Undocumented individuals will become a larger share of the uninsured

As of March 2010, there were an estimated 11.2 million undocumented immigrants in the United States.  Currently, three in ten immigrants are undocumented, while only one in seven of the uninsured is an undocumented immigrant.  As there exists no consensus on immigration reform, undocumented individuals will gradually become a larger share of the uninsured population due to exclusion from all programs of the Affordable Care Act.

This study utilized data from the 2000-2008 Current Population Survey, a major source for health insurance coverage information in the US.  The authors compiled insurance coverage data, as well as information on age, race, sex, health status, income, education, and employment.  Immigration status was not a variable in the survey.  Instead, undocumented status was derived by subtracting individuals presumed to be in the country legally from the entire foreign-born population.  Foreign-born residents who arrived in the US before 1980, refugees, those granted political asylum, and those earning legal status under the Immigration Reform and Control Act were assumed to be legal.

This study focused on the non-elderly population.  The authors performed a descriptive analysis of trends in coverage and logistic regression models to isolate the impact of immigration status (native-born citizens, naturalized citizens, legal permanent residents, and undocumented immigrants) on the probability of having private coverage, public coverage, or being uninsured.

Between 1999 and 2007, the number of uninsured Americans increased by 6.7 million (39.3 to 46 million).  The number of undocumented immigrants increased by 1.8 million (4.9 to 6.7 million). Uninsured undocumented immigrants accounted for 27 percent of the increase in the uninsured during this period. While there was a 37.6 percent increase in undocumented immigrants, the native born population only increased by 5.9 percent. The growth of uninsured undocumented immigrants was due to overall population growth and not an overwhelming increase in their rates of uninsurance.

The distribution of coverage by immigration status revealed that almost three-quarters of citizens (native-born and naturalized) had private insurance. On the contrary, only slightly more than half of legal residents and slightly more than one-third of undocumented immigrants had private insurance.  After adjustment for various social factors, the authors determined that higher rates of uninsurance persist for the undocumented population, all else being equal.

As an example, the researchers compared insurance coverage among all people living below 133 percent of the federal poverty level ($27,465 for a family of 4 in 2007). There existed a similar rate of private coverage across all immigration types yet dramatic variations in the rate of uninsurance; nearly half (49.7 percent) of poor undocumented immigrants were uninsured while only 26.6 of poor native born citizens were uninsured. The major factor affecting uninsurance rates for people of different immigration statuses turned out to be public insurance coverage. Even at higher income levels (above 400 percent FPL or $82,600), undocumented immigrants were over three times as likely to be uninsured compared to native-born citizens (19.5 vs. 6.6 percent).

Commentary

The CBO estimates that that even after full implementation of the Affordable Care Act, 23 million will remain uninsured.  Undocumented immigrants will constitute a much higher percentage of this group by virtue of increasing coverage for citizens and legal residents.  As do many other provisions in US law, the ACA provides rights to native-born individuals that are not afforded to certain foreign-born individuals.  Such unequal treatment ignores an entire group of individuals who greatly impact the US health care system.  As in other forms of non-immigration law, the exclusion of undocumented immigrants from the ACA is a roundabout way of crafting anti-immigration policy.

US health law is riddled with anti-immigration policy.  In the 1990s, California passed (and eventually overturned) Proposition 187, which prohibited undocumented immigrants from public benefits, including health coverage. In 1993, the NIH Revitalization Act imposed an HIV travel and immigration ban requiring all immigrants to be tested for HIV.  The ban was lifted in January 2010.  The 2005 Deficit Reduction Act requires proof of citizenship for all Medicaid applicants.

While anti-immigration policy appears in health care law, American citizens are often the unspoken casualties of such attempts to exclude immigrants. For example, proof of citizenship has proven to be more of a burden on Medicaid eligible Americans, contributing to the “eligible but uninsured” category of the uninsured.

The US has pit immigration reform against health care reform.  If this country is truly committed to eliminating the problem of uninsurance as well as illegal immigration, it should seriously consider either a pathway to legal status or devise a way to deport all 11.2 million (and counting) undocumented people.  Either way, uninsured undocumented immigrants cannot simply be ignored.

Renée Volny is a physician who blogs at Policy Prescriptions.

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