Abstract
Insurance coverage for prenatal care, labor and delivery care, and postpartum care for undocumented immigrants consists of a patchwork of state and federal policies, which varies widely by state. According to federal law, states must provide coverage for labor and delivery through Emergency Medicaid. Various states have additional prenatal and postpartum coverage for undocumented immigrants through policy mechanisms such as the Children’s Health Insurance Program’s “unborn child” option, expansion of Medicaid, and independent state-level mechanisms.
Using a search of state Medicaid and federal government websites, we found that 27 states and the District of Columbia provide additional coverage for prenatal care, postpartum care, or both, while 23 states do not. Twelve states include any postpartum coverage; 7 provide coverage for 12 months postpartum.
Although information regarding coverage is available publicly online, there exist many barriers to access, such as lack of transparency, lack of availability of information in multiple languages, and incorrect information. More inclusive and easily accessible policies are needed as the first step toward improving maternal health among undocumented immigrants, a population trapped in a complicated web of immigration policy and a maternal health crisis. (Am J Public Health. 2024;114(10):1051–1060. https://doi.org/10.2105/AJPH.2024.307750)
The patchwork policy landscape of pregnancy coverage for people who are undocumented across the United States is difficult to navigate. Immigration law is complex, dynamic, and regulated at the federal level, while policies determining health care coverage are regulated at both the federal and state levels, leading to variable coverage across and within states. Pregnant people who are undocumented are thus left with the extremely challenging experience of navigating the labyrinths of the immigration and health care systems while living at an intersection of divisive anti-immigration rhetoric and policy1 and a devastating maternal health crisis.2
The United States continues to have poor—and worsening—maternal health outcomes, including dramatic inequities in pregnancy outcomes by race and ethnicity2 with limited understanding of intersectional structural barriers, such as immigration and language. People who are undocumented remain at increased vulnerability because of gaps in access and quality of pregnancy care.3 Prenatal care is a valued preventive health service with associated improvements in maternal and infant health outcomes and reduced risk of pregnancy complications.4 Few studies investigating pregnancy outcomes collect immigration status, and those that do are hampered by nonstandardized, inaccurate proxies for undocumented populations.5
Little is known about health outcomes for pregnant people who are undocumented.6 Research is limited by the inherent challenge of understanding a population that holds valid concerns about disclosure of immigration status for fear of discrimination, job loss, deportation, and family separation.7 In addition, there are multiple barriers that undocumented patients face in accessing pregnancy care, including fear of procedures or disclosure of pregnancy, long wait times, distant location, clinic hours that interfere with childcare or work obligations, lack of language access, implicit bias of staff, and cost of services.7
This analytic essay provides an overview of current federal and state-level mechanisms providing coverage for pregnant people who are undocumented and presents a cross-sectional analysis of state policies based on publicly available information. These findings can help inform policymakers and facilitate future research on the impact of these policies. The essay concludes with policy recommendations to improve care for this population at the crossroads of 2 highly complex systems.
FEDERAL PREGNANCY COVERAGE
Immigrants with authorized status include naturalized US citizens, lawful permanent residents (green card holders), or individuals who have been granted temporary lawful resident status, such as students from another country.8 For example, the Deferred Action for Childhood Arrivals (DACA) program allows people who arrived in the United States as children a temporary status that may be renewed every 2 years and may allow them to live and work in the United States.9 However, DACA itself does not offer citizenship. The US Department of Homeland Security also has power to grant “parole” to some noncitizens, allowing them to enter or remain in the United States if there are urgent humanitarian or public health benefits for someone to be in the United States.10 This leads to a complex, “in-between” zone for some individuals and further complicates understanding of authorized status in this country.
