How Immigration Status Shapes Access to Healthcare Across Borders

BY SOPHIE NGUYEN

Despite contributing significantly to public health systems, undocumented immigrants across the U.S. and Europe are systematically excluded from essential healthcare, revealing that immigration status is a core structural barrier to health equity. 

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Healthcare is recognized globally as a fundamental human right, yet access to it remains unevenly distributed. The United Nations’ Sustainable Development Goal three on Universal Health Coverage (UHC) demands that we leave no one behind and ensure equitable implementation regardless of immigration status.⁵ Undocumented immigrants contribute billions of tax dollars a year; their contributions strengthen the viability of public health programs like Medicare and Medicaid in the United States.³ Undocumented immigrants, however, cannot reap the same benefits, and are persistently excluded from healthcare systems in both the United States and Europe. Thus, undocumented status functions as a negative structural determinant of health, where access is variable across states and countries. 

Systemic Barriers to Healthcare in the United States 

In the United States, federal legislation explicitly excludes undocumented immigrants from nearly all public health programs. The Personal Responsibility and Work Opportunity Reconciliation Act and the Affordable Care Act (ACA) bar undocumented immigrants, including Deferred Action for Childhood Arrivals (DACA) recipients, from enrolling in Medicaid, Medicare, and the Children’s Health Insurance Program (CHIP) or purchasing insurance on federal marketplaces.¹¹ The Emergency Medical Treatment and Labor Act (EMTALA) guarantees access only to emergency services, meaning most preventive, reproductive, and mental health care remains inaccessible unless paid out-of-pocket or provided through limited local programs.¹¹ As a result, 50% of undocumented immigrant adults reported being uninsured compared to 6% naturalized citizens and 8% US-born adults as of 2023.⁹ 

The exclusion persists despite the economic contributions of undocumented immigrants. A 2024 report by the Institution on Taxation and Economic Policy found that undocumented workers contributed $96.7 billion in federal, state, and local taxes in 2022, with $6.4 billion funding Medicare.⁴ In 2023, the federal government only spent 0.4% of total Medicaid expenditures on emergency services for undocumented patients, the only care that is covered by their own tax dollars.³ 

Alongside navigating legal restrictions, fear and stigma further prevent undocumented individuals from seeking any care. Many immigrants avoid hospitals or clinics out of concern that personal information will be shared with Immigration and Customs Enforcement (ICE). As of July 9, 2025, to September 9, 2026, the Centers for Medicare & Medicaid Services (CMS) entered an agreement with the Department of Homeland Security (DHS) to allow ICE temporary access to Medicaid enrollee data, an alarming move that deters both nonlegal and legal immigrants from seeking care.¹² 

In response, a multistate lawsuit consisting of California, Connecticut, New York, and other states has created an injunction currently in effect to block DHS from using Medicaid data for immigration enforcement.¹² Similarly, in states like Texas, policies have further intensified fear. An executive order effective November 2024 requires hospitals to ask patients about their immigration status, despite everyone being entitled to emergency medical care regardless of immigration status, creating confusion and distress among immigrant families.¹⁰

While patients are entitled to the right to refuse to answer, and they do not face any consequences for declining to answer, the lack of transparency further deters vulnerable populations from seeking care.  

Policies Across Borders 

Across the United States, access to healthcare for undocumented immigrants varies dramatically by state. California has adopted some of the most inclusive policies, expanding Medi-Cal coverage to all children and most adults regardless of status.¹² Pregnant women and children receive full coverage, while adults will continue to have access to emergency and dental services even as premiums come into effect starting July 1, 2026.¹² In contrast, Texas and other restrictive states provide only emergency care, perpetuating regional inequities and worse health outcomes among immigrant populations.¹⁰ 

Notably, New York City has emerged as a national model through its NYC Care program, which provides low- or no-cost services from primary care to routine screenings to all residents, regardless of status or ability to pay.² For instance, around 90,000 members were recommended for cancer screenings, a luxury for patients prior to the creation of this initiative.² The program serves the lowest-income community members, with 65% living below the federal poverty line, demonstrating the feasibility and public health benefits of inclusive local initiatives.² 

Beyond the United States, Europe presents a similarly uneven landscape. While international law, including Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) and Article 24 of the Convention on the Rights of the Child (CRC), guarantees healthcare “without discrimination,” national implementation varies widely.⁶ In France, the State Medical Aid (AME) program provides healthcare to undocumented migrants, but due to its application and non-automatic nature, it leaves more than one-third of eligible individuals uncovered even after five years of residence.⁷ 

Sweden and Finland allow some access to maternity and chronic care, yet undocumented women still face significantly higher rates of preterm birth, infection, and inadequate prenatal screening.¹³ In contrast, paragraph 87 of the German Residence Act requires public authorities, including social welfare offices and hospitals, to report undocumented individuals to immigration enforcement.¹ As a result, many undocumented residents forgo medical care altogether, seeking help only from volunteer doctors or NGOs in emergencies. Due to these limitations, coalitions led by the Doctors of the World have been campaigning against Germany’s policies to allow undocumented immigrants to access healthcare without mandated reporting to immigration enforcement.¹ 

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Evidence shows that exclusionary systems are counterproductive. Studies across Europe suggest that expanding access to primary and preventive care for undocumented migrants reduces emergency department use.¹³ Furthermore, extending coverage supports reducing the spread of infectious diseases like tuberculosis and measles in the general population, thus reducing overall healthcare spending.¹³ Healthcare access for undocumented populations is not a financial liability but a public health necessity. 

