(An earlier version of this article was published as “Health Insurance for U.S. Immigrants” by Tony Novak, CPA, MBA, MT, NAHU certified consumer driven health care consultant, on July 27, 2012 prior to full implementation of the Affordable Care Act, The article is updated now to include the impact of changes in 2017).
This article highlights some of the important considerations of immigrants to the U.S. when it comes to making health insurance choices and lists a few of the more popular low-cost health insurance options available throughout most of the United States.
Immigrants are less likely to be insured
Immigrants to the U.S. are twice as likely to be uninsured as other Americans. While 1 in 6 of all Americans lack health insurance or are underinsured with significant gaps in coverage, the ratio of uninsured immigrants is higher at 1 in 3 according to the 2009 report by the Center for Immigration Studies. Stated another way, first generation immigrants and their dependent children make up 17% of the total U.S. population but represent 32% of the total of those without health insurance. Illegal immigrants are even more likely to be uninsured. In 2012 we estimated that as many as 2 out of 3 illegal immigrants have no health insurance. The number may be lower today in states like California that have extended enrollment efforts to include undocumented residents.
Research by the New Jersey Department of Health and Human Services in 2011 concluded that immigrants are less likely to die from the common causes of death of most Americans.
Collectively, these indications suggest that immigrants are more likely to: 1) work in jobs that do not provide employer-provided health benefits, 2) have a low-income, and 3) face language barriers, lack education and resources necessary to use the online insurance exchange. It is important to realize that these three factors act in combination, rather than individually, to contribute to the high rate of uninsured immigrants. For example, college-educate middle-income immigrants who could afford health insurance are almost as likely to be uninsured as other immigrants. In this respect, the situation is the same as with other uninsured Americans, where research indicate the lack of health insurance cannot be attributed solely to income or affordability of insurance. The National Institute for Health Care Management (NIHCM) issued a report titled “Understanding the Uninsured: Tailoring Policy Solutions for Different Subpopulations” in April 2009 that detailed these findings.
The most significant difference between uninsured immigrants and other uninsured Americans is the length of time without insurance. The majority of Americans without insurance remain uninsured for less than a year. In contrast, the Center for Immigration Studies found that 29% of immigrants who entered the US in the late 1980s are still uninsured almost two decades later. Chronically uninsured are less likely to access routine medical care and early screenings and this is suspected to contribute to greater (and more expensive) medical problems over the long-term.
Despite these challenges, some type of insurance exchange is available the majority of immigrants, regardless of other factors.
Citizenship and social security number requirements
Despite popular notion to the contrary, citizenship is not a significant issue in qualifying for health insurance. Enrollment in U.S. health insurance plans does not require U.S. citizenship. In fact, most insurance applications do not ask about citizenship. Most domestic insurance plans do require applicants to have a social security number or tax identification number (TIN). A TIN is available to any person who does not qualify for a social security number, regardless of legal status, so this requirement should not be a deterrent to anyone who needs health insurance.
Legal and political considerations
State law – Health insurance in the United States is primarily controlled by state law. That means that there are 50+ variations on every topic associated with health insurance. For an incoming immigrant, the most important immediate consideration is that the location at the time of purchase affects the insurance choices available. Once a health insurance is issued it is equally valid in all states so the only concern is the availability of the best insurance at the location of purchase. Whenever possible, an immigrant should consider the options of purchasing insurance before entering the U.S. Migratory immigrants like farm workers, for example, will find that health coverage to be more liberal and affordable in one state than another. Some states like New York limit the availability of the most attractive immigrant policies. In this case it is possible to obtain a better insurance value by purchasing insurance before relocating to New York state.
Medicaid – Currently about 4 million immigrant adults and about 5 million immigrant children are covered under state Medicaid plans. These health benefits are increasingly at risk by state governments facing budget deficits (see “Impact of federal health reform law” below). Budgetary problems are likely to persist for the foreseeable future in many states so we expect this trend of cutting Medicaid eligibility for immigrants to continue.
Health insurance and immigration reform – The political debate continues on the best way to integrate those undocumented residents already living and working in our communities. Many believe that denying health coverage to any specific group is not only ethically wrong and impractical to enforce, it would ultimately be damaging to the rest of us as well. A recent New York Times editorial summed up this position stating “There is a line beyond which antipathy to the undocumented can be damaging to those voters’ health, not to mention the federal budget”.