The term “undocumented” fails to capture the dynamic complexity of all different authorized and unauthorized immigration statuses yet remains an umbrella term for those who are present in the United States without the permission of the US government. Many individuals have a status that may offer temporary reprieve but does not put them on the pathway toward permanent residence or citizenship. The Pew Research Center estimated that 77% of immigrants held an authorized status and approximately 23% were undocumented in 20178 or unauthorized, meaning they did not have sufficient documentation to remain in the country.11 In 2017, there were an estimated 10.5 million unauthorized immigrants in the United States, making up about 3.2% of the US population.8 For example, they may have an expired visa or a pending or denied application for asylum, or they may have entered the country outside of an official entry point. Notably, 6% of all children born in the United States have an undocumented parent.12
Historically, major federal public benefits programs have excluded undocumented immigrants and some immigrants on temporary stay.13 Before immigration policy changed in 1996, some immigrants were eligible for certain benefits based on a category (not an immigration status) called “permanently resided in the U.S. under color of law,” which has been interpreted differently depending on region and program.13 Generally, it meant that the US Department of Homeland Security was aware of the person’s presence in the United States and had no plans to deport them from the country. A few states continue to use this definition.14
In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act was enacted and created 2 categories of immigrants for the purpose of benefits eligibility: “qualified” and “not qualified.” The “qualified” category includes lawful permanent residents (green card holders), refugees, and other specific inclusion criteria, such as country of origin.14 All other immigrants, including those who are undocumented, and many others who are lawfully present, are considered “not qualified.” This law also created time requirements of 5 years or longer for lawfully residing qualified immigrants to become eligible for benefits coverage.14 This is colloquially referred to as a “5-year bar.” As of now, there do exist exceptions to the 5-year waiting period, including for refugees, asylees, or lawful permanent residents who were formerly refugees or asylees.15 States also have the option to remove the 5-year waiting period to cover children or pregnant people under Medicaid or Children’s Health Insurance Program (CHIP). This 5-year bar does not apply to unqualified immigrants, including those who are unauthorized or undocumented, who are not eligible for full Medicaid benefits even after 5 years.
The law itself does not specify which programs are covered as “federal public benefits programs.” In 1998, the Department of Health and Human Services published a notice of which programs fall under this definition, including Medicaid, CHIP, and Medicare, among others. Importantly, the law includes some exceptions.14 Nonqualified immigrants, including undocumented immigrants, are eligible for Emergency Medicaid if they otherwise meet income requirements and other eligibility criteria for their state’s Medicaid program.14
All states must provide Emergency Medicaid to people who would otherwise qualify for Medicaid with the exception of their immigration status. Emergency Medicaid provides limited coverage during pregnancy, usually for childbirth only, and is essentially a payment mechanism to cover health care costs for individuals who have been diagnosed with an emergency medical condition as defined by each state, such as a heart attack or kidney failure requiring dialysis. Emergency Medicaid may cover prenatal care in the case of high-risk pregnancies only and postpartum care in cases of severe morbidity, both covering conditions that may be life-threatening. There is a federal statutory definition of “emergency medical condition” that allows states some flexibility for interpretation; however, states cannot create a new or different definition of an emergency medical condition.16,17
In 2010, the Affordable Care Act (ACA) catalyzed sweeping health care reform and improved access, except for people who are undocumented. The ACA does allow lawfully present people with status of less than 5 years to purchase insurance on the health care exchange, even if they may not meet income requirements.15 People who were undocumented were excluded from state insurance exchanges, ineligible for tax credits and lower copayments, and exempt from the individual mandate to hold health care coverage; they remained eligible for Emergency Medicaid services only.18 Notably, as of May 2024, the Biden–Harris administration removed the prohibition on DACA recipient’s eligibility for ACA coverage, allowing more than 100 000 individuals to access health insurance.19
The public charge ruling is a federal policy that has had a chilling effect on immigrant communities, including those who are undocumented, even though it does not directly pertain to those who are undocumented.19,20 In 2022, the US Department of Homeland Security issued a final rule clarifying public charge as a method to determine whether someone applying for lawful permanent residence (green card) or another specific visa would be likely to depend on the government as their primary means of support.21 This did not apply to naturalized citizens, people who already have green cards, individuals with DACA, those with Temporary Protected Status, undocumented individuals without authorized status, or people with humanitarian status. However, because an earlier 2020 ruling included several additional factors in the determination of likelihood of becoming a “public charge” (including some uses of Medicaid, nutritional assistance, cash assistance, and housing with federal funding), many immigrants, regardless of whether they were subject to this rule, avoided accessing health-promoting benefits for which they were eligible.22
The final 2022 rule restored the understanding that supplemental public health benefits, like Medicaid and nutritional assistance programs, are not part of the public charge inadmissibility determination.21 However, the previous policy was seen to have a chilling effect on public program participation. In the months following the passage of the 2020 policy, health care centers reported that immigrant families declined to enroll themselves, their children, or both in Medicaid, along with other programs like the Special Supplemental Nutrition Program for Women, Infants, and Children.19 A study from the Kaiser Family Foundation reported that pregnant women were delaying care or seeking prenatal care less frequently on the basis of their fear of enrollment.20 Overall, these policy changes led to widespread misinformation and fear regarding seeking health care among many immigrant populations, including undocumented pregnant women, even if they were not subject to the rulings.
