The undocumented population in the United States has been forced to navigate a country where vitriol against immigrants runs rampant, which makes them exceptionally vulnerable and much less likely to seek help in times of need. In this atmosphere, most undocumented individuals and families are forced to deal with health care needs largely on their own. This has become abundantly clear during the Covid-19 pandemic. With a death toll of over 500,000 and counting, the pandemic has brought to light the many deficiencies of our current health care system. Millions of people in the United States have lost their jobs in the wake of the global pandemic and have lost their health care as a result. While undocumented immigrants are among those who have lost insurance coverage as a result of job loss, undocumented immigrants are even more likely to have no health coverage at all. Undocumented immigrants are ineligible for Medicaid in most states and are ineligible to purchase health insurance from the Affordable Care Act (ACA) Marketplace due to prohibitions specifically aimed at them in the legislation. An exploration of health care options available to undocumented immigrants in the United States reveals the limitations of those options and the various roadblocks undocumented immigrants face in attempting to receive health care.

Undocumented immigrants are ineligible for Medicaid in most states and are ineligible to purchase health insurance from the Affordable Care Act (ACA) Marketplace . . .

Undocumented but Essential

There are approximately 10.5 million undocumented immigrants in the United States as of 2017, making up about 3 percent of the total U.S. population.[1] A common misconception is that undocumented immigrants do not contribute to tax revenue when, in reality, they pay billions of dollars annually in federal, state, and local taxes, including income and sales taxes. It is estimated that undocumented immigrants paid $27.2 billion in taxes in 2017, with $9.9 billion going directly to state and local governments.[2] Not only do undocumented immigrants contribute to tax revenue, but about 80 percent of undocumented adults are also a part of the country’s labor force. Much of their work, which helps sustain the country, has largely gone unseen. It has taken a pandemic to shine a light on the contributions made by undocumented workers. According to a report by the Center for American Progress, an estimated 5 million undocumented immigrants have been performing essential work.[3] These immigrants generally work on farms and in food-processing plants; in grocery stores, laundromats, and restaurants; perform domestic work; and do building maintenance and—critically—essential care work in hospitals, nursing facilities, and private homes. Without proper access to health care for themselves, they are at maximum risk of contracting the virus. Moreover, when essential workers like these get sick on a massive scale, whole industries can be impacted severely, particularly in agriculture and food processing. The meatpacking industry alone—which relies on many immigrants and undocumented workers—has been a hotbed for coronavirus cases, with at least 42,708 workers having been exposed to the virus in 496 meat and poultry plants.[4]

In many circumstances, undocumented immigrants deal with critical health, social, and financial problems with little to no help. Though Covid-19 testing and related hospital care, if needed, are free under federal law,[5] many undocumented people do not avail themselves of these options for fear they may reveal their immigration status and expose themselves to deportation.[6] Undocumented immigrants—especially those employed in farm work or food-processing plants—may also feel the need to work, even if they fall sick. Many simply cannot afford not to work, given basic expenses for housing, food, and medicine. In addition, since undocumented immigrants are currently ineligible for stimulus checks and unemployment benefits—or any other form of government aid—they have little choice but to continue to work during this global pandemic. With such limited options and the looming undocumented immigrants remain poor. Undocumented pregnant women are more likely to forgo or delay prenatal care and experience complications in childbirth.[7] Their babies are also more likely to be born premature or underweight. Many undocumented immigrants may have undiagnosed conditions and diseases that go untreated, causing premature death. Due to their often physically demanding jobs, they are at increased risk of workplace injury and of chronic conditions due to intense manual work. Undocumented adults and children are vulnerable to mental health problems due the trauma of their journeys and the fear of deportation in public spaces and even their homes.[8] Given their marginalized status, it is difficult to learn of other issues they may be facing.

Current Health Care Options Available to Undocumented Immigrants

Some undocumented immigrants may be allowed to purchase private insurance or to receive coverage through a spouse. However, high premiums and fear of revealing immigration status prevent many from doing so.[9] Undocumented immigrants can receive health care through their employer or union, but most undocumented immigrants work in low-wage jobs and industries that are less likely to offer employer-sponsored coverage. Though they are allowed to form or participate in unions, most undocumented immigrants who are working in the informal sector face barriers to unionizing, such as retaliation from their employer, which threatens exposure of their immigration status.[10]

Only six states . . . provide CHIP to children of undocumented immigrants under the age of eighteen by using state-only Medicaid funds to cover the cost.

