By Joanne Kenen
KFF HEALTH NEWS
KFFmedia@kff.org
Maria Sanchez immigrated to the Chicago area from Mexico about 30 years ago. Now 87, she’s still living in the U.S. without authorization. Like many longtime immigrants, she has worked — and paid taxes, including Medicare taxes — all that time.
But Sanchez never had health insurance, and when she turned 65, she couldn’t enroll in Medicare. She has never had preventive care or screenings. No physicals. No cholesterol checks. No mammograms.
“Nada, nada, nada,” she said in an interview conducted in Spanish. Nothing, nothing, nothing.
When she did get sick, she delayed seeking care until she was so ill that she was twice hospitalized with pneumonia. She finally got covered last year under a landmark Illinois program for older people without legal residency that took effect in December 2020.
Democratic-led states such as Illinois are increasingly opening public insurance programs to immigrants lacking permanent legal status. A dozen had already covered children; even more provided prenatal coverage. But now more states are covering adults living in the country without authorization — and some are phasing in coverage for seniors, who are more expensive and a harder political sell than kids.
The expansions recognize the costs that patients living here illegally can otherwise impose on hospitals. But the policies are under harsh attack from former President Donald Trump and other Republicans who seek to make his opponent, Vice President Kamala Harris, the face of reckless immigration policies.
Republicans point to Harris’ home state of California’s expansion of Medi-Cal coverage to immigrants of all ages regardless of legal status, saying it comes at the expense of American citizens.
Read more: What a GOP fight over undocumented health care says about California’s changing politics
It’s a regular complaint for Trump. “She’ll go around saying, ‘Oh, Trump is going to do bad things to Social Security,’” he said of Harris at a Sept. 13 news conference. “No, she’s going to do it because she’s putting these illegal immigrants onto Social Security, onto Medicare, and she’s going to destroy those programs, and the people are going to have to pay.”
Harris’ choice of Minnesota Gov. Tim Walz as her running mate added fuel to Republican attacks at the intersection of immigration and health policy.
Under a law Walz signed, immigrants living without authorization in Minnesota will be able to gain health coverage starting next year through the state’s MinnesotaCare program for people with low incomes who aren’t eligible for Medicaid.
The issue is top of mind for some Americans. At an Oct. 10 town hall in Las Vegas, an audience member event host Univision identified as Ivett Castillo asked Harris what her administration would do about health care for people like her mother, who had immigrated from Mexico without authorization many years ago, worked her whole life, and died this year without ever receiving “the type of care and service that she needed or deserved.”
“What are your plans, or do you have plans, to support that subgroup of immigrants who have been here their whole lives, or most of them, and have to live and die in the shadows?” Castillo asked.
Harris noted her past support for a path to citizenship for unauthorized residents — and for a bipartisan border security bill that Senate Republicans killed earlier this year at the behest of Trump.
“This is one example of the fact that there are real people who are suffering because of an inability to put solutions in front of politics,” Harris said.
Even without state policies expanding coverage, immigrants can get free or inexpensive primary care at community clinics throughout the country — assuming they know it’s an option and feel safe at the facilities. But primary care can’t take care of all medical needs, particularly as people age and develop more complex health problems and chronic illnesses. So immigrants often rely on charity care, go into debt, or, like Sanchez, skimp. Some even return to their home countries for care.
Illinois, where Sanchez got covered, was a pioneer in extending insurance coverage to unauthorized migrants. Now, six states and the District of Columbia — all led by Democrats — cover at least some low-income older immigrants under Medicaid or Affordable Care Act waivers. Minnesota next year will become the seventh. State funds must be used for the expansions, as federal dollars generally can’t cover people lacking legal status.
Whether or how quickly more states follow remains to be seen, and if Trump wins the White House, his administration would likely try to thwart the trend, given that he has pledged mass deportations. Coverage for all immigrants is still a tough sell economically and politically — and the noncitizen population can’t vote its gratitude at the ballot box. Immigrant health initiatives in several other states have fizzled or been scaled back.
Maryland, for example, settled on opening its Obamacare exchange to people living in the state without authorization, starting in 2026 — but without taxpayer subsidies for their premiums.
Still, there’s enough activity in states to make advocates for immigrant health believe something has shifted. The pandemic’s severity and its uneven toll helped build support for covering older immigrants, said Lee Che Leong, the senior policy advocate at Northwest Health Law Advocates in Washington state.
“People are looking around and realizing that our health is interconnected, both globally and locally,” Leong said. “The pandemic really brought that home, that when you look at the disparities in who got covid, who was exposed to covid, and who died from covid.”
Access to U.S. health care has long been an obstacle for immigrants, even those in the country legally. People with green cards must wait five years for coverage under Medicaid or other government health programs. Some older green-card holders have to pay extra premiums for Medicare Part A — the portion that covers hospital care — if they haven’t been employed for at least 10 years in the U.S.
The new state health programs close those gaps, said Shelby Gonzales, vice president for immigration policy at the Center on Budget and Policy Priorities.
In July, Washington state started covering low-income immigrants in a Medicaid-like program called Apple Health Expansion, using a federal waiver. Enrollment is capped and the program filled quickly, but some slots were reserved for people 65 and older, Leong said. Earlier this year, the state opened its Obamacare exchange to immigrants living in the U.S. without authorization.
Oregon and Colorado now also offer some coverage to people in their states who lack legal status, though the Colorado program didn’t attract many older immigrants, according to data recently presented to the state Affordable Care Act exchange oversight committee.
New York has covered child immigrants lacking legal residency for years, and the state’s Medicaid program was opened in January to all adult immigrants regardless of status. About 25,000 people signed up in the first four months, according to New York Medicaid Director Amir Bassiri.
Back in Illinois, Maria Sanchez said her new coverage has been life-changing — and possibly lifesaving. Her bouts of pneumonia were severe, partly because she had delayed care. After her second hospitalization, she needed follow-up cardiac care. The hospital didn’t charge her for her stay.
But now, with her “tarjeta medica” — her medical card — she can see a doctor. Her heart condition is under control. She has seen a dentist. She’s getting her cataracts removed.
“With my medical card, I have peace of mind,” Sanchez said.
Illinois has gradually added coverage for other age groups; in summer 2022, it lowered eligibility to age 42. That means immigrants like Gaby Piceno, 45, can age more healthily.
“I don’t have to worry anymore,” she said, referring not just to herself but to her family.
Read more: Immigrant advocates tout new report showing benefits of state-funded health plans | Copays take effect for immigrant health programs as cost estimates continue to decline
But the coverage expansion has cost more than Illinois projected. People like Sanchez and Piceno, already on the rolls, remain covered, but new enrollment was paused this year. More people signed up than expected, and many continued seeking care in more costly hospital emergency departments rather than at doctors’ offices, said the state’s acting insurance commissioner, Ann Gillespie, who was an Illinois state senator when the program was established.
The state is now shifting covered immigrants into Medicaid managed-care plans, hoping to bring down the cost over time.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.
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