Federally qualified health centers are the backbone for preventive care among minoritized communities, including those who are undocumented. Federally qualified health centers qualify for funding under the Public Health Service Act and enhanced reimbursement from Medicare and Medicaid. They must offer a sliding fee scale and provide comprehensive services, importantly serving all community members, regardless of citizenship or documentation status. They must also be governed by a board with a majority of members who receive care at the federally qualified health center.19,23
STATE PREGNANCY COVERAGE
According to federal requirements, CHIP, which is jointly funded by both the state and federal government, is administered by the individual state. Generally, CHIP provides coverage to eligible low-income uninsured children and pregnant women whose income is too high for Medicaid eligibility. States have broad flexibility in terms of the scope of services that are covered. Under federal regulations as of 2009,24 states can provide pregnancy-related care through the CHIP state plan to low-income children from conception to birth. This program was called the “unborn child” option by Congress, though others have objected to the use of this term.25 Advocates describe the use of the term unborn child as an attempt to integrate fetal personhood into policy in the context of the ongoing antiabortion movement, thereby narrowing eligibility for services specifically for the unborn child and indicating that the people carrying the pregnancies are not worthy of coverage themselves.26 We will use the term “CHIP pregnancy care” to refer to this policy. This program allows states the option to provide prenatal, childbirth, and postpartum care to pregnant people regardless of immigration status.25 Given that it is implemented through CHIP, the specificities of the CHIP pregnancy care option vary by state in regard to the income requirements and extent of prenatal and postpartum coverage.
Recently, some states have expanded their Medicaid programs to include coverage for undocumented immigrants with state funds, not federal funds. Some states have also expanded Medicaid or CHIP to “lawfully present” children and pregnant noncitizens.15 People who are considered lawfully present may include those with qualified status, including asylees and refugees, persons from specific geographies or lawful permanent residents holding a green card, and others. States also have the option to remove a waiting period for all pregnant people if they are lawfully present rather than only those who are qualified. Eligibility criteria for coverage is complex and opaque. States vary in their coverage of what pregnancy services are included. Furthermore, there is proposed legislation in Congress that would repeal the arbitrary 5-year waiting period before accessing health care coverage and other public benefits created by the Personal Responsibility and Work Opportunity Reconciliation Act.27 Figure 1 shows a timeline of relevant federal and state policies for health care coverage for undocumented immigrants.
FIGURE 1—
Overview of Federal and State Policies Relevant to Health Care Coverage for Undocumented Immigrants: United States, 1990s‒2020s
Note. CHIP = Children’s Health Insurance Program; SNAP = Supplemental Nutrition Assistance Program.
Because there is no centralized resource that allows for easy access to information regarding health care coverage for undocumented immigrants, we searched each state Medicaid website, many of which were not user-friendly and described health care coverage with policy jargon. Furthermore, when this information could not be identified on state Medicaid websites, researchers reviewed secondary policy websites, such as the Kaiser Family Foundation website, which led to conflicting or outdated information. Despite the myriad challenges in corroborating and confirming some information, we report what was found to be most accurate at the time of data collection. A detailed list of websites and resources reviewed can be found in Table A (available as a supplement to the online version of this article at https://ajph.org).
PREGNANCY COVERAGE LANDSCAPE
We analyzed pregnancy coverage mechanisms by estimated total population and proportion of undocumented people in each state using data from the Pew Research Center. We present the landscape of policy mechanisms that provide health care coverage for pregnant people who are undocumented, including both state and jointly funded state and federal mechanisms, and the relative magnitude of the population affected by these policies.
Each state has distinct pregnancy care services that can be covered by different funding mechanisms. For example, many states use Emergency Medicaid funding to cover inpatient labor and delivery and apply CHIP to fund prenatal and postpartum services. Our research found that only 18 states and Washington, DC provided prenatal, labor and delivery, and postpartum coverage for undocumented individuals, although the cost to patients, specific services covered, and length of coverage within these pregnancy phases varied. In addition, 9 states provided limited coverage of some prenatal care services, labor and delivery services through Emergency Medicaid, and no postpartum care. The 23 remaining states had severely restricted coverage, offering only labor and delivery coverage through Emergency Medicaid. Figure 2 summarizes the state-based scope of pregnancy care coverage for undocumented people.
