The U.S. is home to 22 million noncitizens. Immigration status has been repeatedly identified as a social determinant of health. COVID-19 is taking a disparate toll on immigrants. Immigrants are, and have been, reporting concentrated outbreaks in meat packing plants and among farm workers, poor communication from government actors, feeling “left behind” as states open up while cases are rising in their communities, and most of all, fear.
Exclusion is Built Into the Health Care System
It is entirely predictable that immigrants would experience worse outcomes. Our existing Medicaid and public benefits programs purposefully exclude the majority of immigrants. Even without a global pandemic, these systems by design produce health disparities based on immigration status.
For instance, the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) classified immigration statuses as either “qualified” or not qualified groups. All non-qualified immigrants and most “qualified” immigrants are excluded from Medicaid and CHIP for the first five years after obtaining their qualifying status (except in very limited circumstances). PRWORA’s list of qualified statuses is quite narrow and stripped Medicaid coverage away from a large number of people who were lawfully present in the United States (including, egregiously, COFA communities).
In 2009 Congress restored the ability for lawfully residing children and pregnant women to receive care—but only if a state elects that option, and not all have. Even this lawfully residing category still has critical gaps: DACA recipients, for example, are still ineligible under this option.
The Affordable Care Act does permit lawfully present immigrants to purchase health insurance on the Marketplaces, but excludes undocumented immigrants from eligibility for Marketplace coverage. DACA recipients are also, once again, excluded.
The result of these policies is, of course, significant disparities in insurance status between citizens and immigrants. Among the nonelderly population, 23% of lawfully present immigrants and more than four in ten (45%) undocumented immigrants are uninsured compared to less than one in ten (9%) citizens.
Fear of Seeking Health Care
Outright exclusions are not the only problem. As we’ve described elsewhere, even when immigrants are eligible for benefits, they consistently face barriers and strong disincentives to accessing care. For instance, this administration’s new public charge rule allows immigration officials to consider receipt of Medicaid when determining whether to provide certain individuals a green card.
Although many immigrants are exempt from the rule, the fear and confusion has prompted many to avoid Medicaid and CHIP coverage anyway. A recent report revealed that one in five adults in immigrant families with children reported that they or a family member avoided a public benefit such as SNAP, Medicaid, CHIP, or housing subsidies for fear of risking their future green card status.
To make matters worse, immigrant families also have to worry about whether they will run into Immigration and Customs Enforcement when seeking care.
Layering the COVID-19 pandemic on top of an already inequitable health care and immigration system is only exacerbating these disparities. This is not the product of benign neglect, but rather of intentional design. To achieve health equity for immigrants we must redesign our existing immigration and health care systems to provide truly universal coverage.