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

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.

Figure 1.. Health Insurance Coverage and Annual Health Care Expenditure by Place of Birth

Graphs show data from before (2011-2013) and after (2014-2019) implementation of the Patient Protection and Affordable Care Act (ACA). The sample is restricted to adults aged 19 to 64 years in households with incomes below 138% of the Federal Poverty Level. Error bars are 95% CIs.

Figure 2.. Association of State Medicaid Expansion With Annual Health Care Expenditures of US-Born and Immigrant Adults Aged 19-64 Years, 2011-2019

Graphs show marginal estimates and 95% CIs derived from 2-part models. Sample is restricted to adults aged 19 to 64 years in households with incomes below 138% of the Federal Poverty Level. All models control for individual-level age, sex, race and ethnicity, educational attainment, marital status, family size, number of children, preexisting chronic condition, state unemployment rate, state gross domestic product, state fixed effects, and year fixed effects. Robust SEs are clustered on state of residence. Results are adjusted for Medical Expenditure Panel Survey sampling weights.

Figure 3.. Association of State Medicaid Expansion With Annual Health Care Expenditures, in Major Categories, of US-Born and Immigrant Adults Aged 19-64 Years, 2011-2019

Graphs show marginal estimates and 95% CIs derived from 2-part models. See the Figure 2 caption for sample and model specifications. Results are for the 3 largest expenditure categories, which account for 77% of the total health care expenditure.