While many states provide a few locally run free clinics, most do not provide Medicaid or any other form of affordable health care to undocumented immigrants. On the federal level, undocumented immigrants are ineligible for coverage through the ACA Marketplace, Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). Only six states—California, Illinois, Maine, New York, Oregon, Washington, and Washington, DC—provide CHIP to children of undocumented immigrants under the age of eighteen by using state-only Medicaid funds to cover the cost. California expanded Medicaid to undocumented immigrants under the age of twenty-six in 2019.[11]

Undocumented immigrants are allowed to seek emergency care under the Emergency Medical Treatment and Labor Act . . . However, nothing prohibits hospitals from charging patients for services provided . . .

Charity-run free clinics and Federally Qualified Health Care Centers (FQHCs), also known as Community Health Centers, can provide primary care services and some specialty care to undocumented immigrants. However, patients, including undocumented immigrants, are charged on a sliding fee scale based on the ability to pay and only have limited access to specialized care if needed.12 For most undocumented immigrants in the United States, FQHCs might be the only viable option for receiving some form of health care, but since they are funded through federal Medicare grants, they have been severely underfunded and their budgets undergo a yearly congressional vote, averaging only about $6 billion in funds to allocate across the country.[13] Undocumented immigrants are allowed to seek emergency care under the Emergency Medical Treatment and Labor Act (EMTALA), since federal law requires hospital emergency rooms that accept Medicare to treat patients—including the undocumented—with life-threatening emergencies.[14] However, nothing prohibits hospitals from charging patients for services provided and patients can be sent home with an exorbitant bill, well beyond the means of most undocumented immigrants. The undocumented can usually receive only preventive or primary care through clinics, forcing them to forego specialized care and treatment. Besides states that provide some coverage under such programs, there are a few cities that provide much more comprehensive coverage for undocumented immigrants, most notably New York City’s NYC Care and Los Angeles’ My Health LA (MHLA).

NYC Care

In 2019, Mayor Bill de Blasio launched NYC Care in collaboration with the NYC Health + Hospitals publicly funded system (HHC). NYC Care provides low-cost and no-cost services to New Yorkers who do not qualify for, or cannot afford, health insurance—regardless of the immigration status. NYC Care operates similarly to health insurance by enrolling members and giving them a membership card, allowing them to receive care from a primary care physician by visiting a NYC Health + Hospital or one of its off-site clinics. Members can receive prescription medications, help with mental health or substance abuse problems, receive preventive care such as vaccinations, and get routine screenings and mammograms. Service fees are based on household income and size. For example, according to its fee schedule, a member of a three-person household with income between $42,661 and $53,325 annually would pay $30 for a clinic visit, $80 for an emergency room visit, $10 per prescription medication, $300 for ambulatory surgery or magnetic resonance imaging (MRI) testing, $400 for an inpatient stay, and a $10 co-pay or deductible, though the website does not specify the services in which co-pays and deductibles are required. The fine print below the fee schedule states, “additional fee may be charged if savings are more than $8,000.” In addition, dental care is available on a sliding fee basis.[15]

As of 2020, there were about 504,000 undocumented immigrants living in New York City. A little over a year into the launch of the NYC Care program, about 45 percent of all undocumented immigrants in the New York City remain uninsured despite their eligibility. This is likely due to a lack of knowledge that the program exists or fear that they might need to disclose immigration status to apply. The Mayor’s Office of Immigrant Affairs (MOIA) and NYC Health + Hospitals report that it led a group of trusted community-based organizations (CBOs) in community outreach to promote the program, and by the end of 2019, the CBOs reached more than 22,000 unique community members and the program enrolled approximately 10,000 New Yorkers in the Bronx.[16] The MOIA also spearheaded a public awareness campaign in Spanish, Chinese, Urdu, Bengali, French, and other languages, in key neighborhoods in Manhattan and Queens and near all HHC facilities, “including three subway stations and bus shelter ad dominations [advertisements], neighborhood locations, and LinkNYC terminals.” The MOIA appears to have set the goal of expanding enrollment for NYC Care for undocumented immigrants by spreading word of the program in different languages and working within communities. However, to enroll nearly half of all undocumented immigrants in the city who are uninsured, much more community outreach will have to be done to get the word out to immigrant enclaves, emphasizing that there is no need to reveal immigration status to receive NYC Care health care services.

