Hispanics Make Up Nearly Half the Nation's Uninsured [Governing]

Apr. 22—In Brief:

* Hispanic Americans are three times more likely than Anglos to lack health insurance. They are almost half of the nation's uninsured.

* A third of those without coverage are undocumented immigrants, although they are employed at higher rates than U.S.-born workers.

* Insuring the undocumented won't completely fill the coverage gap, but some states are expanding Medicaid programs to include them.

Nearly 1 in 5 Hispanic Americans don't have health insurance, a share almost three times greater than Anglos. They account for close to half of all those in the country who aren't covered. It might be tempting to pin this on immigration status, but that's an incomplete explanation.

The Center for Migration Studies estimates that there about 7.4 million undocumented immigrants of Hispanic origin in the U.S. Half of them don't have health insurance, but they make up only about a third of the total number without coverage in a Hispanic population of 65 million.

Emergency room care is the most expensive of all, but this is where people whose health problems have gone undiagnosed and untreated end up. "All those uncompensated emergency room bills are sure to be reflected in the next year's insurance prices," says Arturo Vargas Bustamante, a public health researcher and professor at UCLA. "It's an incredibly inefficient way of paying for health care."

The barriers to obtaining coverage are complicated and nuanced. Some are strictly tied to immigration status, others are not. The common denominator is the risk that being uninsured presents to these millions of people, their families and public health.

Policy and Politics

The current rate of 18 percent of Hispanics without coverage represents significant progress since 2010, when it was pegged at 33 percent. Coverage rates began to improve in 2014 when implementation of the Affordable Care Act (ACA) brought new options for those with low and moderate incomes. Medicaid expansion made it possible for more of the poorest to obtain coverage.

ACA's Medicaid expansion opened the program to adults with incomes up to 138 percent of the poverty level, which is now just over $20,000. Ten states have not adopted the expansion, including Texas, Florida and Georgia, all of which have significant numbers of uninsured Latino residents (see map).

Even in states where they might be eligible for Medicaid coverage, some Latinos are reluctant to apply due to uncertainty about immigration policy. Immigrants who are seeking to become lawful permanent residents can run into trouble on their path to citizenship if they are determined to be a "public charge," reliant on certain forms of government support. Technically, they could even be subject to deportation, though this is extremely rare. (Only one-tenth of one percent of deportations result from public charge determinations.)

For decades, Medicaid, Medicare and nutritional assistance programs were excluded from the forms of government aid that were considered in a public charge assessment. This exemption was ended by the Trump administration. That rule change was, in turn, revoked by the Biden administration in 2021, but the back and forth has created anxiety.

It's possible that a new administration could reverse current policy, especially at a time when immigration policy is so politically charged. Some Hispanics lawfully in the country worry that accessing health benefits might harm their long-term citizenship prospects.

In states where benefits are extended to them, the undocumented may fear that accepting them will make them targets. "Some of them are fearful of enrolling or disclosing their immigration status, even if the state guarantees that they are not going to share that information with the federal government," says Bustamante.

Language and Culture

Language is also a stumbling block. More than 1 in 10 people in the U.S. speak Spanish at home, and more than half of them have limited English proficiency. Physician Jessica Himmelstein investigated how this affects health-care use while a fellow at Cambridge Health Alliance. Hispanics with limited English proficiency were more than twice as likely to be uninsured than proficient English speakers.

Enrolling in health insurance can be daunting for anyone, Himmelstein says. Adding a language barrier on top of that makes things even harder. Misinformation about imagined risks of seeking coverage can spread among Spanish-language speakers who aren't reached by English-only health campaigns.

There can also be cultural misunderstandings. For some immigrants, health insurance is a totally new concept, compared to the way they accessed health care in their country of origin, Bustamante says. It may not be immediately apparent to them why they would need or want coverage, all the more so because recent immigrants tend to be in better health than the U.S.-born population. Overcoming these obstacles requires outreach that takes both language and culture into account.

Nine out of 10 undocumented Hispanic men are employed, as compared to 6 in 10 men born in the U.S. Overall, immigrants pay much more in taxes and insurance premiums than they receive in benefits from private insurers or the government.

Immigrants — most of all, the undocumented — aren't getting a "free ride," but are subsidizing a system that doesn't give back to them equitably. A study involving over 200,000 individuals concluded that immigrants "appear to subsidize the U.S. health-care financing system." In the year the researchers analyzed, immigrants contributed nearly $60 billion more than insurers or the government paid for their health care. Undocumented immigrants accounted for nearly 90 percent of this surplus.

Working, Not Covered

Across the U.S., Latino immigrants work disproportionally in jobs that are categorized as "essential" but for which employers aren't likely to provide health insurance benefits. These include such areas as construction, cleaning, grounds maintenance, food service, truck driving and personal care. Employers with fewer than 50 employees aren't required to provide health insurance. Close to half of all private sector jobs are at companies of this size.

Immigrants who are not in the country lawfully can buy private health insurance, but they can't get the lower rates available through state health insurance exchanges. Some California legislators are considering opening the state health exchange to undocumented residents.

This could help, but just like citizens, some may earn too much to qualify for exchange discounts, yet not enough to afford coverage that protects them against high out-of-pocket costs. Immigrants tend to be healthier than the norm for the U.S. population when they arrive, Bustamante notes, and may decide they don't need insurance. Some don't intend to stay in the U.S. indefinitely and see insurance as an unnecessary long-term commitment.

The Role of Medicaid

Access to care and preventive services is a mainstay of local health departments, says Lori Freeman, CEO of the National Association of County and City Health Officials. Immigrants and refugees are coming to more and more smaller and rural communities, requiring resources that aren't supported by investments in local systems.

Over the past decade, states that have adopted Medicaid expansion have seen broad returns on their investment. These include fewer emergency room visits and greatly reduced risk of catastrophic health expenditures.

At nearly 16 million, the Hispanic population in California is bigger than the entire population of all U.S. states, except four. About 2 million are undocumented immigrants. In January, the state began to offer them access to the state's Medicaid program, Medi-Cal. Oregon opened its program to undocumented residents last July.

It's been estimated that as many as 700,000 undocumented residents ages 26 to 49 could obtain full coverage as a result of the new Medi-Cal policy. Three out of 4 people in the U.S. who could gain coverage through Medicaid expansion live in Texas, Florida and Georgia. More than 4 million uninsured Hispanics live in these states.

This wouldn't be a cure-all. Given the fact that almost all undocumented immigrants are active in the workforce, a fair number likely earn too much to qualify for Medicaid. At $40,000 a year, the median construction worker salary is well over the income limit. It might be more cost-effective to open health exchanges to them.

Bustamante argues that California is making the right move at the right time, before more of its relatively young Latino population ages. "We buy insurance because we want to be protected against catastrophic health expenses," he says. "This is about the benefit in the long term, and the cost is negligible compared to the savings."

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