by Rodrigo Stein, MSc.*

Gaps in access to public health insurance like Medicaid and other subsidized programs, coupled with restrictions in private job-based health coverage, create significant barriers for immigrants in obtaining essential healthcare services. The disparate treatment of immigration statuses leads to a fragmented health coverage system, resulting in many immigrants, including those lawfully present, foregoing necessary medical care. This contributes to poorer health outcomes, reduced life expectancy, and increased morbidity rates among immigrant populations in the Washington, D.C. metropolitan area.¹

Immigration Status Impacts Health

The Washington, D.C. metropolitan area is home to over 900,000 Latinos, 53% of whom are foreign-born.^[i] A significant portion of this immigrant population hails from Central American countries such as El Salvador, Honduras, and Guatemala. Numerous studies highlight how immigration and immigration status impact health outcomes through various material and psychological mechanisms.^[ii],[iii]  These include heightened fear and stress, unequal access to resources, experiences of prejudice and violence, and disparities in accessing safe employment and quality housing.^2,3 Despite the implementation of the Affordable Care Act (ACA), individuals with Central American heritage are still less likely to have health insurance compared to non-Latino Whites.⁴

Over 32,000 Temporary Protected Status (TPS) holders who have sought protection in the United States due to conflict or natural disasters in their home countries reside primarily in the Washington, D.C. metropolitan area. ^[i] TPS holders (the majority, Salvadoran nationals) qualify for ACA subsidies and plans but not Medicaid.^[ii] Medicaid, the primary public health program for low-income working-age adults, is limited to citizens and “qualified non-citizens,” a category that requires both legal status and (in most cases) completion of a five-year waiting period to be eligible for public assistance programs.^[iii]

These provisions combine to make thousands of immigrants ineligible for public health services and financial assistance for purchasing insurance, forcing them to choose between purchasing expensive private market insurance at cost, going without health insurance, or relying on the emergency room as their main source of care. (See Table 1).

 Table 1 Eligibility for Federally Funded Health Care Coverage Based on Immigration Status

Eligibility for Federally Funded Coverage Based on Immigration Status
Immigration Status	Marketplace Eligible	Medicaid/CHIP Eligible
Lawfully Present and Eligible for Federally Funded Coverage
Valid non-immigrant visa holders (e.g. students, worker visas)	✔	X
Humanitarian statuses or circumstances (including Temporary Protected Status, Special Juvenile Status, asylum applicants, Convention Against Torture, victims of trafficking)	✔	X
Legal status conferred by other laws (temporary resident status, Legal Immigration Family Equity Act, Family Unity individuals)	✔	X
Qualified non-citizens • Lawful Permanent Residents [(LPR)/Green Card Holder)]* • Paroled into the U.S. for at least one year*  • Battered non-citizens, spouses, children, or parents* • People fleeing persecution (e.g., asylees, refugees)  • Granted withholding of deportation  • Cuban/Haitian entrants • Certain Amerasian immigrants  • Members of a federally recognized Indian tribe or American Indian born in Canada  • Veterans or active duty military and their family members  • Victims of trafficking and their family members  • Citizens of the Marshall Islands, Micronesia, and Palau who are living in one of the U.S. states or territories [“Compact of Free Association (COFA) migrants”] • Granted Iraqi or Afghan special immigrant status  • Children receiving foster care or adoption assistance  • Conditional entry granted before 1980	✔	✔
Ineligible for Federally Funded Coverage
Undocumented immigrants:Individuals who entered the country without authorizationIndividuals who entered the country lawfully and stayed after their visa or status expired	X	X
DACA: Temporary status allowing individuals who came to the country as children to remain in the U.S.	X	X
Deferred Action for Parents of Americans and Lawful PermanentResidents (DAPA): Temporary status allowing parents of citizens or LPRs to remain in the country	X	X
*Subject to the five-year bar (i.e. requirement to reside in the U.S. for five years or more before becoming eligible for Medicaid/CHIP). Note that there is no five-year bar for accessing subsidized Marketplace coverage.

