The era of “free health care” for people not living lawfully in the United States is waning as states such as California, Illinois, and Minnesota begin to pause or eliminate Medicaid enrollment for this population. Fourteen states and Washington, DC provide coverage for low-income immigrant children, and seven of those states and DC cover eligible adults as well.
A key driver of this change is Sec. 71110 in President Donald Trump’s One Big Beautiful Bill (BBB), which reduces the enhanced federal matching rate for emergency services provided to people not living lawfully in the country who reside in Medicaid expansion states. Linda Gorman, director of the Health Care Policy Center at the Independence Institute, spoke with Health Care News reporter Kenneth Artz about how the United States arrived at this point and how the BBB alters health care access for illegal immigrants.
Health Care News: With the passage of President Trump’s BBB in July, what happens to the millions of illegal immigrants who are being removed from Medicaid?
Gorman: People removed from Medicaid because they are unlawfully present in the United States will still have access to care. Those with chronic conditions may face challenges with continuity, but emergency and basic care will still be available, typically at no charge.
The silver lining is that if states can no longer pass these costs on to federal taxpayers, they may finally be forced to address the fiscal unsustainability of their Medicaid and public health programs. That’s unlikely, but we can hope.
What’s more probable is that officials will decry the “growing uninsured population,” implying that a lack of coverage means no access to care. That’s false. And aiming for zero uninsured is a misguided national goal for many reasons.
Health Care News: Under what circumstances will illegal immigrants still qualify for health care in the United States?
Gorman: Illegal immigrants who are dropped from regular Medicaid rolls but otherwise meet Medicaid eligibility requirements will still qualify for Emergency Medicaid. We’re assured that these individuals are otherwise fully eligible, so they’ll continue to receive lifesaving care.
States have flexibility in how they define “emergency,” and many have stretched that definition to include more routine or ongoing treatments. For instance, labor and delivery have always been covered.
Health Care News: How will the BBB affect access to federal and state health programs for low-income citizens and illegal immigrants?
Gorman: Federally Qualified Health Centers will still offer free primary care for those below 100 percent of the Federal Poverty Level. Others pay on a sliding scale. That hasn’t changed.
Noncitizens can always pay cash for care. Some states still allow less costly short-term major medical plans. Unlike Americans, noncitizens often have the option of returning to their home countries for more affordable care. I know legal residents who have done exactly that.
Health Care News: What changes does the BBB make to coverage of emergency and long-term care?
Gorman: The Emergency Medical Treatment and Active Labor Act, or EMTALA, still requires hospitals to assess and stabilize emergency cases regardless of immigration status. Hospitals can’t discharge patients without an adequate plan, which means they often keep noncitizens longer than clinically necessary.
However, nursing homes and rehab centers won’t admit nonpaying patients. So, hospitals either absorb huge losses or spend exorbitantly to send patients back to their home countries.
Health Care News: With illegal immigrants losing Medicaid, do you expect emergency-room use to surge?
Gorman: I don’t expect a dramatic change. Emergency-room usage has been rising for years, and Medicaid expansion accelerated the trend. Coverage doesn’t guarantee timely access to care, so people still go to the ER.
The bigger issue is that Medicaid and Medicare pay below cost. As more people rely on them, hospitals in high-Medicaid or high-uninsured areas cut departments that lose money—like ER and OB. In areas with large noncitizen populations, hospitals sometimes shut down completely.
Health Care News: What drove the expansion of public health programs to include illegal immigrants?
Gorman: Three main things: First, the belief that “health care is a human right” and that charging for it is immoral. Second, decades of propaganda claiming European systems offer better care at lower cost—claims that didn’t hold up but served an anti-private-sector agenda. Third, a massive increase in health care costs began in the 1980s, when medicine became more advanced and expensive than it had been in the 1960s, when Medicare and Medicaid were created.
Health Care News: How have the federal and state governments continued to fund Medicaid expansion, and how much longer can they?
Gorman: Foundations helped states game the system, exploiting federal match funds and waivers to expand coverage. “Medical care” was rebranded as “health care,” a vague term that’s hard to define or limit. “Health care for the poor” became a winning slogan, even though the real beneficiaries were bureaucrats.
Budgets ballooned. Wasteful spending multiplied. Now the federal government is broke, and the private sector is maxed out. The choice is clear: either scale back to Medicaid’s original mission—care for the truly needy—or risk collapsing the entire health care system.
Health Care News: If it’s unsustainable, why do they keep doing it?
Linda Gorman: In states like Colorado—an early testing ground for the Robert Wood Johnson Foundation—ideological motives played a big role. Many in the nonprofit and government health sectors despised profits and distrusted the private sector. They misunderstood incentives and viewed the people they regulated as incapable of making good choices.
They saw themselves as moral saviors, displacing “profit seekers” with a government-run insurance system—Medicaid—that now covers a quarter of their state’s population.
You can’t overstate how intellectually lazy, financially reckless, and politically driven this movement has been. It’s no surprise that the system is imploding.
At best, we may end up with an NHS-style health care model. At worst—something like Canada’s system, or worse.
Artz has more than 20 years’ experience in nonprofit organizations, publishing, newspaper reporting, and public policy advocacy.
