While low-income, undocumented immigrants do not qualify for federal health insurance programs, they may be able to access affordable health services via two key avenues: (1) state-funded coverage initiatives (in a select group of states); and (2) community-based charity care programs (CCPs). Over the past few years, a handful of states have championed coverage initiatives for undocumented individuals. During the same time, numerous CCPs across the country refocused their efforts to better meet the needs of undocumented residents as many formerly uninsured individuals attained health coverage through Medicaid expansion and the health insurance Marketplaces. Following the November 2016 elections, however, there is now considerable uncertainty about how health care policies will affect undocumented residents in the coming years. This is particularly true if the Affordable Care Act (ACA) is repealed and millions of low-income Americans lose their coverage.

State-Funded Coverage Initiatives

Undocumented residents are not eligible for Medicaid, with the exception of some limited emergency services. Furthermore, the ACA explicitly excludes undocumented residents — even those protected under the Deferred Action for Childhood Arrivals (DACA) program — from purchasing health insurance on the Marketplaces. However, states have the option to use their own dollars to pay for health services for individuals not covered by federally funded programs. Currently, five states and the District of Columbia use state-only funds to provide health coverage to undocumented children (see chart below).

Jurisdictions that Currently Provide Coverage to All Children

Over the past two years, a handful of other states have sought to secure health coverage for certain subsets of undocumented residents. The following three examples highlight new state-level coverage policies or proposals for undocumented adults and minors:

• California: In October 2015, Medi-Cal (the state’s Medicaid program) used state-only funds to extend coverage to undocumented children under age 19.
• Oregon: In December 2016, Oregon’s governor requested that the 2017-2019 budget fund coverage for undocumented minors. If approved by the legislature (expected between February and March 2017), the Cover All Kids initiative would make Oregon the seventh jurisdiction to provide health coverage to undocumented children.
• New York: Using state-only funds, New York offers Medicaid to specific groups of income-eligible immigrant residents shut out of federal coverage (as does California, Massachusetts, and the District of Columbia). The New York State Health Foundation awarded a grant of more than $340,000 to the Mayor’s Fund to Advance New York City to run a campaign in 2016 highlighting DACA recipients’ potential eligibility for Medicaid in the state. The campaign, conducted in 11 languages through ads posted on subway lines, phone kiosks, check-cashing businesses, and laundromats, as well as on social media, was very successful. It resulted in a large influx of immigrant- and DACA-specific inquiries; almost 14,000 visits to the web within three weeks, compared to a monthly average of 1,000 visits in a previous campaign; and nearly 50,000 Facebook, Instagram, and Twitter interactions, illustrating reach to younger social media-focused audiences.

Community-Based Charity Care Programs

Community-based charity care programs (CCPs) are the second vehicle for providing health coverage and care to undocumented residents. Following passage of the ACA, many CCPs adjusted their care delivery models to better meet the needs of low-income individuals in the post-ACA landscape. In addition to providing basic health services to low-income, uninsured individuals, many CCPs now also: (1) offer health insurance enrollment assistance services; and (2) address the social determinants of health through screening, referrals, health literacy efforts, and wellness classes.

With higher percentages of undocumented residents in their caseloads, many CCPs have also been increasing their capacity to provide linguistically relevant care and communications — such as by hiring bilingual staff members and ensuring that key resources are translated into multiple languages. Portico Healthnet, based in Minnesota, is using multilingual community members to serve as care management coordinators and community health workers to serve its undocumented clients.

CCPs are also adjusting the way they deliver care to ensure cultural competence for all populations. For example, Grameen PrimaCare in New York City launched a health promotion program specifically for immigrant women, which provides unlimited access to a bilingual and culturally sensitive primary care team, as well as interactive group sessions, health coaches, and peer supports.

CCPs Moving Forward

Although states such as California, Oregon, and New York have made recent progress in securing health coverage for certain groups of undocumented residents, CCPs remain the only source of affordable health services for most of the approximately 11 million undocumented residents in the US. In addition, while many CCPs have deftly adapted to the ACA’s coverage changes, if a major ACA overhaul is passed in the coming year, both states and CCPs will have to balance the ongoing health needs of undocumented residents with the needs of tens of millions of newly uninsured Americans.

Less federal funding for Medicaid would mean that states may have to shift money they were using to cover undocumented individuals to instead continue covering documented Medicaid populations. CCPs would likely also see a large influx of newly uninsured but documented individuals, thereby diminishing the resources available to devote to undocumented communities. Less federal funding for Medicaid would mean that states may have to shift money they were using to cover undocumented individuals to instead continue covering documented Medicaid populations. CCPs would likely also see a large influx of newly uninsured but documented individuals, thereby diminishing the resources available to devote to undocumented communities. The repeal of Medicaid expansion would not only hurt those losing Medicaid coverage; less federal Medicaid funding to states could also have a trickledown effect and result in fewer resources for health programs focused on undocumented populations.