Cost of Public Health Insurance for US-Born and Immigrant Adults

Key Points

Question

What is the cost of providing public health insurance to immigrants in the US?

Findings

This serial cross-sectional study of 44 482 low-income, working-age adults found that increased insurance coverage from the Medicaid expansion accompanying the Patient Protection and Affordable Care Act was associated with statistically significantly higher health care expenditures for US-born but not immigrant adults. Providing insurance to immigrants costs the health care system less than half the corresponding cost for US-born adults ($3800 vs $9428 per person per year).

Meaning

These findings suggest that upon receiving public insurance, low-income immigrants’ health care utilization and cost remain low, whereas US-born adults’ health care utilization and costs increase, thus refuting the widely held belief that providing insurance to immigrants imposes a heavy fiscal burden.

Abstract

This cross-sectional study estimates the cost of providing public health insurance to US-born adults compared with those who immigrate to the US.

Abstract

Importance

The immigrant population in the US has low health insurance coverage. Surveys find that approximately one-half of the US population is opposed to public health insurance of immigrants, and there is a widely held belief that immigrants are a state fiscal liability.

Objective

To estimate the cost of providing public health insurance to immigrants in the US.

Design, Setting, and Participants

This serial cross-sectional study used restricted data from the 2011 to 2019 Medical Expenditure Panel Survey (and data from 2011-2020 in supplemental analyses). The data are nationally representative of the US civilian noninstitutionalized population. Participants included adults aged 19 to 64 years with family incomes below 138% of the Federal Poverty Level, the population that benefited from the Medicaid expansions. Data analysis was performed from November 2022 to August 2023.

Exposures

State Medicaid expansion.

Main Outcomes and Measures

The primary outcomes were insurance coverage, total health care expenditures, expenditures categorized by payment source (paid by self or family and paid by others), expenditures by major health care type (office based, inpatient, and prescription), and health care utilization (number of office-based visits, outpatient facility visits, emergency department visits, hospital discharges, dental care visits, home health clinician days, and prescription medicine refills). A difference-in-differences method was used to compare the health care cost and utilization by low-income, working-age US-born and immigrant adults in states that adopted the Patient Protection and Affordable Care Act (ACA) Medicaid expansions with the corresponding change in nonexpansion states before and after the policy implementation.

Results

Among the study sample of 44 482 individuals (mean [SD] age, 38.5 [14.0] years; 25 221 female individuals [56.7%]; 34 052 [76.6%] US born), 46% of immigrant adults (1953 participants) and 70% of US-born adults (9396 participants) had insurance coverage in the pre-ACA period. Medicaid expansions increased insurance coverage of both groups by 7 percentage points (95% CI, 3 to 11 percentage points). The resulting change in health care increased total expenditures (self-paid plus insurer paid) by $660 (95% CI, $79 to $1242) and insurer-paid expenditures by $745 (95% CI, $141 to $1350) per US-born adult. For immigrant adults, the corresponding changes in total ($266; 95% CI, −$348 to $880) and insurer-paid ($308; 95% CI, −$352 to $968) expenditures were small and not statistically significant. Estimates suggest that providing insurance to immigrants costs the health care system approximately $3800 per person per year, less than one-half the corresponding cost ($9428 per person per year) for US-born adults.

Conclusions and Relevance

These findings suggest that the direct cost of providing public health insurance to immigrants is less than that for the US born, and immigrants’ health care utilization, upon coverage, remains comparatively modest, thus refuting the notion that providing insurance to immigrants imposes a heavy fiscal burden.