FIGURE 2—
Map of State-Based Pregnancy Care Coverage for Undocumented Individuals: United States, 2023
All states provided coverage for labor and delivery regardless of documentation status under Emergency Medicaid, though the scope of services covered is determined by each state. Twenty-seven states and the District of Columbia provided additional coverage for prenatal care, postpartum care, or both, while 23 states did not. Twenty states opted in to the CHIP pregnancy care option, though with considerable variation. Some states, such as Louisiana and Nebraska, only provided coverage for pregnancy-related care, while other states, such as Connecticut, covered most medical needs as long as the individual qualified for the CHIP pregnancy care option. Limited information is available on the state websites regarding the details of this plan and how it is administered in each state. Of the information that could be found regarding this option, 12 states explicitly mention postpartum coverage, with only 7 states providing postpartum coverage for a full 12 months after birth. Details outlining the states that utilize the CHIP pregnancy care option and their respective postpartum coverage can be found in Table 1. An overview of the federal and state policies is available in Figure A (available as a supplement to the online version of this article at https://ajph.org).
TABLE 1—
State-Based Pregnancy Care Coverage for Undocumented People: United States, 2023
| Statea | Unauthorized Immigrant Percentage of Population,28 % | Uptake of the CHIP Pregnancy Care Option24 | CHIP Pregnancy Care Option FPL Requirement,24 % | Postpartum Coverage Through CHIP Pregnancy Care Optionb | Inclusion in State Medicaid Program | State Medicaid FPL Requirement, % |
| Arkansas | 1.9 | Yes | 214 | 60 d | No | … |
| Californiac | 5.6 | Yes | 322 | 12 mo | Yes | 213d |
| Connecticut | 3.5 | Yes | 263 | 12 mo | No | … |
| Illinoise | 3.2 | Yes | 213 | 12 mo | Yes | 213 |
| Louisiana | 1.5 | Yes | 214 | None | No | … |
| Maine | 0.4 | Yes | 213 | None | Yes | 214 |
| Maryland | 4.5 | No | … | … | Yes | 250 |
| Massachusetts | 3.8 | Yes | 205 | 12 mo | Yes | 200 |
| Michigan | 1.0 | Yes | 200 | None | No | … |
| Minnesota | 1.7 | Yes | 283 | 12 mo | No | … |
| Missouri | 1.0 | Yes | 305 | 60 d | No | … |
| Nebraska | 3.1 | Yes | 202 | None | No | … |
| New York | 3.6 | No | … | … | Yes | 223 |
| Oklahoma | 2.2 | Yes | 210 | None | No | … |
| Oregon | 2.6 | Yes | 190 | None | Yes | 185 |
| Rhode Island | 2.8 | Yes | 258 | 12 mo | Yes | 258 |
| South Dakota | 0.7 | Yes | 138 | None | No | … |
| Tennessee | 2.0 | Yes | 255 | 60 d | No | … |
| Texas | 5.7 | Yes | 207 | 2 postpartum care visits | No | … |
| Virginia | 3.4 | Yes | 205 | 60 d | No | … |
| Washington | 3.3 | Yes | 198 | 12 mo | Yes | 193 |
| Wisconsin | 1.3 | Yes | 306 | None | No | … |
Note. CHIP = Children’s Health Insurance Program; FPL = federal poverty level (according to the US Department of Health and Human Services).
States that did not participate in the programs listed in the table are AL, AK, AZ, CO, DC, DE, FL, GA, HI, IA, ID, IN, KS, KY, MS, MT, NC, ND, NE, NH, NJ, NM, OH, PA, SC, UT, VT, WV, and WY.
Several states extended coverage to 12 months under the CHIP pregnancy care option to align with Medicaid postpartum coverage extension from 60 days to 12 months established by the American Rescue Plan of 2021.
Medi-Cal (Medicaid of CA) provides coverage for all young adults aged 19–26 years regardless of immigration status and adults aged ≥ 50 years.
To meet eligibility requirements for Medi-Cal, applicants must have income meeting 213% FPL. Income that is meeting 214%–322% FPL qualifies applicants for the Medi-Cal Access Program, which provides low-cost comprehensive health care throughout pregnancy through 1 y postpartum to middle-income families.
Illinois has a Medicaid/CHIP joint-funded program called Moms and Babies that covers health care for women while they are pregnant and up to 12 months after delivery. It is a full Medicaid benefit package including outpatient health care, inpatient hospital care, and prescription drugs.
