The United States (U.S.) has a long history of regulating and restricting immigrants’ self-determination over their health, bodies, reproduction, families, and futures. Moreover, Medicaid eligibility has always been shaped by white supremacist notions of which people are worthy of access to health care, a basic human right. In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) continued these xenophobic and racist traditions when it significantly narrowed eligibility for Medicaid, the Children’s Health Insurance Program (CHIP), and some other public benefits to U.S. citizens, immigrants admitted under certain mostly humanitarian statuses, and people who have been lawful permanent residents (LPRs) for five years or more. PRWORA’s “five-year-bar” forces LPRs to wait years before they can access Medicaid and other specified public benefits, and the law excludes undocumented immigrants from these programs altogether. While federal law requires that all states provide “emergency Medicaid” to uninsured people who are not eligible for Medicaid based on their immigration status, it solely covers services necessary to treat emergency medical conditions other than organ transplants, such as labor and delivery. This limited-scope and -duration coverage does not cover non-emergency care for life-threatening conditions, let alone the comprehensive health care services that people need to support their health and thrive.
While Congress has largely excluded immigrants from federal health care reforms designed to further near-universal health coverage, such as the Patient Protection and Affordable Care Act, it has authorized states to cover certain populations. The CHIP Reauthorization Act of 2009 granted states the option to provide Medicaid and CHIP coverage to lawfully residing pregnant women1 or children without a five-year waiting period. As of January 2023, twenty-five states and D.C. provided Medicaid coverage for lawfully residing pregnant people and thirty-four states and D.C. covered lawfully residing children without waiting periods. In 2002, a federal regulation inadvertently created an “unborn child” CHIP state plan amendment (SPA) option that enables states to cover prenatal and labor and delivery services for undocumented people when their fetus is the beneficiary. As of January 1, 2023, twenty states adopted this option. This loophole has enabled states to provide some vital coverage to undocumented immigrants after they become pregnant. However, limiting the scope of covered services to those for which the fetus is the beneficiary arguably relegates pregnant people to mere fetal vessels by excluding crucial services necessary to support maternal health, such as cancer treatment. Moreover, this approach leaves people without vital preconception, early prenatal, and postpartum coverage and care. Federal law does not currently enable the use of federal funds to cover undocumented immigrants beyond emergency Medicaid, yet in recent years, a handful of progressive states have used their own funds to provide undocumented populations with limited or full-scope coverage.
Nevertheless, PRWORA and other discriminatory coverage policies continue to leave millions of immigrants across the country, and especially immigrants of color with low incomes, without any health coverage whatsoever, undermining access to care and harming intergenerational health outcomes. By 2001, five years after Congress enacted PRWORA, Medicaid coverage decreased by almost half among recent and longstanding resident immigrant women, the latter of whom were still Medicaid-eligible. As of 2019, immigration-related eligibility restrictions barred 4.3 million income-eligible noncitizens, particularly Latine and Asian people, parents, and workers, from Medicaid with full benefits. Today, immigrant women are less likely to have health coverage and use sexual and reproductive health services than women born in the U.S. Eligibility restrictions based on immigration status or length of stay also contribute to our national maternal health crisis by limiting access to prenatal and postpartum care. These policies not only undermine the health and wellbeing of immigrants with low incomes, but also affect their children’s health.
Before joining the National Health Law Program, I worked as a community lawyer in Mississippi. Through my work with low-income and mixed-status immigrant communities of color, I saw how these xenophobic and racist eligibility restrictions operate as intended to obstruct access to essential care. Without health insurance coverage, parents and children go years without care for life-threatening chronic conditions. Women and gender-expansive immigrants cannot access the maternal, contraceptive, and abortion care that they need to experience reproductive autonomy and support intergenerational health and wellbeing. I witnessed how, together, these unjust federal policies reinforce vast health inequities for and withhold reproductive justice—the right to parent, not parent, and raise the children we have in safe and sustainable communities—from immigrant communities.
I witnessed how, together, these unjust federal policies reinforce vast health inequities for and withhold reproductive justice—the right to parent, not parent, and raise the children we have in safe and sustainable communities—from immigrant communities.
To alleviate interconnected health inequities and reproductive injustices, the U.S. urgently needs to expand equitable Medicaid and broader health insurance coverage to immigrants, regardless of status or length of stay. To that end, today, Representatives Pramila Jayapal and Nanette Barragan and Senator Cory Booker are reintroducing the Health Equity and Access Under Law (HEAL) for Immigrant Families Act of 2023, the most expansive version of the bill to date. This groundbreaking legislation dismantles longstanding barriers to Medicaid and other health insurance programs for immigrants by:
- Ending the five-year bar on Medicaid and CHIP eligibility as well as barriers related to sponsor deeming and liability for LPRs;
- Ensuring that all immigrants with federally authorized presence in the U.S. (g., Deferred Action for Childhood Arrivals recipients) are considered lawfully present for Medicaid, CHIP, and Marketplace plan eligibility (including eligibility for Marketplace premium subsidies and cost-sharing reductions);
- Creating a new SPA option for Medicaid coverage of undocumented immigrants, enabling federal financial participation;2
- Ending the discriminatory exclusion of undocumented immigrants from Marketplace plans, related premium tax credit and cost-sharing reductions, and state Basic Health Programs; and
- Expanding Medicare Part A and B eligibility to LPRs.2
Without these reforms, reproductive health equity and justice will remain out of reach for our country. Immigrant women, gender-expansive people, and families cannot wait. The National Health Law Program urges Congress to pass the HEAL for Immigrant Families Act of 2023.
The National Health Law Program urges Congress to pass the HEAL for Immigrant Families Act of 2023.
1 In this blog post, I employ “women” to match statutory terms and describe findings from cisgender women-centered research. Otherwise, I use gender-inclusive language to reflect the reality that people across gender identities need reproductive and broader health care access. More gender-inclusive policy terms and research are needed.
2 The HEAL for Immigrant Families Act of 2023 is the first version of the bill to include these provisions.
