María Sánchez immigrated to the Chicago area from Mexico about 30 years ago. He is now 87 years old and still living in the United States without authorization. Like many long-time immigrants, she has worked and paid taxes, including Medicare taxes, all that time.
But Sánchez never had health insurance and when he turned 65 he couldn’t sign up for Medicare. You have never had preventive care or screenings. No physical exams. No cholesterol controls. No mammograms.
“Nothing, nothing, nothing,” he said in an interview conducted in Spanish. Nothing, nothing, nothing.
When she became ill, she delayed seeking care until she was so sick that she was hospitalized twice with pneumonia. It finally gained coverage last year under a historic Illinois program for non-legally resident seniors that went into effect in December 2020.
Democratic-led states, like Illinois, are increasingly opening public insurance programs to immigrants who lack permanent legal status. A dozen had already covered the children; even more provided prenatal coverage. But more states now cover adults living in the country illegally, and some are gradually adding coverage to seniors, who are more expensive and harder to sell politically than children.
The expansions recognize the costs that patients living here illegally can impose on hospitals. But the policies are under heavy attack from former President Donald Trump and other Republicans seeking to make his opponent, Vice President Kamala Harris, the face of reckless immigration policies.
Republicans point to Harris’ home state’s expansion of Medi-Cal coverage to immigrants of all ages, regardless of their legal status, saying it comes at the expense of American citizens.
It’s a common Trump complaint. “She’ll go around saying, ‘Oh, Trump is going to do bad things to Social Security,’” he said of Harris at a Sept. 13 press conference. “No, it will because it will put these illegal immigrants on Social Security, on Medicare, and it will destroy those programs, and people will have to pay.”
Harris’ choice of Minnesota Gov. Tim Walz as her running mate has added fuel to Republican attacks at the intersection of immigration and health policy.
Under a law signed by Walz, immigrants living illegally in Minnesota will be able to get health coverage starting next year through the state’s MinnesotaCare program for low-income people who are not eligible for Medicaid.
The issue is a priority for some Americans. At an Oct. 10 town hall in Las Vegas, a Univision event host identified as Ivett Castillo asked Harris what her administration would do about health care for people like her mother, who had immigrated from Mexico without authorization. Many years ago, he worked with her. his entire life, and died this year without ever receiving “the kind of care and service he needed or deserved.”
“What are your plans, or do you have plans, to support that subgroup of immigrants who have been here all their lives, or most of them, and have to live and die in the shadows?” -Castle asked.
Harris highlighted her past support for a path to citizenship for unauthorized residents and a bipartisan border security bill that Senate Republicans killed earlier this year at Trump’s behest.
“This is an example of the fact that there are real people who are suffering from the inability to put solutions before politics,” Harris said.
Even without those policies, immigrants can get free or affordable primary care at community clinics across the country, assuming they know it’s an option and feel safe in the facilities. But primary care cannot address all medical needs, especially as people age and develop more complex health problems and chronic diseases. That’s why immigrants often rely on charity care, go into debt or, like Sánchez, scrim. Some even return to their home countries to receive care.
Illinois, where Sánchez obtained coverage, was a pioneer in extending insurance coverage to unauthorized immigrants. Now, six states and the District of Columbia, all led by Democrats, cover at least some older, low-income immigrants under Medicaid or the Affordable Care Act waivers. Minnesota next year will become the seventh. State funds must be used for expansions, since federal dollars generally cannot cover people who lack legal status.
It remains to be seen whether and how quickly more states will follow this trend, and if Trump wins the White House, his administration would likely try to thwart the trend, given that he has promised mass deportations. Coverage for all immigrants remains a tough sell economically and politically, and noncitizens cannot express their gratitude at the ballot box. Immigrant health initiatives in several other states have failed or been scaled back.
Maryland, for example, decided to open its Obamacare exchange to people living in the state illegally, starting in 2026, but without taxpayer subsidies for their premiums.
Still, there is enough activity in the states to make immigrant health advocates believe something has changed. The severity of the pandemic and its uneven toll helped build support for covering older immigrants, said Lee Che Leong, senior policy advocate at Northwest Health Law Advocates in Washington state.
“People are looking around and realizing that our health is interconnected, both globally and locally,” Leong said. “The pandemic really brought home that to us, when you look at the disparities between who got Covid, who was exposed to Covid, and who died from Covid.”
Access to health care in the United States has long been an obstacle for immigrants, even those who are in the country legally. People with green cards must wait five years to get coverage under Medicaid or other government health programs. Some older green card holders have to pay additional premiums for Medicare Part A (the part that covers hospital care) if they have not worked for at least 10 years in the US.
The new state health programs close those gaps, said Shelby Gonzales, vice president of immigration policy at the Center on Budget and Policy Priorities.
In July, Washington state began covering low-income immigrants in a Medicaid-like program called Apple Health Expansion, using a federal waiver. Registration is limited and the program filled quickly, but some spots were reserved for people 65 and older, Leong said. Earlier this year, the state opened its Obamacare exchange to immigrants living in the United States illegally.
Oregon and Colorado now also offer some coverage to people in their states who lack legal status, although Colorado’s program did not attract many older immigrants, according to data recently presented to the state’s Affordable Care Act exchange oversight committee.
New York has covered immigrant children who lack legal residency for years, and the state’s Medicaid program opened in January to all adult immigrants regardless of status. About 25,000 people signed up in the first four months, according to New York Medicaid Director Amir Bassiri.
Back in Illinois, María Sánchez said her new coverage has changed her life and possibly saved her life. His bouts of pneumonia were severe, in part because he had delayed care. After his second hospitalization, he required follow-up cardiac care. The hospital did not charge him for his stay.
But now, with her”medical card”—your medical card—you can see a doctor. His heart condition is under control. You have seen a dentist. They are going to remove his cataracts.
“With my medical card I have peace of mind,” Sánchez said.
Illinois has gradually added coverage for other age groups; In the summer of 2022, he reduced eligibility to 42 years. That means immigrants like Gaby Piceno, 45, can age more healthily.
“I don’t have to worry anymore,” she said, referring not only to herself but to her family.
But expanding coverage has cost more than Illinois projected. People like Sánchez and Piceno, who are already registered, are still covered, but this year new registrations were suspended. More people signed up than expected, and many continued to seek care in more expensive hospital emergency departments rather than doctors’ offices, said acting state Insurance Commissioner Ann Gillespie, who was a state senator. Illinois when the program was established.
The state is now moving covered immigrants to Medicaid managed care plans, hoping to reduce the cost over time.
