­able at: http://www.urban.org/toolkit/fivequestions/fortuny.cfm
  20. 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).
  21. 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
  22. 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.
  23. 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.
  24. 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.
  25. 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.

Suggested citation

Michael K. Gusmano, "Undocumented Immigrants in the United States: Use of Health Care," Undocumented Patients web site (Garrison, NY: The Hastings Center), last updated: March 27, 2012. Available at http://www.undocumentedpatients.org/issuebrief/health-care-use/