Healthcare is at issue in immigration reform

New bill is best hope for reform

By Adam Sonfield Senior Public Policy Associate Guttmacher Institute Washington, DC

In the wake of the 2012 elections, President Obama and members of Congress from both political parties declared immigration reform a top legislative priority. A “Gang of Eight” Senators, four Democrats and four Republicans, introduced a purportedly comprehensive bill in April 2013 that is widely viewed as the best hope for reform.

If enacted, the legislation would grant provisional status and a path to citizenship, including a 10-year waiting period prior to receiving a green card, to millions of undocumented immigrants in the United States. Yet, as introduced, that bill is far from comprehensive when it comes to integrating immigrants into the U.S. healthcare system. It leaves in place two decades’ worth of legal barriers to immigrants’ access to affordable health insurance coverage, including coverage for sexual and reproductive health care.

For public health insurance, including Medicaid and the Children’s Health Insurance Program (CHIP), the most notable restriction dates to 1996, when Congress established a five-year waiting period for lawfully present immigrants before they are deemed eligible to enroll. In the years since, that waiting period has been lifted only in limited circumstance — only in states that have taken up options to exempt children or pregnant women. Beyond those options, Medicaid will only pay for emergency care, including labor and delivery, to individuals regardless of immigration status.

The Affordable Care Act of 2010 was a missed opportunity to repeal the five-year ban. The law does allow lawfully present immigrants, regardless of their length of residency in the United States, to purchase private coverage through the health insurance “exchanges” starting in 2014 and to receive federal subsidies to make this coverage affordable. But even with those subsidies, the coverage will be less affordable than Medicaid. Undocumented immigrants, by contrast, are not only ineligible for subsidies but are even barred from purchasing coverage through the exchanges at full cost.

Women at risk

These legal restrictions have made it difficult for many immigrants to find health coverage they can afford. In fact, among women of reproductive age (15-44), 45% of the 6.6 million noncitizen immigrants were uninsured in 2011, compared with 24% of naturalized citizens and 18% of U.S.-born women.1 Those figures are just as striking among poor women in that age-group: 60% percent of noncitizen immigrant women were uninsured, compared with 34% of U.S.-born women. The Medicaid waiting period is particularly salient for this group: Only 26% of poor noncitizen immigrant women of reproductive age had Medicaid coverage, compared with 44% of those who are U.S. born.

The political difficulty of reversing restrictions on immigrants’ access to health insurance was driven home in 2012, when President Obama took an initial, unilateral step toward immigration reform by establishing the Deferred Action for Childhood Arrivals (DACA) program. That program allows young people who immigrated without documentation as children and who are in school or working to remain in the country for renewable two-year periods. Yet, the program bars young people granted DACA status from almost every form of public and private health coverage. Essentially, immigrants granted DACA status are treated as undocumented when it comes to health coverage.

The Gang of Eight’s bill starts from the same position of barring immigrants granted provisional status from many safety-net programs, despite being required to pay federal taxes. The five-year waiting period for Medicaid and CHIP would remain and would kick in only after an immigrant receives her green card, which would typically be 10 years down the line, resulting effectively in a wait of roughly 15 years. Immigrants with provisional status likewise would be barred from receiving federal subsidies to purchase private insurance through the exchanges. Unlike undocumented immigrants, they would be allowed to purchase unsubsidized coverage on the exchanges, but such coverage is unlikely to be affordable for lower income women and families.

Advocates for immigrants’ access to health coverage, including advocates focused on sexual and reproductive health, are working with members of Congress to move away from this harmful starting point. They have a strong case to make for why blocking immigrants’ access to health coverage is bad for women, families, and society. Immigrant women, and especially undocumented immigrants, have higher birthrates than U.S.-born women.2,3 They also are particularly likely to be young, low-income and women of color, which are demographic characteristics linked to an elevated risk of unintended pregnancy and STIs.3-5 Ensuring they have coverage for services such as maternity care, contraception, cervical cancer screening, and STI testing and treatment would benefit their health and the health of their partners and children.

One promising sign is that, according to a February 2013 poll, most Americans believe immigrants granted provisional status should be able to qualify for Medicaid (63%) and for subsidies to buy insurance on the exchanges (59%).6


1. Hasstedt K. Toward equity and access: removing legal barriers to health insurance coverage for immigrants. Guttmacher Policy Review 2013; 16(1): 2-8.

2. Passel J, Taylor P. Unauthorized Immigrants and their U.S.-Born Children, Washington, DC: Pew Hispanic Research Center. Accessed at

3. Motel S, Patten E, Statistical Portrait of the Foreign-Born Population in the United States, 2011. Washington, DC: Pew Research Hispanic Center. Accessed at

4. Finer LB, Zolna MR, Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception 2011; 84(5):478-485.

5. Centers for Disease Control and Prevention. CDC Fact Sheet: Incidence, Prevalence, and Cost of Sexually Transmitted Infections in the United States. Accessed at

6. Kaiser Family Foundation, Kaiser Health Tracking Poll: Public Opinion on Health Care Issues, 2013. Accessed at