A state-based mechanism to provide coverage for pregnant undocumented immigrants is using state funds to cover undocumented immigrants in Medicaid. See Box 1 for details about the programs. Five states and Washington, DC, have created other independent mechanisms to provide pregnancy-related services to undocumented immigrants. For example, in 2021, OmniSalud was created to provide a secure, online marketplace for undocumented persons living in Colorado to compare and purchase insurance plans without sharing their data with federal agencies. OmniSalud does not require information about immigration status by any user, and information provided to the online platform cannot be used for immigration enforcement. As a requirement of OmniSalud, all companies that sell health insurance in Colorado must provide an affordable plan for everyone, regardless of immigration or pregnancy status.
BOX 1—
Other State Programs of Pregnancy Care Coverage for Undocumented Individuals: United States
| State | Programs | Description |
| Colorado | OmniSalud |
|
| District of Columbia | DC Healthcare Alliance Program Cover All DC |
|
| Indiana | Indiana Health Coverage Plans (Emergency Medicaid extension) |
|
| Michigan | Maternity Outpatient Medical Services program (Emergency Medicaid extension) |
|
| New Jersey | New Jersey Supplemental Prenatal and Contraceptive Program |
|
| Vermont | Immigrant Health Insurance Plan |
|
Washington, DC, has a similar program, Cover All D.C., which allows people who are undocumented to purchase full-cost private health insurance. Washington, DC, also has a district-funded program, Healthcare Alliance, that provides medical care for DC residents who are not eligible for Medicaid. In 2021, Vermont created a new state-funded health care program to provide care for pregnant people who do not meet Medicaid requirements because of immigration status, called Immigrant Health Insurance Plan. This program covers hospital, medical, and dental services, as well as prescription drugs. While programs may allow undocumented immigrants to buy health care plans, this does not equate with meaningful access. Many of these plans can be very expensive, especially if they are not offered at a subsidized rate.
The Pew Research Center found that the 5 states with highest proportions of undocumented individuals were Nevada (7.1%), Texas (5.7%), California (5.6%), New Jersey (5.2%), and Maryland (4.5%).28 Despite having the largest proportion of undocumented individuals, Nevada provides no pregnancy care coverage for this population aside from childbirth services through Emergency Medicaid only (Table 1). California, on the other hand, provides the most extensive pregnancy coverage for the undocumented population, while the other states provide variable coverage (Table 1).
LACK OF TRANSPARENCY AND ACCESSIBILITY OF STATE POLICIES
Lack of transparency of information about pregnancy care coverage for undocumented individuals was a major barrier. Websites were not up to date (e.g., had last been updated more than 5 years ago), or information was vague and incomplete. At times, there was contradictory information found on different web pages. Six follow-up phone calls to Medicaid offices were made. Only 1 office was able to provide accurate information within a period of less than 10 minutes of waiting. Out of the 5 other offices, 4 offices were unable to confirm the information because of automated messages or did not lead to a human contact within approximately 10 minutes of waiting. The remaining office did not know the information off hand, but pointed to the Medicaid website.
Language access for individuals who speak languages other than English was limited. While 31 state Medicaid websites integrated Google Translate functionality into the website itself, the quality of this translation mechanism for highly specialized policy jargon often poses challenges for accuracy and comprehension. Some websites only included information in English (n = 15), while only a few included information in both English and Spanish (n = 5). Given that 2 major barriers for immigrants in seeking care are lack of knowledge of the complex health care system and language barriers,29 increasing accessibility to this information is critical. Our findings should be contextualized in the limitations of the approach we used in reviewing state Medicaid websites, which may have missed other relevant policies and programs for undocumented immigrants.
POLICY IMPLICATIONS
Understanding the labyrinth of programs and policies that allow access to pregnancy care coverage for undocumented individuals presents a challenge for clinicians, resource specialists, and pregnant people themselves. Overall, fragmented state- and federal-level mechanisms provide pregnancy care to undocumented individuals, such as CHIP and Medicaid on the state level and Emergency Medicaid on the federal level. As a result, the eligibility requirements and coverage for pregnancy care vary widely from state to state. The overall complexity and lack of transparency of these policies makes navigating these systems—for patients, for advocates and community organizations, for clinicians, and even for policymakers—extremely difficult. Given these findings, one important improvement would be for all states and federal agencies to adopt plain-language explanations in all public materials, enhance transparency and clarity of coverage policies, and provide multilingual access to information.