. . . [A]bout 45 percent of all undocumented immigrants in the New York City remain uninsured despite their eligibility . . . likely due to lack of knowledge that the program exists or fear that they might need to disclose immigration status to apply.

Despite the expansive coverage that NYC Care provides to low-income and undocumented immigrants, there are some gaps in the program’s execution and several substantial problems. All services provided by NYC Care must take place in an HHC facility. This means that roughly 226,800 undocumented and uninsured immigrants across the city are limited to visiting one of eleven HHC hospitals and twenty-three neighborhood health centers. (Only one of these centers is on Staten Island.) In addition, there is no access to virtual appointments through the program. All this puts the undocumented population in competition with the rest of the city’s low-income residents who also use HHC hospitals and centers, either independently or as eligible members of NYC Care.

Adding to these problems, New York City has been dealing with overcrowded and underfunded hospitals for decades, a situation exacerbated by the Covid-19 pandemic. Much of the city’s Covid-19 testing takes place in HHC locations, with scores of people waiting in line to get tested. Fear of exposure to the virus could lead some undocumented individuals to avoid seeking health care in these hospitals. Only a limited number of HHC locations provide specialized care, including emergency care, maternal care, and inpatient and outpatient surgeries. Under these conditions, it can take several weeks or even months to get an appointment for specialized care through NYC Care. Due to the lack of funding for more staff, translation services may also be limited. Another quite serious problem is confidentiality. It can be assumed that participants in the NYC Care program have unauthorized immigration status since other low-income New Yorkers can receive health care through Medicaid if they provide proof of legal residency or citizenship status. Although federal policy states that Immigration and Customs Enforcement (ICE) agents should “avoid” stopping, searching, or arresting immigrants in hospitals, anti-immigrant policies originating in the Trump administration have likely deterred many undocumented immigrants from seeking care in the program for fear of being detained and deported by ICE. The experience of one undocumented immigrant I interviewed, whom I will call “Mira,” illustrates the pervasiveness of this fear and the impact it has on the ability of undocumented people to comfortably seek care when they or their families are ill.

Mira’s Story

“Mira” is an undocumented immigrant who has lived in the United States for the past twenty-six years. She had worked steadily in retail and food service jobs for over two decades, despite holding a master’s degree in business from her native Bangladesh. However, once the Trump administration began its reign of restrictive and punitive policies toward immigrants, Mira preemptively quit her job in 2017, fearing that ICE agents would detain her after her employer asked that all employees fill out a verification form administered by the Department of Homeland Security. Some of the hardships Mira described stemmed from the constant fear of deportation everywhere she goes, heightened by the Trump administration’s egregious efforts to target immigrants.

Mira had gone years without seeing a doctor for medical help, even after several injuries on the job. She described an instance in which she slipped from her ladder when stocking a shelf and several heavy goods fell on her:

I hurt my shoulder very badly from the fall. I couldn’t go to the hospital and just took Tylenol for several weeks. My employer wanted me to go to the ER, but I refused since I did not know how I could afford it and if I needed to be a citizen to get help. This was seven years ago, and I still have trouble carrying groceries and can’t do heavy lifting at all.

When she heard about the NYC Care program from a local community organization, Mira was grateful to finally be able to get regular medical check-ups. “I hadn’t seen a doctor since my visa ran out 19 years ago. When I finally was able to see a doctor last year, I found out that I had hypothyroidism, hypertension, and recently developed type 2 diabetes.” Mira’s hypothyroidism had gone untreated for so long that she needed immediate surgery to remove one of her thyroid glands. Mira said,

It takes me anywhere from 3 to 6 months to get an appointment. This is especially difficult when something is causing pain, or if I need an adjustment to my medication. Sometimes, I have to wait in the waiting room for more than 3 hours to be seen for my appointment with no communication from the front desk.