Community Perspectives 

Behind policy debates and fiscal costs are the lived experiences of undocumented patients and healthcare providers. Clinicians frequently describe moral distress when forced to choose between following restrictive policies and providing ethically mandated care. In the United States, healthcare providers have reported scenarios in which undocumented parents of hospitalized children must decide whether to remain with their child, risking detection by Border Patrol, or send them alone across internal checkpoints to receive care.⁸ Similarly, in Europe, a man in Germany was denied a heart operation to avoid a second heart attack after losing his residency status, and a woman was diagnosed with late-stage breast cancer after years of avoiding hospitals out of fear of deportation.¹ 

Such experiences reveal how immigration status not only limits physical care but also harms mental well-being. Chronic fear, anxiety, and depression are disproportionately prevalent among undocumented populations, where studies in Sweden and Switzerland report that undocumented migrants report higher rates of post-traumatic stress disorder (PTSD) and chronic illnesses, exacerbated by unstable living conditions, exploitation, and lack of continuity in care.¹³ 

Conclusion 

Across both the U.S. and Europe, a consistent pattern emerges: the more tightly healthcare is tied to immigration enforcement, the worse the health outcomes for undocumented populations. Inclusive and community-based care models like NYC Care, France’s AME, and California’s Medi-Cal expansion demonstrate measurable improvements in coverage, disease prevention, and community trust. The fear that providing healthcare to undocumented migrants acts as a “pull factor” for migration is not supported by evidence, with research showing that migration decisions are driven by violence, economic instability, and family reunification, not healthcare availability.¹³ Moreover, inclusive health policies strengthen public health security and foster economic growth through the contributions of immigrants. 

Undocumented status functions as a structural determinant of health across borders, where legal and political barriers result in moral and practical failures, including preventable deaths, untreated illnesses, and psychological torment. To move toward genuine Universal Health Coverage, nations must separate healthcare access from immigration enforcement, invest in community-based health systems, and train providers to deliver culturally competent care without fear or bias.⁵ Expanding healthcare to the undocumented strengthens not only the health of marginalized individuals but also the health of entire societies. 

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References

1. Aalto-Setälä, S. Germany: the fight against obligations to denounce undocumented migrants. PICUM https://picum.org/blog/germany-the-fight-against-obligations-to-denounce-undocumente d-migrants/ (2024). 

2. About NYC Care. NYC Care https://www.nyccare.nyc/about/. 

3. Artiga, S. Less than 1% of Total Medicaid Spending Goes to Emergency Care for Noncitizen Immigrants. KFF 

https://www.kff.org/quick-take/less-than-1-of-total-medicaid-spending-goes-to-emergen cy-care-for-noncitizen-immigrants/ (2025). 

4. Davis C. et al. Tax Payments by Undocumented Immigrants. ITEP https://itep.org/undocumented-immigrants-taxes-2024/. (2024) 

5. Goal 3: Ensure healthy lives and promote well-being for all at all ages. United Nations Sustainable Development https://www.un.org/sustainabledevelopment/health/. 6. Hintjens, H. M., Siegmann, K. A. & Staring, R. H. J. M. Seeking health below the radar: Undocumented People’s access to healthcare in two Dutch cities. Social Science & Medicine 248, 112822 (2020). 

7. Jusot, F. Access to State Medical Aid by Undocumented Immigrants in France: First Findings of the “Premiers Pas’ Survey. 

8. Kellett, A. Sick or injured undocumented immigrants in South Texas face a choice: Medical care or deportation. Vital Record 

https://vitalrecord.tamu.edu/sick-or-injured-undocumented-immigrants-in-south-texas-fa ce-a-choice-medical-care-or-deportation/ (2025). 

9. Key Facts on Health Coverage of Immigrants. KFF https://www.kff.org/racial-equity-and-health-policy/key-facts-on-health-coverage-of-im migrants/ (2025). 

10. New Texas executive order requires hospitals to ask about immigrant status. Here’s what it means for Texas children and their families. Children’s Defense Fund https://www.childrensdefense.org/blog/texas-hospitals-are-now-required-to-ask-patients about-their-immigration-status/. 

11. Noncitizens’ Access to Health Care. Congress 

https://www.congress.gov/crs-product/R47351. (2024).

12. Services, D. of H. C. Medi-Cal-Immigrant-Eligibility-FAQs. https://www.dhcs.ca.gov/keep-your-Medi-Cal/Pages/Medi-Cal-Immigrant-Eligibility-FA Qs.aspx. 

13. Stevenson, K. et al. Universal health coverage for undocumented migrants in the WHO European region: a long way to go. Lancet Reg Health Eur 41, 100803 (2024).