Reducing fragmentation across state policies and programs to expand coverage for full-spectrum pregnancy care, including miscarriage, prenatal, labor and delivery, and postpartum services, for all populations regardless of immigration status, is critical to enhance access and outcomes. Studies of Oregon’s expansion of Medicaid found that increasing prenatal care coverage for undocumented immigrants led to an increase in infants receiving recommended preventive health services, a decrease in the probability of extreme low birth weight infants, and a decrease in infant mortality.30 Increasingly restrictive legislation around access to reproductive health care and stigmatizing anti-immigrant rhetoric produce particular vulnerability for the pregnant undocumented population, especially in states like Florida that have begun to require hospitals accepting Medicaid to ask about a patient’s immigration status.31 Recent literature shows that immigrants living in states with public insurance restrictions are less likely to receive postpartum care.32 It is essential that health policy efforts focus on increasing access to care for everyone, regardless of immigration status.
Eroding access to abortion care adds further complexity to the landscape of care for pregnant people who are undocumented who may experience heightened fears of seeking reproductive health care. We did not find any studies that analyzed the impact of abortion policy and coverage for abortion care specifically for pregnant people who are undocumented. The lack of studies on this topic is likely attributable to the challenges in collecting sensitive information about immigration status amid an increasingly restrictive landscape of abortion access.
Research on health outcomes among undocumented immigrants is limited because of challenges in identifying the marginalized population. Common proxies are absence of a social security number on a birth certificate33 or enrollment in Emergency Medicaid at the time of delivery.30,34 Studies that compare state policies often use utilization of health care as a primary outcome.30,34 One study found that coverage of prenatal care for undocumented pregnant people was associated with increased prenatal care screening (anemia, blood typing) and influenza vaccinations.35 Another study found expansion of Emergency Medicaid to cover prenatal care for undocumented immigrants in Oregon was associated with better detection of pregnancy complications, including diagnosis of diabetes, hypertensive diseases, and poor fetal growth.34
Another important policy option is expansion of postpartum care coverage through 12 months postpartum for undocumented immigrants. Given that one half of pregnancy-related deaths occur after birth,36 health care coverage during the postpartum period is a critical opportunity for reducing overall pregnancy-related mortality and morbidity in the United States. Although there are a variety of different solutions that can be implemented to increase pregnancy care, California’s Medi-Cal policy seems to be a promising approach, but it is still in need of studies to evaluate its long-term outcomes. Instead of using a patchwork of programs and funding sources for different stages of pregnancy, California uses Medicaid to cover all prenatal, childbirth, and postpartum services. Through Medi-Cal, California has extended Medicaid to all individuals, regardless of immigration status, through age 26, with plans to extend this program to individuals of all ages in 2024.
Nonprofits and advocacy organizations may aim to fill some of the current policy gaps and help individuals and families understand their eligibility for services. For example, the Nurse Family Partnership is a free program for low-income parents that connects nurses with first-time parents in the prenatal period.37 Another key group of organizations include medical‒legal partnerships, integrating lawyers into the health care setting to address legal concerns that perpetuate health inequities, such as access barriers to the health care system.38
PUBLIC HEALTH IMPLICATIONS
Human responses to climate change, increasing political instability, severe impoverishment, continued economic impacts of COVID-19, the asylum system backlog, and deteriorating economic conditions have led to an influx of migrants to the United States over the past few years.39 Ensuring all individuals have access to health care coverage is a critical priority for public health with important economic benefits, especially for reproductive-aged individuals who make up a large proportion of the workforce.
Pregnancy care coverage for people who are undocumented remains a complex labyrinth of federal and state policies, which leads to variable, fragmented, and often inadequate access for undocumented pregnant individuals, which has important implications for maternal‒newborn outcomes. In recent years, more states have moved toward enacting inclusive policies. While 20 states have applied the CHIP pregnancy care option for prenatal coverage regardless of documentation status, fewer states have expanded Medicaid or state programs to be inclusive of all pregnant people. More-inclusive policies are needed for this marginalized population at the crossroads of a complicated web of immigration policy and a maternal health crisis. Advocacy efforts around equitable maternal health care should include all regardless of immigration status. Increased clarity and accessibility of policies is needed on state and other public websites. Information should be updated for accuracy to ensure accountability, and resources should be made in accordance with national cultural and linguistic standards.
ACKNOWLEDGMENTS
This project was supported by grant K12HS026370 from the Agency for Healthcare Research and Quality.
