What state programs provide health care to undocumented immigrants and which states pay most (2023-2024)
Executive summary
States have increasingly created state-funded alternatives to federal programs to give undocumented and other noncitizen immigrants access to health coverage: examples include full state-funded Medicaid-like programs in California, Oregon, Illinois and New York, state marketplace subsidies in Colorado and Washington, and targeted programs for seniors or pregnancy-related care in other states [1] [2] [3]. The largest measurable state spending in 2023–2024 appears in Illinois’ Health Benefits programs (hundreds of millions annually) and California’s broad Medi‑Cal expansions that reached hundreds of thousands of beneficiaries, while newer marketplace‑subsidy approaches in Colorado and Washington are significant but more capped and constrained by funding [4] [1] [5].
1. What programs exist: full state-funded Medicaid-like coverage and age- or population-targeted expansions
A growing set of states now uses wholly state dollars to extend Medicaid-like coverage to immigrants excluded from federal programs: California, Oregon, New York, Illinois and several others have created programs that explicitly cover income‑eligible adults regardless of immigration status or that extend full-scope Medi‑Cal to specific age groups of undocumented adults [1] [6] [7]. Some states opted for targeted, federally allowable routes — for example, states that cover prenatal care or use the “unborn child”/FCEP CHIP option limit coverage to pregnancy‑related services, while other states have opened full-scope coverage for children or seniors [3] [8]. Legal and advocacy trackers such as NILC map these variations state‑by‑state because eligibility rules differ markedly by age, service scope, and funding source [8].
2. Marketplace enrollment plus state subsidies: Colorado and Washington as prototypes
Two recent, high‑profile approaches use state marketplaces with state funds to subsidize private plans for undocumented residents: Colorado’s OmniSalud program subsidized plans and in 2024 funded assistance for up to 11,000 people and earlier offered premium subsidies for incomes up to 300% FPL; Washington secured a Section 1332 waiver to let undocumented people enroll through its Healthplanfinder and planned state premium subsidies up to 250% FPL, though federal law bars federal premium tax credits for undocumented residents [5] [7] [3] [2]. Demand has outstripped supply in Colorado—the 2024 enrollment cap was hit in days—illustrating both demand and the fiscal limits states place on these subsidy programs [5].
3. Who is spending the most (2023–2024): Illinois and California as measurable big spenders
Illinois publicly reports large fiscal outlays: in FY24 Illinois spent $487 million administering its Health Benefits for Immigrant Adults (HBIA) program and combined HBIA/HBIS spending reached $682 million in FY24, with additional FY25 spending reported through December 2024 [4]. California’s expansion to older adults and to ages 26–49 in January 2024 put hundreds of thousands on Medi‑Cal (about 286,000 older Californians were reported receiving full‑scope Medi‑Cal after that expansion), signaling substantial program costs even when exact statewide line‑item totals aren’t provided in these excerpts [1]. Other states’ programs—Oregon’s July 2023 expansion, New York’s targeted elderly coverage, and Washington’s capped enrollment—represent meaningful fiscal commitments but are often smaller or more capped than Illinois’ explicit FY24 expenditures [1] [3].
4. Limits, caps, and funding volatility: what the reporting highlights
Most state efforts come with caps, enrollment pauses, or sunset risks: Colorado capped OmniSalud assistance and reached its enrollment limit; Washington’s 1332 waiver and a 2024 expansion were later paused or limited due to funding constraints; California has signaled future pauses and benefit changes beginning 2026–2027 as policymakers respond to budget pressures [5] [1]. Policymakers and budget watchdogs note that these programs depend on state legislative choices and one‑time funding sources, so fiscal exposure and program scale can change rapidly [1] [2].
5. Political and policy context: benefits, critiques, and data gaps
Advocates frame state expansions as public‑health investments that reduce uncompensated care; critics argue they strain budgets and may create political backlash — reporting documents both the public‑health rationale and the political critique about fiscal burden and incentives [3] [9]. Reported per‑person health expenditures for immigrant groups tend to be lower than for U.S.-born populations in national studies, a fact cited in Congressional summaries and research that complicates cost narratives but does not negate budgetary impacts of large state programs [10]. Precise national ranking of “which states pay most” is limited by inconsistent public reporting, but Illinois’ FY24 figures and California’s large beneficiary counts make them two of the most financially significant state programs in 2023–2024 based on available sources [4] [1].