The Affordable Care Act
The Affordable Care Act (ACA) expanded health coverage for millions of Americans, but it explicitly left out undocumented immigrants. Under the ACA, only U.S. citizens and lawfully present immigrants are eligible to enroll in health insurance marketplaces (exchanges) or gain coverage through Medicaid expansion. Undocumented immigrants are barred by law from purchasing insurance on ACA exchanges and from enrolling in Medicaid or the Children’s Health Insurance Program (CHIP). This exclusion was written to ensure that federal subsidies and public insurance benefits would not be available to people without legal status. In practice, that means the ACA’s coverage pathways simply do not exist for an estimated 10+ million undocumented U.S. residents.
Uninsured rates remain extremely high for undocumented immigrants due to these eligibility restrictions. Surveys and research indicate that roughly half of undocumented immigrant adults are uninsured, far above the uninsured rate for U.S.-born citizens (around 6–8%). Lacking access to ACA plans or Medicaid, undocumented immigrants have a choice between paying full price for private insurance or going without coverage. This disparity in access translates to undocumented communities frequently foregoing care or seeking care outside of the traditional insurance system.
About 50% of undocumented immigrants in the U.S. lack health insurance, compared to under 10% of U.S.-born citizens and ~18% of lawfully present immigrants. Studies show that having insurance is strongly linked to whether people can access timely health care. This disparity leads to undocumented migrants often delaying care or relying on emergency rooms for conditions.
Because so many undocumented immigrants are uninsured, they rely heavily on safety-net providers for whatever care they do receive. These include community health centers, free/low-cost clinics, and public hospitals. However, the safety net has limits and is under a lot of strain. The ACA enacted cuts to federal Disproportionate Share Hospital payments – funds that help reimburse hospitals for uncompensated care – on the expectation that hospitals would have fewer uninsured patients. For safety-net hospitals in areas with large undocumented populations, this has created financial challenges. Those hospitals still face high uncompensated costs (treating uninsured undocumented patients), but with less federal support to offset expenses.
Health coverage options for undocumented immigrants now largely depend on state and local policies, leading to stark regional differences. A few states have chosen to create programs to cover some undocumented residents using state funds. For instance, California now offers Medi-Cal (Medicaid) coverage to all low-income children and young adults regardless of status (and is expanding to older adults). These initiatives, often through “state-only” funding or innovation waivers, aim to fill some of the gaps left by the ACA’s exclusions.
The Southern United States stands out as a region with limited state-funded alternatives to cover undocumented immigrants. Most Southern states have not expanded any health insurance options for undocumented residents beyond emergency care. In these states, an undocumented person’s only consistent access to care may be through charity clinics, emergency rooms, or local programs (if available).
The lack of options in many states means geography plays a huge role in an undocumented individual’s health care access. In states like Texas or Georgia, which offer no public insurance to undocumented adults, an uninsured person with chronic illness must rely on intermittent care from emergency departments or federally-funded community health centers.
Sources: The information above is drawn from the text of the ACA and related federal regulations, analyses by Kaiser Family Foundation (KFF) and the Congressional Research Service, and research from health policy experts. Key references include Section 1312(f) of the ACA excluding undocumented immigrants, official guidance from HealthCare.gov and the Centers for Medicare & Medicaid Services, KFF data on immigrant uninsured rates, and studies on safety-net care for undocumented populations (see inline citations). These sources provide a factual basis for understanding how ACA policy impacts undocumented immigrants’ health coverage and access to care.
https://healthpolicy.ucla.edu/publications/Documents/PDF/undocumentedreport-aug2013.pdf#:~:text=coverage%20for%20the%20large%20number,carried%20out%20by%20the%20states