Note. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.
CONFLICTS OF INTEREST
The authors have no potential or actual conflicts of interest to disclose.
HUMAN PARTICIPANT PROTECTION
This study does not constitute human participant research.
REFERENCES
- 1.Al-Kire R, Pasek M, Tsang J-A, Leman J, Rowatt W. Protecting America’s borders: Christian nationalism, threat, and attitudes toward immigrants in the United States. Group Process Intergroup Relat. 2022;25(2):354–378. 10.1177/1368430220978291 [DOI] [Google Scholar]
- 2.Craft-Blacksheare M, Kahn P. Midwives’ and other perinatal health workers’ perceptions of the Black maternal mortality crisis in the United States. J Midwifery Womens Health. 2023;68(1): 62–70. 10.1111/jmwh.13433 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Martinez O, Wu E, Sandfort T, et al. Evaluating the impact of immigration policies on health status among undocumented immigrants: a systematic review. J Immigr Minor Health. 2015;17(3): 947–970. 10.1007/s10903-013-9968-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Conway KS, Kutinova A. Maternal health: does prenatal care make a difference? Health Econ. 2006;15(5):461–488. 10.1002/hec.1097 [DOI] [PubMed] [Google Scholar]
- 5.Larrea-Schiavon S, Vázquez-Quesada LM, Bartlett LR, et al. Interventions to improve the reproductive health of undocumented female migrants and refugees in protracted situations: a systematic review. Glob Health Sci Pract. 2022;10(6): 1–15. 10.9745/GHSP-D-21-00418 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Molina RL, Beecroft A, Pazos Herencia Y, et al. Pregnancy care utilization, experiences, and outcomes among undocumented immigrants in the United States: a scoping review. Womens Health Issues. 2024:S1049‒3867(24):6‒9. 10.1016/j.whi.2024.02.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Phillippi JC. Women’s perceptions of access to prenatal care in the United States: a literature review. J Midwifery Womens Health. 2009;54(3): 219–225. 10.1016/j.jmwh.2009.01.002 [DOI] [PubMed] [Google Scholar]
- 8.Budiman A. Key Findings About US Immigrants. Pew Research Center. August 20, 2020. Available at: https://www.pewresearch.org/short-reads/2020/08/20/key-findings-about-u-s-immigrants. Accessed August 2, 2023.
- 9. Boundless. Deferred Action for Childhood Arrivals (DACA). Explained. Available at: https://www.boundless.com/immigration-resources/what-is-daca . Accessed April 18, 2024.
- 10.Fact Sheet: The Use of Parole Under Immigration Law. Washington, DC: American Immigration Council; 2024. [Google Scholar]
- 11. National Immigration Forum. Immigration Primer . December 16 , 2019. . Available at: https://immigrationforum.org/article/immigration-primer/#current-system . Accessed September 7, 2023. [Google Scholar]
- 12. Health care for immigrants: ACOG committee statement no. 4. Obstet Gynecol. 2023;141(2): e427–e433. 10.1097/AOG.0000000000005061 [DOI] [PubMed] [Google Scholar]
- 13. Kaiser Family Foundation. Health Coverage and Care of Immigrants . December 20, 2022. . Available at: https://www.kff.org/racial-equity-and-health-policy/fact-sheet/health-coverage-and-care-of-immigrants . Accessed August 2, 2023.
- 14.Broder T. Overview of Immigrant Eligibility for Federal Programs. National Immigration Law Center. March 2023. Available at: https://www.nilc.org/issues/economic-support/overview-immeligfedprograms. Accessed September 8, 2023.
- 15.Healthcare.gov. Coverage for lawfully present immigrants. Available at: https://www.healthcare.gov/immigrants/lawfully-present-immigrants. Accessed August 11, 2023.
- 16. MyMedicare.com . Emergency Medicaid. 2018. . Available at: https://mymedicare.com/medicaid/emergency-medicaid . Accessed September 13, 2023.
- 17.Park JK, Reyes-Becerra C, Makhlouf MD. State flexibility in Emergency Medicaid to care for uninsured noncitizens. JAMA Health Forum. 2023;4(7): e231997. 10.1001/jamahealthforum.2023.1997 [DOI] [PubMed] [Google Scholar]
- 18.National Immigrant Law Center. Immigrants and the Affordable Care Act (ACA). January 2014. Available at: https://www.nilc.org/issues/health-care/immigrantshcr. Accessed September 8, 2023.
