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Undocumented and Uninsured: Barriers to Affordable Care for Immigrant Populations

Executive Summary

The Affordable Care Act will significantly reduce the number of U.S. residents without health insurance to ensure appropriate access to health services, but the law specifically excludes one group from all its provisions: the approximately 11 million undocumented immigrants residing in this country.

In California, where almost one-quarter of the nation’s undocumented immigrants reside, data show that, as compared with lawful permanent residents (LPRs), naturalized citizen immigrants, and U.S.-born nonelderly adults, undocumented immigrants:

  • have the highest male labor force participation (95%);
  • are younger (90% are between ages 18 and 44);
  • are more likely to live in families with children (61%);
  • have the highest rates of poverty (57%); and
  • have the highest rate of being uninsured (51%).

When statistically controlling for age and gender, undocumented residents of California have a health profile that is generally similar to U.S.-born residents. Undocumented immigrants report the lowest rates of asthma but the highest rates of obesity and being overweight. This is significant since obesity and being overweight increase the risk of diabetes, hypertension, and other conditions where timely access to medical care is essential.

Access to health care in California is significantly worse for undocumented immigrants, even after controlling for age and gender. Compared with LPRs, naturalized citizen immigrants, and U.S.-born nonelderly adults, undocumented immigrants:

  • have the highest rate of having no usual source of care (35%);
  • are the least likely to have seen a doctor in the past year (28%); and
  • are the least likely to have used an emergency department in the past year (12%).

Estimates presented in this report show that the health reform law will have little impact on the coverage of undocumented residents. Nationally, an estimated three-fifths (61.5%) of nonelderly adults who are undocumented immigrants are expected to remain uninsured. As a result, undocumented residents will make up a larger share of the remaining uninsured population in the country. In states with the highest concentration of undocumented immigrants, such as California, they will account for up to two-fifths of all remaining uninsured residents.

Undocumented residents are concentrated in a small number of states. As a result, safety-net hospitals in those states will be particularly affected by the reduction in disproportionate share hospital (DSH) payments scheduled under the Affordable Care Act that have previously cushioned the impact of providing uncompensated care. Many hospitals are expected to have a lower uncompensated care burden as a result of fewer uninsured patients, but those with a large proportion of undocumented immigrants may not experience the increase in insured patients that would otherwise be expected.

Despite being in working families, most undocumented immigrants are not covered by health insurance and face significant access-to-care barriers. Policy innovations for undocumented residents from around the United States and internationally provide examples of how access to health care can be improved. These include:

  • expanding insurance options to undocumented residents, either directly as in Vermont’s proposed single-payer system, or indirectly through increased employer coverage;
  • increasing access to specific high-value services through low-cost or free care to those without health insurance; and
  • maintaining or increasing subsidies to safety-net providers in communities with a high number of immigrants to allow them to provide uncompensated or low-cost services to all persons without health insurance.

The Affordable Care Act’s goal of affordable, quality health care for all will not be achieved unless policies also assist the country’s approximately 11 million undocumented residents. Helping improve access to care or health insurance coverage is an investment in maintaining the good health of this population and will also stabilize the financial viability of safety-net providers who are essential to the residents of their communities.

Undocumented Immigrants


Publication Details



S. P. Wallace, J. M. Torres, T. Z. Nobari et al., Undocumented and Uninsured: Barriers to Affordable Care for Immigrant Populations, The Commonwealth Fund and the UCLA Center for Health Policy Research, August 2013.