Supporting Health Equity and Affordable Health Coverage for Immigrant Populations

A nurse listens to a patient's chest using a stethoscope.

A series from State Health and Value Strategies highlights strategies for states to expand affordable health coverage to immigrant populations in the United States.

The Issue

Ensuring affordable health coverage and healthcare for immigrant populations in the United States is critical to advancing health equity. This series will examine a range of strategies that states have at their disposal to help extend coverage to immigrant populations, including those who do not qualify for subsidized health insurance under the Patient Protection and Affordable Care Act (ACA) or other public programs due to immigration status.

The latest issue brief in the series, "Overview of the Public Charge Proposed Rule," provides key provisions of the U.S. Department of Homeland Security's 2022 notice of proposed rulemaking (NPRM) and includes commentary to describe how the proposed rule differs from the 1999 Field Guidance, as well as how the proposed rule seeks to promote clarity and address the chilling effects caused by elements of the now-repealed 2019 Rule.

Key Findings

  • To cover low-income residents who are ineligible for subsidized health insurance under the ACA or through Medicaid/the Children's Health Insurance Program (CHIP) as a result of immigration status, states and localities are pursuing legislative and administrative actions to extend affordable healthcare coverage using state or local-only funds. These include new coverage programs leveraging Medicaid/CHIP and state subsidies for individual Market coverage.

  • Some states are leveraging targeted CHIP authority to provide Medicaid coverage to pregnant individuals and children [e.g., Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) 214, the “unborn child” option].

  • Section 1332 waivers and Medicaid Buy-In may offer states alternative pathways to providing coverage for immigrant populations. 

  • The federal government's recent reorientation of the public charge is an opportunity to enroll more individuals and provide much-needed health insurance to eligible immigrants.

  • State Medicaid agencies play an important role in educating immigrant communities that enrolling in public health coverage will not hurt their chances of obtaining a green card or becoming a U.S. citizen.  

  • The 2022 NPRM rejects the 2019 Rule’s system of projecting whether a noncitizen would surpass a specific threshold of public benefits use in the future based on their current or past use of non-cash benefits. Under the 2022 NPRM, individuals who rely on their own resources, in addition to some limited government supports, are less readily characterized as public charges.


Absent new federal policy and funding options, states seeking to advance universal coverage and health equity will continue to lead the way in innovating and advancing coverage solutions for immigrant populations.

About State Health and Value Strategies—Princeton University School of Public and International Affairs

State Health and Value Strategies (SHVS) assists states in their efforts to transform health and healthcare by providing targeted technical assistance to state officials and agencies. The program is a grantee of the Robert Wood Johnson Foundation, led by staff at Princeton University’s School of Public and International Affairs. The program connects states with experts and peers to undertake healthcare transformation initiatives. By engaging state officials, the program provides lessons learned, highlights successful strategies and brings together states with experts in the field. Learn more at

About State Health Access Data Assistance Center

State Health Access Data Assistance Center (SHADAC) is an independent, multi-disciplinary health policy research center, housed in the School of Public Health at the University of Minnesota, with a focus on state policy. SHADAC produces rigorous, policy-driven analyses and translates its complex research findings into actionable information for states. Learn more at

About Manatt Health

Manatt Health integrates legal and consulting expertise to better serve the complex needs of clients across the healthcare system. Our diverse team of more than 160 attorneys and consultants from Manatt, Phelps & Phillips, LLP, and its consulting subsidiary, Manatt Health Strategies, LLC, is passionate about helping our clients advance their business interests, fulfill their missions, and lead healthcare into the future. For more information, visit

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