Still, the NYC Care program has made a world of a difference to her.

Mira was able to see a physician and specialists regularly as well as have her thyroid surgery at Elmhurst Hospital in Queens, which is part of NYC Health + Hospitals. Coincidentally, Elmhurst Hospital had been ground zero for the coronavirus back in the spring of 2020. The hospital faced obstacles, such as a severe lack of beds, including in intensive care units (ICUs), as well as shortages in staff and personal protective equipment (PPE).17 Despite the advantages of NYC Care, patients like Mira, who rely on the program and the NYC Health + Hospitals system, have no other options. They can choose to forgo medical care or risk waiting hours in strained public hospitals that care for thousands of Covid patients around the city.

My Health LA

Another comprehensive publicly funded health care program that covers undocumented immigrants is Los Angeles County’s MHLA. Launched in 2014, the program expanded its coverage to include undocumented immigrants in 2018. MHLA provides health care to low-income residents of Los Angeles County who do not have health insurance. To enroll, applicants must provide personal identification, proof that they live in Los Angeles County, and proof of income. The program also assures that the personal information provided will not be shared with anyone. Participants can expect to receive “ongoing, quality health care from a team of health care providers at community clinics.”[18] MHLA is a partnership between the county and local community clinics and health centers. Clinics provide primary care services like screenings, physicals, chronic disease management, and prescription medications. MHLA covers ongoing preventive care and health screenings, health information and advice, specialty care at the Department of Health Services (DHS), hospital and emergency care at DHS clinics and hospitals, prescription medicines, laboratory services and tests, [and] other related health care services. More than 150,000 residents get services through MHLA for free or at low cost.[19]

Like NYC Care, MHLA provides basic health coverage for undocumented immigrants. Both programs offer coverage through an existing network of health centers. However, with 226 local clinics, compared to NYC Cares’ 11 hospitals and 23 health centers, MHLA provides more coverage through local clinics and centers than does NYC Care.[20] This means it is more streamlined, covering more patients at a quicker, more efficient rate. The program has also made it mandatory for patients to get an appointment for routine care within twenty-one days and for urgent primary care to be made available within ninety-six hours.[21] Both MHLA and NYC Care show promise for improving health coverage for low-income and undocumented immigrants in the United States. However, MHLA in some respects has adopted a better model since the program runs on a more expansive network. Since NYC Care is still a newer program, it is difficult to know how well the program will work on the current public hospital network, but as mentioned, outreach to undocumented immigrants is crucial to increase enrollment.

Like NYC Care, MHLA provides basic health coverage for undocumented immigrants. Both programs offer coverage through an existing network of health centers.

What Else Can Be Done

Though NYC Care and MHLA are among the very few programs that provide substantial health coverage for undocumented immigrants, there is a dire need to expand this type of coverage on a national scale. Considering that millions of people, including undocumented immigrants, remain uninsured every year and that few municipalities provide comprehensive coverage, the current health care system in the United States needs restructuring. A bill pending in the New York State legislature—the New York Health Act, introduced by Democratic New York State Assembly member Richard Gottfried and Democratic State Senator Gustavo Rivera—is one model that could revolutionize health care in the United States. The bill would provide all New Yorkers health coverage under a single-payer system, regardless of the income, employment, or immigration status. Specifically, it would provide comprehensive outpatient and inpatient medical care, long-term care, primary and preventive care, prescription drugs, laboratory tests, rehabilitative care, plus care for dental, vision, and hearing. These benefits are required by current state insurance law or provided by the state public employee package, Family Health Plus, Child Health Plus, Medicare, or Medicaid, and other insurance plans. If passed, the bill would guarantee coverage for undocumented immigrants, without stigma or other roadblocks to receiving health care. According to the bill,[22] coverage through the New York Health Act would be funded by existing Medicare and Medicaid and other public funds, along with a progressively graduated tax on payroll and taxable non-payroll (investment) income on those who are employed. Employers would pay at least 80 percent of the payroll tax and employed individuals would pay no more than 20 percent. A self-employed person would pay the full payroll tax. Unemployed people will still have coverage under the New York Health Act and would still be fully covered by the program. Unfortunately, the bill lacks broad union support and faces opposition from Governor Cuomo—which he chalks up to budgetary shortfalls caused by the pandemic—and is unlikely to pass.[23] Despite this, the New York Health Act still serves as a model for one of the ways in which universal health care can be achieved in the United States.

