How do immigrant legal status and insurance coverage impact emergency department use and preventable hospitalizations?
Executive summary
Immigration legal status and insurance coverage shape where and when immigrants seek care: uninsured and non‑citizen immigrants are more likely to lack a usual source of primary care and to rely on emergency departments (EDs), while programs like Emergency Medicaid and EMTALA require hospitals to stabilize emergencies regardless of status [1] [2]. Studies and program evaluations show linking undocumented patients to primary care reduces ED visits (21% drop in one NYC program) and uninsured immigrants report much higher rates of having no usual source of care (42% vs. 13% for insured immigrants) [3] [1].
1. Legal status determines eligibility but EDs remain a medical safety net
Federal law generally bars unauthorized immigrants from Medicaid, Medicare, and ACA Marketplace coverage, while some lawfully present immigrant categories can access programs with restrictions; states and federal policy changes have recently tightened or expanded which lawfully present groups are eligible [4] [5] [6]. Regardless of eligibility, hospitals with EDs must screen and provide stabilizing treatment under EMTALA, and Emergency Medicaid reimburses emergency care for people who would qualify for Medicaid except for immigration status — a safety‑net payment that persisted even amid 2025 budget fights [2] [7].
2. Insurance gaps push people toward EDs and delay routine care
Survey and research data show uninsured immigrant adults are far more likely to lack a usual source of care and to delay or skip care: uninsured immigrants reported being about three times as likely to lack a usual non‑ED source of care (42% vs. 13%) and to have gone a year without a doctor visit (52% vs.18%) [1]. Academic reviews find immigrants may use EDs for reasons beyond urgency — convenience, no‑paper barriers, language and administrative simplicity — producing higher ED reliance when primary care access is limited [8] [9].
3. Evidence that primary care access reduces preventable ED use
Intervention studies demonstrate causality: a New York City program that helped nearly 2,500 undocumented immigrants get appointments at safety‑net primary care clinics produced a 17% increase in primary‑care visits and a 21% reduction in ED visits, saving roughly $200 per person in ED costs during the 14‑month study period [3]. The academic literature similarly links better access to primary care with lower inappropriate ED utilization among immigrant populations [8].
4. Policy shifts in 2025 raise coverage loss risks, with downstream ED consequences
The 2025 tax and budget law and related federal actions are estimated to make about 1.4 million lawfully present immigrants uninsured and to restrict ACA and Medicaid access for many groups; KFF and CBO analyses predict coverage losses that could shrink risk pools and raise premiums, while making immigrants more likely to lack non‑ED sources of care [6] [5] [10]. Analyses note uninsured immigrants are much likelier to use EDs as primary care, implying policy‑driven coverage losses could increase preventable ED and inpatient use [1] [10].
5. Funding and reimbursement changes alter hospital incentives and capacity
Although EMTALA preserves emergency access, the federal share and reimbursements for Emergency Medicaid and other programs have been politically contested: some 2025 legislative actions reduced federal funding shares and shifted costs to states or providers, which fact‑checkers note does not remove the legal requirement to treat emergencies but may change who pays and could strain hospital finances [2] [7]. Providers and state programs that previously extended coverage to immigrants are being scaled back in several states, which could increase uncompensated care and alter where patients seek treatment [11] [12].
6. Competing perspectives: public‑health logic vs. political framing
Public health organizations and researchers argue that extending coverage and primary‑care access reduces costly ED use and prevents hospitalizations — the empirical literature and program evaluations support this [3] [1]. Policymakers pressing for cuts counter that EMTALA and Emergency Medicaid already protect emergency care and that many legislative changes target lawfully present immigrants’ program eligibility rather than undocumented people; fact‑checking groups point out some political claims (e.g., that undocumented immigrants will gain ACA benefits) are misleading since federal programs require lawful status [7] [13].
7. Limits of the evidence and remaining questions
National surveys and cross‑sectional studies document associations between status, insurance, and ED use but cannot always isolate documentation categories (MEPS/NHIS do not include documentation status), and longitudinal causal evidence is limited beyond targeted intervention studies [9]. Available sources do not mention granular national estimates tying recent 2025 policy changes directly to measured increases in preventable hospitalizations — modeling and state‑level reports point to risk but do not yet quantify national hospitalization changes post‑policy [9] [6].
Conclusion: The weight of evidence in peer‑reviewed studies, program evaluations, and policy analyses is consistent: restricted legal status and lack of insurance push immigrants toward EDs and away from preventive and primary care, while better access to primary care reduces ED reliance; EMTALA and Emergency Medicaid protect emergency treatment, but recent policy shifts that reduce coverage eligibility or funding create fiscal and access pressures that can increase preventable ED visits and uncompensated hospital care [3] [2] [6] [1].