Lack of Coverage for Undocumented Patients Puts Pressure on the Health Care Safety Net

Sep 26, 2014, 9:00 AM, Posted by

The nation’s 11 million undocumented immigrants constitute a “medical underclass” in American society. [1,2] Apart from their eligibility for emergency Medicaid, undocumented immigrants as a population are ineligible for public health insurance programs, including Medicare, Medicaid, the Child Health Insurance Program (CHIP), and subsidies available to purchase private health insurance under the Patient Protection and Affordable Care Act (ACA) of 2010, because they are not “lawfully present” in the United States. [3] Federal health policy does provide undocumented immigrants with access to safety-net settings, such as an acute-care hospital’s emergency department (ED), or a community health center (CHC). Since 1986, the Emergency Medical Treatment and Active Labor Act (EMTALA) has required that all patients who present in an ED receive an appropriate medical screening and, if found to be in need of emergency medical treatment (or in active labor), to be treated until their condition stabilizes. CHCs such as Federally Qualified Health Centers and other nonprofit or public primary care clinics serving low-income and other vulnerable populations trace their origins to health policy that includes the Migrant Health Act of 1962. [4]

"The health care safety net is crucial for maintaining access to care for low-income patients, including undocumented immigrants. But the net is unraveling."

Because it is imprudent to project that undocumented immigrants will be able to defer the need for affordable health care for the next decade or longer, one measure of the long-term success of health care reform will be whether and how it can intersect with local and regional efforts to provide undocumented immigrants with better access to health care and related public services. The health care safety net is one of the locations in which undocumented immigrants and their children encounter public services that can help or hinder their ability to live, work and flourish in a community and in this nation. Changes include ACA-mandated cuts in “disproportionate share hospital” (DSH) payments to safety-net institutions, based on the assumption that these hospitals will recoup this funding through reimbursements from newly insured patients. Because DSH funds have helped cover care for uninsured patients who are undocumented, safety-net providers are concerned that the differences between the care available to formerly-uninsured low-income patients, and to still-uninsurable undocumented low-income patients, will become pronounced. [5]

Without access to insurance or federal benefits, they will continue to rely heavily on safety-net health care even while ACA implementation expands options for other currently uninsured populations. The health care safety net is crucial for maintaining access to care for low-income patients, including undocumented immigrants. But the net is unraveling. The costs of providing care to undocumented immigrants are disproportionately borne by health care organizations and physicians in communities and states with large populations of undocumented immigrants. [6] Requiring professionals, organizations and taxpayers in these communities to take on the disproportionate burden of unresolved immigration policy problems is unfair. A national policy is called for on both ethical and economic grounds.

More information is available at the web site for the Hastings Center Project on Undocumented Patients.


[1] Sommers, Benjamin D., “Stuck Between Health and Immigration Reform - Care for Undocumented Immigrants,” New England Journal of Medicine (2013): 1-3, doi: 10.1056/NEJMp1306636

[2] Passel, Jeffrey S. and D’Vera Cohn, ‘“Unauthorized Immigrant Population: National and State Trends, 2010,” Pew Hispanic Center (February 2011): 1-32, at 1. Estimates are based on the U.S. Census Bureau’s Current Population Surveys, March 2010 Supplement, available at:; accessed August 10, 2013.

[3] 62 Fed. Reg. 61344, November 17, 1997. The public benefits category “Persons Residing Under Color of Law” (PRUCOL) permits some undocumented patients, such as asylum seekers, to obtain Medicaid coverage if they meet exacting conditions.

[4] Section 330 of the Public Health Service Act (42 USCS § 254b)

[5] Iverac, Mirela, “Hospitals Treating Immigrants Here Illegally Worry About Upcoming Cuts,” WNYC, June 10, 2013, Accessed June 10, 2013; Salimah Ebrahim, “Health Reform May Expose Immigrant Status of Millions,” Reuters, August 9, 2012,, accessed May 24, 2013.     

[6] Breen JO. Lost in translation - ¿Cómo se dice, "Patient Protection and Affordable Care Act"? N Engl J Med 2012; May 16. DOI: 10.1056/NEJMp1202039.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.