Health Coverage for Undocumented Migrants: A European Smorgasbord

As states continue to make key decisions concerning the implementation of the Affordable Care Act (ACA), one large faction of America’s uninsured population stands to be left behind. Undocumented migrants accounted for one in seven of America’s uninsured population according to 2007 estimates. Despite efforts by advocacy groups, the ACA bars undocumented migrants from gaining health insurance coverage through the Medicaid expansion. Nor can they qualify for the low-income subsidies created to assist with purchasing insurance through newly created health insurance exchanges.

The United States is not alone in facing a large undocumented migrant population lacking health insurance. Albeit on a much smaller scale, countries in Europe have also struggled with and debated this issue for years. In a report for the Commonwealth Fund, researchers from the Urban Institute and the Commonwealth Fund Harkness Fellowship Program outlined policies in seven European countries and how they have performed in practice in an effort to highlight possible strategies for providing coverage to undocumented migrants, as well as issues that would need to be addressed to import those policies to the US.

Certain legal conventions in Europe afford rights to health care to undocumented migrants, including the definition of emergency care as a basic human right by the International Covenant on Economic, Social, and Cultural Rights and the Council of Europe. Beyond these definitions, considerable variation exists between, and even within, countries with regard to eligible populations, level of services, and funding mechanisms. According to the Nowhereland Project, the majority of European countries provide access only to emergency care. The countries highlighted in the report represent those that provide additional access to health services for specific subgroups or under certain conditions.

Four countries highlighted—France, the Netherlands, Spain, and Switzerland—provided undocumented migrants with full access to coverage available to nationals under specified conditions. For instance, nearly 200,000 undocumented migrants in France apply for coverage through the State Medical Assistance (AME), which requires proper identification, proof of residency, and meeting certain income thresholds. Individuals who cannot meet these requirements are still entitled to some care beyond emergency care, including care for children, maternity care, and treatment of contagious diseases. And, prior to September 2012, undocumented migrants who are registered as residents of a municipality in Spain were eligible for universal coverage through the National Health Service. However, in both of these countries many undocumented migrants faced barriers to accessing health services—including uneven interpretation across regions, lack of acceptable documents, and fear of police—leading to under-participation.

Similar problems persist in the represented countries that only provide access to specific services and to certain groups of undocumented migrants: Italy, England, and Germany. For example, in Germany undocumented migrants are eligible for emergency care without being reported to authorities. And in some circumstances, they are also entitled to the same subsidized health care benefits as asylum seekers, but they need to apply for a medical card at a welfare office. By applying, however, undocumented migrants run the risk of being deported, because public officials are required to report them to immigration.

Given the current rules from the ACA, in addition to a highly charged political environment on immigration reform, the future of health care access for undocumented migrants in the United States is foggy at best. Nevertheless, the authors argue that the experiences of certain European countries demonstrate that it is possible to provide some access to health coverage for undocumented migrants. While there was no standard strategy across the countries and barriers continued to persist for many undocumented migrants, experience in European countries shows that it is possible to expand coverage to undocumented groups.

Feature Photo: cc/Barack Obama