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Fact check: How do state-level programs (California, New York) affect per-person healthcare costs for undocumented immigrants?
Executive Summary
California and New York’s state-level programs expand access to care for undocumented immigrants but do not create a uniform per-person cost picture: state-funded coverage reduces uninsured rates and shifts some costs from uncompensated care to structured payments, while federal restrictions and population heterogeneity leave many undocumented people uninsured and complicate per-capita cost comparisons [1] [2] [3]. Estimates from cross-state research suggest insured immigrants often generate lower annual public insurance costs than US-born adults, but state-specific program design, eligibility limits, and potential federal funding threats materially alter net fiscal impacts and per-person expenditure calculations [4] [5] [6].
1. Why California’s expansion changes the uninsured math — but not everyone’s costs
California’s decision to expand Medi-Cal to more low-income adults, including targeted coverage for some undocumented residents, lowers the state’s overall uninsured population and shifts spending away from emergency and uncompensated care toward routine covered services. Reports from 2023 analyzed by state research centers find the Medi-Cal expansion significantly reduces uninsured counts but still leaves roughly 500,000+ undocumented residents without affordable coverage options due to federal eligibility limits and enrollment barriers [1] [2]. That means per-person costs calculated across all undocumented residents can appear to fall because higher-cost emergency-only care is replaced by lower-cost primary and preventive services for those who enroll; however, per-person costs among the remaining uninsured may remain high because they continue to rely on emergency services and safety-net clinics, which are costlier on a per-visit basis and funded differently.
2. New York’s approach and the challenge of direct per-capita comparisons
New York offers more generous sub-state and local programs than many states, providing coverage pathways for certain undocumented populations, but state and city programs vary in scope, eligibility, and benefit design, making direct per-person cost comparisons to California fraught. Public-facing summaries and immigrant health guides indicate multiple coverage options exist in New York City, yet these materials do not translate into a single per-capita expenditure figure and often omit undocumented-specific utilization patterns [7]. When researchers study Medicaid expansion effects broadly, they examine aggregate expenditures for immigrant groups versus US-born adults, but those studies typically do not isolate undocumented people, so policymakers must infer likely impacts from related immigrant data rather than rely on a precise, documented per-person cost for undocumented populations [6].
3. Evidence that insured immigrants cost less than US-born enrollees — and why that matters
Comparative research finds that providing public insurance to immigrants tends to generate lower annual expenditures per enrollee than for US-born adults, with one analysis indicating immigrant public insurance costs were less than half of corresponding US-born costs, around $3,800 per person annually [4]. This suggests state-funded programs that enroll undocumented immigrants could be fiscally manageable on a per-person basis and may reduce uncompensated care burdens. Yet this aggregate finding masks important variation: age, health status, family composition, and prior access to care all influence utilization. States with concentrated populations of older or higher-need undocumented residents could see higher per-person costs than those with younger, healthier immigrant cohorts, so extrapolating a single national per-person estimate to California or New York risks mischaracterizing true state fiscal effects.
4. The RAND tool and KFF warnings: scenario planning and political risk
Policy tools and state-by-state estimates help project coverage costs, but model outputs depend heavily on assumptions about enrollment, utilization, and federal policy stability. RAND’s ACCESS estimator offers state-level scenarios for immigrant coverage costs but explicitly excludes speculative federal policy changes, limiting its predictive certainty [3]. Conversely, KFF analysis warns that proposed federal penalties for state-funded immigrant coverage could trigger substantial federal funding losses, creating fiscal risks for states that rely on federal matching funds and leading some states to design “trigger” mechanisms or reversible programs [5]. Those political and fiscal contingencies mean per-person cost projections must account for potential shifts in federal support and the possibility that states may change eligibility or benefits in response to federal actions.
5. Bottom line for policymakers: numbers are directionally useful but not definitive
Taken together, the evidence shows state programs in California and New York reduce uncompensated care and can lower average per-person public spending for immigrants who gain coverage, while also exposing fiscal uncertainty for remaining uninsured and program funding sources [2] [4]. Filling the information gap requires more granular, documentation-status-specific utilization and cost data and scenario planning that incorporates enrollment, benefit design, and potential federal policy shifts [3] [5]. Policymakers should treat headline per-person cost estimates as informative directional signals rather than definitive metrics and plan for both savings from preventive care uptake and contingencies tied to federal financing changes.