Health Risks & Social Determinants of Health 

In addition to access barriers, immigrants experience a lack of social support and the absence of culturally and linguistically competent services. This means that many Latino immigrants, even those with access to quality care, forego seeking medical care until they face an emergency. Language barriers contribute to increased rates of misdiagnoses, weaker health literacy skills, and reduced access to acute and preventive care.^[i]

This issue is compounded by the fact that many Latino immigrants are employed in occupations that offer limited access to employer-sponsored health coverage and often have comparatively lower incomes.^[i] As a result, these individuals face barriers to accessing care when trying to afford employer-sponsored coverage, when available, or when navigating the individual health insurance market. Given these barriers, what policy alternatives exist to ensure thousands of Latino immigrant residents in our region are not excluded from health care? 

Current Options: Federally Qualified Health Centers

Because of their limited access to health care, Latino immigrants often seek services at community health centers (CHCs) where they can access care without insurance (over 35% of CHC patients in the U.S. are Latino).^[i] Federally Qualified Health Centers (FQHCs) are CHCs that meet stringent federal requirements and receive funding via the Health Resources and Services Administration (HRSA) to provide primary health care services to all people regardless of their ability to pay or documentation status through a sliding fee scale.^[ii]

FQHC’s like La Clínica Del Pueblo (La Clínica), play a significant role in reducing racial and ethnic health disparities. The success of these centers in narrowing these gaps is attributed to the wide range of services they offer, culturally competent care, and strong relationships built with underserved communities.^[iii] Since all direct service staff are bilingual, and most are first-generation Latino immigrants, La Clínica provides much-needed culturally and linguistically appropriate health care to a large yet excluded population in the Washington, D.C. metro area.

However, despite their effectiveness in producing high-quality healthcare outcomes, FQHCs are limited in size, scope, and resources. Because these centers vary in size, depth, and jurisdiction, addressing the cost of care for those who are ineligible for federally funded health programs is paramount—without them, FQHCs bear the burden of uncompensated care for a population with significant health needs.¹⁶

Potential Policy Solutions

As of March 2024, the District of Columbia and six states—California, Colorado, Illinois, New York, Oregon, and Washington—have expanded fully state-funded coverage to some income-eligible adults regardless of immigration status.^[i] These legislative or administrative actions rely on establishing state Medicaid/CHIP equivalent or comparable programs, and creating state premium or cost-sharing subsidies to enable individuals to purchase marketplace coverage.⁹In addition to these six states, Maryland will allow income-eligible individuals to purchase marketplace coverage regardless of immigration status through a Section 1332 waiver.

Maryland’s Access to Care Act

On May 16, Maryland Governor Wes Moore signed the Access to Care Act into law. Sponsored by Delegate Bonnie Cullison and Senator Antonio Hayes, the law removes immigration status as an eligibility requirement for purchasing a health plan through the Maryland Health Benefit Exchange (MHBE). In doing so, Maryland allows the remaining 6% of uninsured Maryland residents to purchase insurance. Immigrants make up a substantial number of that uninsured population; they are 15% of Maryland’s population overall, and the state’s Montgomery and Prince George’s counties have the highest concentrations of the Latino population in Maryland, with 21% in each jurisdiction. Soon, they will not only have the choice to buy a healthcare plan in the state but also receive care in a culturally and linguistically competent manner.  

Stepping Toward Equity

By expanding eligibility for public health programs and supporting community health centers, we can ensure that all residents, regardless of immigration status, have access to essential healthcare services. Legislative actions like the Maryland Access to Care Act represent significant steps towards achieving health equity for immigrant populations.