. . . President Biden aims to strengthen the ACA by providing health care for undocumented immigrants, allowing them to buy into the public option, but without Medicaid subsidies from the government.

Nearly a decade ago, the ACA left out undocumented folks completely for the sake of passage through a partisan legislature. Now, President Biden aims to strengthen the ACA by providing health care for undocumented immigrants, allowing them to buy into the public option, but without Medicaid subsidies from the government. It would be the first time the country has allowed undocumented immigrants to receive health care on a national scale. In that respect, President Biden’s proposal is remarkably progressive. Still, there are many concerns and questions about the impact on those it is meant to help. For instance, how would information collected from undocumented immigrants be protected from ICE? Given the dark shadow cast by the Trump regime, there will be long lasting psychological implications for the undocumented population, which will continue to fear family separation, detention, and deportation. These fears need to be assuaged by guaranteeing the privacy of undocumented immigrants. Another concern is the high cost of health coverage in the United States, even for those with steady incomes. How are undocumented workers who are paid minimum wage or less expected to afford health insurance without Medicaid subsidies? Biden’s current plan to expand ACA will need to remedy these problems so that undocumented immigrants will actually gain coverage, rather than just be used in name to promote the guise of a progressive agenda.

A major overhaul of our current health care system will be necessary to bring the United States closer to other industrialized nations which have had universal health care for decades and provide some form of access to health care for undocumented immigrants. Countries such as France, Netherlands, Portugal, Spain, and Switzerland provide federally funded health care for undocumented immigrants, though with some conditions attached.[24] Without a nationalized health care system, we risk putting more strain on our already exhausted public hospitals. The United States is way behind other industrialized nations in providing basic necessities such as health care and continue to put profits over people. Among other things, this lag in health care has led to high maternal and infant mortality rates and to many preventable deaths among populations who cannot afford the cost of health care. Health care reform is vital to counteracting the detrimental economic impact the pandemic has already had on the country. It is particularly important to address the needs of immigrant workers who have been shut out of the system, even as they risk their lives working every day to keep the country running.

