Before the end of the year, the Obama administration is expected to announce that millions of undocumented immigrants will be able to lawfully stay in the United States. The new Congress may also take action on immigration reform legislation. Regardless of how it happens, any immigration policy change presents a good opportunity to revisit what has gone wrong with insurance coverage and health care for millions of immigrants, both undocumented and lawfully present, living and working in communities across the country.
A web of policy barriers to public and private insurance options effectively keeps millions of immigrant women and their families from affordable coverage and the basic health care—including sexual and reproductive health services—that coverage makes possible. Removing these barriers would advance the health and economic well-being of immigrant women, their families, and society as a whole. Most immediately, administrative steps advancing access for even some immigrants would be an important step forward. The case for doing so is compelling.
Restrictions on Coverage
Millions of immigrants currently face legal barriers to accessing the coverage and care they need. Many lawfully present immigrants are ineligible for coverage through Medicaid and the Children’s Health Insurance Program during their first five years of legal residency. Undocumented immigrants are largely barred from public coverage, and the Affordable Care Act (ACA) prohibits them from purchasing any coverage, subsidized or not, through its health insurance marketplaces.
Past immigration policy reforms—both executive and congressional—have failed to address immigrants’ health care needs. In 2012, the administration created the Deferred Action for Childhood Arrivals (DACA) Program, enabling many so-called DREAMers to lawfully remain in the United States. Although an important step forward, DACA falls short on health coverage; despite being lawfully present, those with DACA status are essentially treated as if they were undocumented and expressly carved out of nearly all public and private health coverage and affordability programs. Furthermore, the immigration reform bill passed by the Senate in 2013 largely failed to the address the legitimate health insurance and health care needs of our nation’s immigrants, denying those eligible for provisional status access to public coverage and the ACA’s subsidies.
The Case for Coverage
That expanding access to health coverage will advance the health and economic interests of immigrant women and their families—and the country they are part of—is clear. Immigrant women who are not U.S. citizens, especially those living below the poverty level, disproportionately lack health insurance coverage. Among women of reproductive age (15–44), 40 percent of the 6.6 million noncitizen immigrants are uninsured, compared with 18 percent of naturalized citizens and 15 percent of U.S.-born women (see Figure 1).
Of reproductive-age women living below the poverty level (a group in which immigrant women are overrepresented), 53 percent percent of noncitizen immigrant women lack health insurance—nearly twice the proportion of U.S.-born women. Further, only 28 percent of poor noncitizen women of reproductive age have Medicaid coverage, compared with 46 percent of those born in the United States.
Disparities in insurance coverage constrain immigrant women’s ability to obtain needed health care, including preventive sexual and reproductive health services. Lack of insurance is associated with reduced use of health services, especially among low-income women. Immigrant women are particularly likely to be young, low-income, and women of color—demographic characteristics linked to adverse sexual and reproductive health outcomes, including unintended pregnancy and STIs.
Given their heightened risk, it is especially concerning that immigrant women of reproductive age are particularly likely to have gone without any sexual or reproductive health care in the last year—in particular, only half (52 percent) of immigrant women at risk for unintended pregnancy received contraceptive care, compared with two-thirds (65 percent) of U.S.-born women.
Continuing to deny immigrant women and their families access to affordable coverage and care has significant health and economic consequences. Consistent contraceptive use is critical to helping women prevent unintended pregnancies, plan and space wanted pregnancies, and achieve their own educational, employment, and financial goals. Without coverage, immigrant women and couples may well be unable to afford the method of contraception that will work best for them, which is critical to realizing these benefits.
In addition, preventive sexual and reproductive health services are effective in helping women and couples avoid cervical cancer, HIV and other STIs, infertility, and preterm and low-birth-weight births—all while saving substantial public dollars. Notably, cervical cancer disproportionately afflicts and causes deaths among immigrant women, particularly Latinas and women in certain Asian communities, likely because many go without timely screenings.
The Ongoing Need for the Safety Net
Eliminating legal barriers to immigrants’ ability to access affordable coverage is in the best interest of immigrant women, their families, and our country as a whole. To translate coverage into access to care, the publicly supported providers and programs these women and so many others rely on for quality sexual and reproductive health services must be sustained.
Safety-net health centers that provide family planning services are an important source of care for immigrant women. Among those who receive contraceptive services in the United States, 41 percent of immigrant women go to a safety-net family planning center, compared with 25 percent of U.S.-born women. Of those relying on the safety net for contraceptive or other reproductive health services, federally qualified health centers are particularly important to immigrant women, who visit them about twice as often as other types of safety-net family planning providers.
Moreover, seven in ten immigrant women receiving family planning services at a publicly supported health center consider that provider to be their usual source for medical care. This is unsurprising given the cost and language barriers often experienced by immigrant women—issues that health centers are uniquely positioned to help women overcome.
The Title X national family planning program will continue to be critical to meeting the health needs of immigrant women who remain ineligible for coverage, regardless of any action to reform immigration policy. Unlike Medicaid and other federal means-tested benefit programs, Title X funds may be used to serve clients regardless of their immigration status. Indeed, 21 percent of all immigrant women who receive any contraceptive care get that care at a Title X–supported health center.
The Way Forward
The prospect of long-overdue policy action offers a chance to embrace the human needs, including health care, of immigrant women, men, and children. As a starting point, the Health, Equity and Access under the Law (HEAL) for Immigrant Women and Families Act of 2014, introduced by Rep. Michelle Lujan Grisham (D-NM), offers a model for restoring affordable health insurance coverage to lawfully present immigrants, including those granted DACA status.
Further, funding for grant programs such as Title X is vital to ensuring that both insured and uninsured immigrant women and their families can access needed family planning services from trusted community providers. And to ensure the quality of that care among the providers to whom immigrant women most often turn, the Health Resources and Services Administration—the federal agency that oversees the network of federally qualified health centers—should require these health centers to implement the federal government’s recently released recommendations on providing quality family planning services.
In sum, policymakers have the authority—and the responsibility—to narrow harmful coverage gaps and shore up important sources of care for sexual and reproductive health services and beyond.
Author’s note: This post is based on Guttmacher Institute research made possible by a grant from the Prospect Hill Foundation. The conclusions and opinions expressed, however, are those of the author and the Guttmacher Institute.