^[1] Martinez O, Wu E, Sandfort T, Dodge B, Carballo-Dieguez A, Pinto R, Rhodes SD, Moya E, Chavez-Baray S. Evaluating the impact of immigration policies on health status among undocumented immigrants: a systematic review. J Immigr Minor Health. 2015 Jun;17(3):947-70. doi: 10.1007/s10903-013-9968-4. Erratum in: J Immigr Minor Health. 2016 Feb;18(1):288. Rhodes SD [corrected to Rhodes SD]. PMID: 24375382; PMCID: PMC4074451.

^[2] Migration Policy Institute. Central American Immigrants in the United States. Migrationpolicy.org. Published May 2023. Accessed February 18, 2024. https://www.migrationpolicy.org/article/central-american-immigrants-united-states

^[3] Yamanis T, Morrissey T, Bochey L, Cañas N, Sol C. “Hay que seguir en la lucha”: An FQHC’s Community Health Action Approach to Promoting Latinx Immigrants’ Individual and Community Resilience. Behavioral Medicine. 2020;46(3-4):303-316. doi:10.1080/08964289.2020.1738320

^[4] Bucay-Harari L, Page KR, Krawczyk N, Robles YP, Castillo-Salgado C. Mental Health Needs of an Emerging Latino Community. The journal of behavioral health services & research. 2020;47(3):388-398. doi:10.1007/s11414-020-09688-3 

^[5] National Immigration Forum. Temporary Protected Status (TPS): Overview and Current Issues. Accessed February, 2, 2024. Available from: https://immigrationforum.org/article/fact-sheet-temporary-protected-status/#:~:text=The%20largest%20populations%20of%20TPS,York%20(23%2C168)%20metropolitan%20areas. 

^[6] HealthCare.gov. Immigration status & the Marketplace. Accessed May 16, 2024. Available at: https://www.healthcare.gov/immigrants/immigration-status/.

^[7] Supporting Health Equity and Affordable Health Coverage for Immigrant Populations: State-Funded Affordable Coverage Programs for Immigrants. Shvs.org. https://www.shvs.org/wp-content/uploads/2021/10/State-Funded-Affordable-Coverage-Programs-for-Immigrants.pdf. Published 2021. Accessed April 3, 2024.

^[8] Nelson B, Tu L and Sanford F. To Advance Health Equity For Patients With Limited English Proficiency, Go Beyond Interpreter Services. Health Affairs (Millwood). October 23, 2023. https://www.healthaffairs.org/content/forefront/advance-health-equity-patients-limited-english-proficiency-go-beyond-interpreter

^[9] American Immigration Council. District of Columbia Immigration Data. American Immigration Council. https://map.americanimmigrationcouncil.org/locations/district-of-columbia/. Published 2023. Accessed February 8, 2024.

^[10] Ortega AN, Rodriguez HP, Vargas Bustamante A. Policy dilemmas in Latino health care and implementation of the Affordable Care Act. Annu Rev Public Health. 2015;36:525-544. doi:10.1146/annurev-publhealth-031914-122421

^[11] Federally Qualified Health Centers. Official web site of the U.S. Health Resources & Services Administration. https://www.hrsa.gov/opa/eligibility-and-registration/health-centers/fqhc/index.html. Published 2022. Accessed April 10, 2022.

^[12] Yamanis T, Morrissey T, Bochey L, Cañas N, Sol C. “Hay que seguir en la lucha”: An FQHC’s Community Health Action Approach to Promoting Latinx Immigrants’ Individual and Community Resilience. Behavioral Medicine. 2020;46(3-4):303-316. doi:10.1080/08964289.2020.1738320

^[13] Kaiser Family Foundation. State Health Coverage for Immigrants and Implications for Health Coverage and Care. Kaiser Family Foundation website. Published October 1, 2021. Accessed May 16, 2024. Available at: https://www.kff.org/racial-equity-and-health-policy/issue-brief/state-health-coverage-for-immigrants-and-implications-for-health-coverage-and-care/

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*Rodrigo Stein is a resourceful public health professional with experience in program management, design and evaluation, advocacy, and strategic planning.