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Notes

1. D’vera Cohn and Jeffrey S. Passel, “20 Metro Areas Are Home to Six-in-Ten Unauthorized Immigrants in U.S.,” Pew Research Center, June 12, 2019, available at https://www.pewresearch.org/fact-tank/2019/03/11/us-metro-areas-unauthorized-immigrants/.
2. Zachary Mueller, “Immigration 101: Do Immigrants Pay Taxes?” America’s Voice Education Fund, May 23, 2019, available at https://americasvoice.org/blog/immigration-101-immigrant-taxes/.
3. Tom Jawetz, “Immigrants as Essential Workers during COVID-19,” Center for American Progress, September 28, 2020, available at https://www.americanprogress.org/issues/immigration/reports/2020/09/28/490919/immigrants-essential-workers-covid-19/.
4. Nathan T. Dollar and Angela Stuesse, “Who Are America’s Meat and Poultry Workers?” Economic Policy Institute, September 24, 2020, available at https://www.epi.org/blog/meat-and-poultry-worker-demographics/.
5. “Community-Based Testing Sites for COVID-19,” U.S. Department of Health & Human Services, January 2020, available at https:// www.hhs.gov/coronavirus/community-basedtesting-sites/index.html.
6. Usha Lee McFarling, “Fearing Deportation, Many Immigrants at Higher Risk of Covid-19 Are Afraid to Seek Testing or Care,” Stat News, April 15, 2020, available at https://www.statnews.com/2020/04/15/fearing-deportation-many-immigrants-at-higher-risk-of-covid-19-are-afraid-to-seek-testing-or-care/.
7. Miriam Jordan, “Farmworkers, Mostly Undocumented, become ‘Essential’ during Pandemic,” The New York Times, April 10, 2020, available at https://www.nytimes.com/2020/04/02/us/coronavirus-undocumented-immigrant-farmworkers-agriculture.html.
8. Committee on Health Care for Underserved Women, “Health Care for Unauthorized Immigrants,” 2017, available at https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/03/health-care-for-unauthorized-immigrants.
9. Samantha Artiga and Maria Diaz, “Health Coverage and Care of Undocumented Immigrants,” Kaiser Family Foundation, July 15, 2019, available at https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-and-care-of-undocumentedimmigrants/.
10. Legal Aid at Work, “Employment Rights of Undocumented Workers,” 2020, available at https://legalaidatwork.org/factsheet/ undocumented-workers-employment-rights/.
11. Kaiser Family Foundation, “Health Coverage of Immigrants,” March 18, 2020, available at https:// www.kff.org/racial-equity-and-health-policy/ fact-sheet/health-coverage-of-immigrants/.
12. Health Resources & Services Administration, “Federally Qualified Health Centers,” May 2018, available at https://www.hrsa.gov/opa/ eligibility-and-registration/health-centers/fqhc/index.html.
13. Corinne Lewis, Pamela Riley, and Melinda K. Abrams, “Care for Millions at Risk as Community Health Centers Lose Billions in Funding,” The Commonwealth Fund, December 21, 2017, available at https://www.commonwealthfund.org/blog/2017/care-millions-risk-community-health-centers-lose-billions-funding.
14. American College of Emergency Physicians, “EMTALA Fact Sheet,” 2021, available at https://www.acep.org/life-as-a-physician/ethics legal/emtala/emtala-fact-sheet/.
15. NYC Health + Hospitals, NYC Care, “What Is NYC Care,” 2021, available at https://www.nyccare.nyc/about/.
16. Official Website of the City of New York, “NYC Care Expands to Manhattan and Queens, Guaranteeing Comprehensive Health Care Citywide for All New Yorkers,” 2020, available at https://www1.nyc.gov/office-of-the-mayor/news/631-20/nyc-care-expands-manhattan-queens- guaranteeing-comprehensive-health-care-citywide-all.
17. Jim Dwyer, “One Hospital Was Besieged by the Virus. Nearby Was ‘Plenty of Space,’” The New York Times, July 1, 2020, available at https://
www.nytimes.com/2020/05/14/nyregion/coronavirus-ny-hospitals.html.
18. “I Want to Enroll in My Health LA (MHLA)! What Do I Do?” Los Angeles County, November 2014, available at http://file.lacounty.gov/SDSInter/dhs/223181_MHLAEnrollmentflyer-English_112014-v2.pdf.
19. Elizabeth Marcellino, “LA County Expands Access to Health Care for Undocumented Immigrants,” NBC Los Angeles, November 21, 2018, available at https://www.nbclosangeles.com/news/health-care-for-undocumentedimmigrants/143380/.
20. Health Services Los Angeles County, “Find a Clinic,” 2021, available at https://dhs.lacounty.gov/my-health-la/find-a-clinic/.
21. Health Services Los Angeles County, “Find a Clinic.”
22. New York State Senate, “Senate Bill S3577A,”2020, available at https://www.nysenate.gov/legislation/bills/2019/s3577/amendment/a.
23. Caroline Leddy, “The Covid Crisis Made the New York Health Act More Urgent, More Unlikely, or Both,” Gotham Gazette, November 24, 2020, available at https://www.gothamgazette.com/state/9910-covid-crisis-new-yorkhealth-act-single-payer-care-urgent-unlikely.
24. Bradford H. Gray and Ewout Van Ginneken,“Health Care for Undocumented Migrants: European Approaches,” Issues in International Health Policy, The Commonwealth Fund, December 2021, available at https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_issue_brief_2012_dec_1650_gray_hlt_care_undocumented_migrants_intl_brief.pdf.

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Author Biography

Nadhia Rahman holds a master’s degree in Urban Policy and Leadership at the City University of New York, Hunter College.