Health care insurance coverage for aliens, especially those who are categorized as unauthorized aliens (i.e., undocumented) is complex and shaped by federal rules on eligibility as well as differences in state policies and benefits. Part of the confusion and complexity is due to the fact that, at any point in time, no one knows how many unauthorized aliens are in the United States, what countries they are from, when they arrived, where they reside, and what their demographic, family, and other characteristics are. Nonetheless, in 2012, an estimated 11.7 million people in the United States were considered to be undocumented and living illegally in the United States. Nine states house 70% of the illegal immigrant population in the U.S.: Arizona, California, Florida, Georgia, Illinois, New Jersey, North Carolina, New York, and Texas.
There are two opposing views about how to manage unauthorized aliens. Interestingly, both have the same goal: to decrease the number of aliens in the country. One view focuses on requiring or encouraging unauthorized aliens to leave the country. Those who support this approach argue that these individuals are in the United States in violation of the law, their presence takes jobs away from Americans, and they may threaten national security.
The second view does not characterize unauthorized aliens in the United States as lawbreakers, but rather as contributors to the economy and society at large. They advocate granting qualifying unauthorized aliens various benefits, including an opportunity to obtain legal status.
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), provides that only “qualified aliens” are permitted access to federal and state public benefits, including Medicaid. A “qualified alien” is one who falls into one of the following nine categories:
Aliens lawfully admitted for permanent residence
- Refugees admitted
- Asylees admitted
- Cuban or Haitian entrants
- Aliens granted parole
- Aliens whose deportation is being withheld
- Aliens granted conditional entry
- Battered aliens
- Victims of a severe form of trafficking.
Under the PRWORA, aliens who do not fall into the categories above are considered “non-qualified aliens.” These individuals can receive only limited federal and state public benefits. However, they may receive Medicaid benefits for care and services for the treatment of an emergency medical condition (excluding organ transplants), provided that they meet all other general Medicaid requirements except those related to immigration status.
“Emergency medical condition” is defined as a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in 1) placing the patient’s health in serious jeopardy, 2) serious impairment to bodily functions, or 3) serious dysfunction of any bodily organ or part. Although the PRWORA severely limits what public benefits a state can provide to non-qualified aliens, it does allow states to provide additional benefits.
Medicaid-funded dialysis services
Every state has enacted some sort of emergency Medicaid program. While states are constrained by federal law in their ability to provide public benefits to certain types of unauthorized aliens, all states provide them coverage for emergency medical services. Program benefits and eligibility vary across the states, with most using the essential definitions and restrictions from federal law. States can provide state-only-funded assistance to unauthorized aliens, and this provides the flexibility for states to offer more benefits, including outpatient dialysis. States that currently offer coverage of outpatient dialysis for non-qualified aliens through their emergency Medicaid programs are Arizona, California, Delaware, District of Columbia, Florida, Illinois, Massachusetts, Minnesota, New York, North Carolina, Virginia, and Washington. Benefits vary. Some cover just the dialysis treatments but no medications. Some do not cover dialysis access- related procedures.
In addition to the state emergency Medicaid programs listed above, some states offer insurance coverage of outpatient dialysis for unauthorized aliens through state risk pools. Prior to the Affordable Care Act (ACA), 35 states had high-risk insurance pools. As of the end of 2014, all but 17 states have shut down their risk pools and most of the remaining ones have limited their plans or are closed to new enrollment due to insurance options available now through state health insurance exchanges. The states that currently offer individual comprehensive plans for unauthorized aliens who meet state residency requirements include Alaska, Iowa, Kentucky, Maryland, New Mexico, and Wyoming. Some have lifetime maximums, and waiting lists, pre-existing waiting periods and/or high premiums, sometimes making these programs inaccessible. While unauthorized aliens are not eligible for any of the Affordable Care Act (ACA) provisions, lawfully present aliens who have been in the United States at least five years are eligible for Medicaid expansion and for subsidies to purchase insurance at the new state health insurance exchanges.
Regardless of one’s view on unauthorized aliens and health care benefits, states will continue to wrestle with the constraints imposed by federal law and the types of benefits they are willing to provide to this population through state funding.
Andorra Bruno, Unauthorized aliens in the United States: Policy discussion, Congressional Research Service, May 8, 2014
Emergency Medicaid for Non-Qualified Aliens, Violence Against Women Office, Office of Justice Programs, U.S. Department of Justice, September 17, 2007
Karina Fortuny and Ajay Chaudry, ASPE Issue Brief, Overview of Aliens’ Eligibility for SNAP, TANF, Medicaid, and CHIP, March 2012
Louise Norris, Health insurance and high-risk pools, Federal pool and state-sponsored programs, http://www.healthinsurance.org/obamacare/risk-pools/, August 28, 2014