Fact check: Do states with high undocumented immigrant populations have higher emergency healthcare costs?

1. Big Picture: Aggregate dollars show a surprising minimal fiscal burden

National analyses across 38 states and Washington, D.C. find emergency Medicaid for undocumented immigrants comprised roughly 0.4% of total Medicaid spending in 2022, translating to about $9.63–$10 per resident on average. Even in states with larger undocumented populations, authors report emergency Medicaid still accounted for less than 1% of state Medicaid budgets, and one analysis noted that it rose to about 0.9% in those states — a measurable increase but still a small share of overall spending ^{[1] [3] [2]}. These figures directly challenge narratives that undocumented immigrants drive major increases in emergency healthcare costs at the state level, showing aggregate fiscal exposure is limited despite localized variations ^[2].

2. Where the nuance hides: per-capita and high-population state impacts

Although the aggregate share is small, researchers found that per-capita emergency Medicaid spending can be substantially higher in states with large undocumented populations, with some analyses reporting states with the largest undocumented communities spending roughly 15 times more per capita than low-population states on emergency Medicaid. This creates geographic concentration effects: a minor national budget line can still be meaningful for a particular state’s acute care providers and financing arrangements, and lawmakers weighing cost shifts must consider those localized pressures even when national percentages appear negligible ^{[3] [2]}.

3. Service use patterns complicate the cost picture

Studies of ED utilization paint a mixed picture: some work shows non-citizen immigrants use ED services less than US-born citizens and are less likely to present with non-urgent or chronic-condition visits, while other clinic-based studies report high proportions of undocumented patient ED visits categorized as preventable or primary care–treatable. A systematic review found no consistent pattern across studies — migrants sometimes use EDs more, sometimes less, and are more likely to leave against medical advice. These mixed findings mean cost differences depend heavily on care setting, coding, and how "preventable" use is defined, which affects who bears the cost and whether shifting care to primary care would reduce emergency spending ^{[4] [5] [6]}.

4. Policy levers and what cutting emergency Medicaid would do

Analysts warn that reducing emergency Medicaid funding would produce small savings for the overall Medicaid program but substantial harm in states with concentrated undocumented populations, because the program is one of the few safety nets that pays for emergency care for non-eligible immigrants. Fact checks and policy analyses highlight that undocumented immigrants are ineligible for many other coverage expansions like premium tax credits or full Medicaid, so cutting emergency Medicaid transfers costs to hospitals, states, and uncompensated care pools rather than producing broad federal savings ^{[7] [2]}.

5. Limits of the evidence and what to watch next

The available studies focus on 2022 expenditures and a subset of states; data gaps remain around non-Medicaid uncompensated care, local hospital cost-shifting, and behavioral responses to policy changes. Variation in ED categorization, reliance on administrative claims, and differing local health-system capacities mean findings are sensitive to methods. Future work should track longitudinal changes, hospital-level uncompensated care metrics, and effects of state policy shifts to understand whether localized higher per-capita spending translates into broader fiscal or access pressures ^{[1] [6]}.

Conclusion: The best reading of current evidence is that states with large undocumented immigrant populations can face higher per-capita emergency Medicaid spending, but undocumented-related emergency care comprises a very small share of total Medicaid spending nationally; policy debates should focus on the geographic concentration of impacts and the downstream effects on hospitals and access to care rather than national budgetary alarmism ^{[1] [2]}.