Undocumented Immigrants in the United States: Use of Health Care

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