Providing public health benefits to immigrants is a politically controversial topic. While some politicians are trying to expand health benefits to immigrants [1] , the myth that expanding health care access to immigrants is too costly persists. Former President Donald Trump signed a proclamation in 2019 banning legal immigrants without health coverage.
“Immigrants who enter this country should not further saddle our health care system, and subsequently American taxpayers, with higher costs,” he said. [2]
But a new study published in JAMA Network Open in September finds that when immigrants receive public health insurance, their medical spending is less than half that of similar U.S.-born adults.
How Medicaid expansion affected immigrants
The authors of the study used data from the Medical Expenditure Panel Survey, which includes individuals’ total medical care expenses, including out-of-pocket costs. They looked at data from the years 2011 to 2019, during which the Affordable Care Act allowed states to expand Medicaid to all residents making below 138% of the federal poverty level.
The study specifically looked at those who would have been eligible for Medicaid. (Because of this, it doesn’t include undocumented immigrants.) While both U.S.-born and immigrant adults saw similar increases in insurance coverage, health care spending and use increased significantly for the U.S.-born, while the increase for immigrants was negligible.
One explanation may be that immigrants are healthier than the native-born population. In the study sample of 44,482 individuals, 44% of the U.S.-born adults had a pre-existing chronic condition, compared to 26% of the immigrant sample. Past research shows that healthier people are more likely to immigrate. [3]
Another reason immigrants spend less is that they may avoid traditional health care, says Neeraj Kaushal, a professor of social policy at Columbia University, and a co-author of the study with Felix Muchomba, an assistant professor of social work at Rutgers University.
“Especially for our study, which was conducted during the Trump years, that could be a factor, the fear that if they use health insurance, their visa could be jeopardized or their immigration status could be jeopardized,” Kaushal says.
Instead, immigrants may seek cheaper alternate forms of care, which may include unlicensed “underground doctors” or homeopathic cures, Kaushal says.
Whatever the reason, the study contradicts Trump’s claim that immigrants saddle the health care system with higher costs, Kaushal says. Instead, it shows that impediments to immigrants’ access to health care should be minimized or removed.
“We know that the cost of health care to them is less and they underutilize health care,” Kaushal says.
Leighton Ku, a professor and director of the Center for Health Policy Research at George Washington University, says the study is consistent with other research that finds that immigrants use less health care and have lower health care expenditures than similar people who are native-born citizens. Because of this, the cost of expanding coverage to them is relatively low.
“This appears to be true for both undocumented and lawfully admitted immigrants, although data about legal status can be problematic,” Ku says.
Why immigrants avoid health care
Immigrants have had to navigate shifting policies when it comes to health insurance. President Joe Biden reversed Trump’s immigrant health policies shortly after taking office, but researchers have found many immigrants are still reluctant to sign up for Medicaid. [4]
Immigrants may be fearful that using health care will jeopardize their immigration status. If the federal government determines you’re dependent on the state — also known as being a “public charge” — it can keep you from becoming a lawful permanent resident. [5]
States have also gone back and forth: After launching a state-funded health insurance program for immigrants in 2020, Illinois Gov. J.B. Pritzker this year paused enrollment, citing high costs. [6]
The mix of laws creates confusion.
“Covering more immigrants is relatively low-cost, which is why some states like California or others have opted to provide coverage,” Ku says. “But there are still legal barriers because of complicated policy issues that concern how the U.S. views and treats immigrants, including many with lawful status as well as those who are undocumented.”
The government and civil rights organizations have a role to play in creating awareness that the use of Medicaid is no longer included in public-charge considerations, as it was under Trump, Kaushal says. Immigrants shouldn’t be afraid of seeking health care, she says.
“If you have an accident or are unhealthy or get sick, you need health care,” Kaushal says. “If immigrants are underutilizing it even if they have health insurance, that’s a serious thing.”
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