Some states have initiated legislation that would require a hospital report to Immigration Services any person who seeks treatment without insurance who is unable to prove citizenship. This reporting could be avoided though use of Inbound Immigrant or other available insurance; citizenship is not required. Insurance companies are not involved in the legalization process and make no report to Immigration Services.
Coverage for children – State Children’s Health Insurance Plans (SCHIP) are available to the children of all low and middle-income families regardless of legal status. While the number of uninsured children has decreased as a result of these programs, the children of low-income illegal immigrants are least likely to access the subsidized coverage available through these programs. It is suspected that the fear of being “discovered” prevents parents from enrolling their children in SCHIP. Additional education and promotion of the programs, including the national “Cover Kids Now” campaign, appears to have had minimal impact in recruiting the children of illegal immigrants.
Impact of federal health reform law
The federal government currently reimburses hospitals about $20 billion per year for treating uninsured patients. Up to 40% of that cost is for treating illegal immigrants. The health care reform law passed in 2010 will soon cut that payment in half, based on the premise that fewer people will lack insurance after 2014.
The problem is that undocumented immigrants are specifically excluded from the health insurance exchange provisions of the health care law that help people get insurance coverage. Health insurance is available to illegal immigrants through commercial health insurance exchanges like Freedom Benefits but many just cannot afford it.
Hospitals are not allowed to refuse basic treatment based on lack of insurance nor are they allowed to ask about a patient’s immigration status.
This loophole in health care reform appears to be a consequence of the politics. Politicians say that the issue is “too hot to handle”. Hospitals are worried. Hospitals located in poor urban or rural areas may be forced out of business. Industry experts expect some to be purchased by for profit companies that take more aggressive procedures to exclude care for patients without insurance. For example, elimination of emergency room services and requiring patients to be referred by a participating doctor significantly reduces the number of patients without insurance. Community medical clinics may take up some of the slack but cannot provide the level of medical care as a hospital emergency room.
We expect that the outcome will be further division in the quality of medical care available to those with health insurance and those without coverage, regardless of immigration status. A natural-born U.S. citizen living in a low-income area will find more difficulty obtaining medical care without basic health insurance.
Commercial health insurance available to U.S. immigrants
The six most popular health insurance choices among immigrants using Freedom Benefits online enrollment service are listed below with a brief description of each option. Not all of these policies are available in all states. For full details on each option, follow the link to the online rate quoting pages that include full descriptions of coverage, definitions, exclusions and eligibility details.
1) Inbound Immigrant Insurance – a health insurance specifically designed for this purpose; provides up to 5 years of liberal coverage at an affordable price. This plan has a low annual deductible and includes maternity coverage. Maximum benefits are lower than most other types of domestic health plans. This combination of features makes this insurance the most popular choice among working class immigrants who buy their own health insurance.
2) Short term medical insurance (other but not all brands are available to new immigrants) is a domestic major medical insurance coverage. Enrollment support and policy contracts are available in both English and Spanish language. Coverage can be issued for up to six months on a month-to-month payment basis.
3) Patriot Exchange Program is ideal for exchange students attending a U.S. college or university. Coverage meets United States J1 travel visa requirements and can be extended for up to 4 years after entering the U.S.
4) Global Medical Insurance is a superior renewable major medical insurance that provides up to $8 million coverage worldwide that is suitable for individuals who expect to travel often or spend significant time in more than one country. Although this is the most expensive option listed on this Web page, it is less expensive than most U.S. domestic health insurance plans.
5) Core Health Insurance is a versatile mini-med plan paying defined amount per day hospitalization and doctor’s visit, priced on a scale that determines the dollar amount of benefits available ranging from minimal/supplemental to a higher price point similar to major medical coverage.
6) Value ER (NOT CURRENTLY AVAILABLE) is a simple supplemental policy that provides emergency coverage for accidents and injuries of $1,000 per person (or $2,000 per family) for a premium of $30 per month. This policy is unique in that the price for individual coverage is the same as the price for a whole family. We have noticed this policy being used by migrant farm workers who otherwise might not have any health coverage at all.
This article is meant to highlight just a few of the available insurance choices for immigrants. Browse the listings on this Web site for more options. Enrollment assistance with all of these affordable insurance plans is offered through OnlineNavigator service. Send an e-mail to Onlinenavigator@freedombenefits.net for more information.
Personal assistance with immigration documentation
Tony Novak, author of this article, is available to attorneys who work in the area of immigration law to help provide fast documentation of health insurance in instances where such documentation is required in advance.