- 19.Daval CJR. Immigration law, public health, and the future of public charge policymaking. J Law Med Ethics. 2022;50(2):336–338. 10.1017/jme.2022.60 [DOI] [PubMed] [Google Scholar]
- 20.Pillai D. 2022 Changes to the Public Charge Inadmissibility Rule and the Implications for Health Care. KFF. May 5, 2022. Available at: https://www.kff.org/racial-equity-and-health-policy/issue-brief/2022-changes-to-the-public-charge-inadmissibility-rule-and-the-implications-for-health-care. Accessed April 18, 2024. [Google Scholar]
- 21.US Citizen and Immigration Services. Clarifying the 2022 Public Charge Final Rule. Available at: https://www.uscis.gov/sites/default/files/document/flyers/PublicChargeFinalRule2022_Infographic_V4_508.pdf. Accessed October 21, 2023.
- 22.Haq C, Hostetter I, Zavala L, Mayorga J. Immigrant health and changes to the Public-Charge Rule: family physicians’ response. Ann Fam Med. 2020;18(5):458–460. 10.1370/afm.2572 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Centers for Medicare and Medicaid Services . Federally Qualified Health Center . September 2019. . Available at: https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/FQHC-Text-Only-Factsheet.pdf . Accessed April 22, 2024.
- 24.KFF. Medicaid and CHIP income eligibility limits for pregnant women as a percent of the federal poverty level. January 1, 2023. Available at: https://www.kff.org/health-reform/state-indicator/medicaid-and-chip-income-eligibility-limits-for-pregnant-women-as-a-percent-of-the-federal-poverty-level. Accessed September 8, 2023. [Google Scholar]
- 25.Manatt Health. Supporting Health Equity and Affordable Health Coverage for Immigrant Populations: CHIP Coverage Option for Pregnant Immigrants and Their Children. State Health & Value Strategies: Driving Innovation Across States. January 1, 2022. Available at: https://www.shvs.org/wp-content/uploads/2022/01/Supporting-Health-Equity-and-Affordable-Health-Coverage-for-Immigrant-Populations_CHIP-Coverage-Option-for-Pregnant-Immigrants-and-their-Children.pdf. Accessed August 1, 2023.
- 26.National Women’s Law Center. CHIP must be reauthorized and it must also be improved to better cover pregnant women. December 14, 2017. Available at: https://nwlc.org/chip-must-be-reauthorized-and-it-must-also-be-improved-to-better-cover-pregnant-women. Accessed April 18, 2024.
- 27.Jayapal H. Cárdenas introduce bicameral legislation to expand public benefits to immigrants. Pramila Jayapal Congresswoman for WA-07. June 15, 2023. Available at: https://jayapal.house.gov/2023/06/15/jayapal-hirono-cardenas-introduce-bicameral-legislation-to-expand-public-benefits-to-immigrants. Accessed September 23, 2023. [Google Scholar]
- 28. Pew Research Center . US unauthorized immigrant population estimates by state, 2016. . Pew Research Center. May 2, 2019. Available at: https://www.pewresearch.org/hispanic/interactives/u-s-unauthorized-immigrants-by-state . Accessed December 3, 2023. [Google Scholar]
- 29.Hacker K, Anies M, Folb BL, Zallman L. Barriers to health care for undocumented immigrants: a literature review. Risk Manag Healthc Policy. 2015; 8:175–183. 10.2147/RMHP.S70173 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Swartz JJ, Hainmueller J, Lawrence D, Rodriguez MI. Expanding prenatal care to unauthorized immigrant women and the effects on infant health. Obstet Gynecol. 2017;130(5):938–945. 10.1097/AOG.0000000000002275 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Chang D. Doctors hesitate to ask about patients’ immigration status despite new Florida law. KFF Health News. August 17, 2023. Available at: https://kffhealthnews.org/news/article/doctors-patient-immigration-status-new-florida-law. Accessed October 21, 2023. [Google Scholar]
- 32.Steenland MW, Fabi RE, Bellerose M, Desir A, White MS, Wherry LR. State public insurance coverage policies and postpartum care among immigrants. JAMA. 2023;330(3):238–246. 10.1001/jama.2023.10249 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Atkins DN, Held ML, Lindley LC. The impact of expanded health insurance coverage for unauthorized pregnant women on prenatal care utilization. Public Health Nurs. 2018;35(6):459–465. 10.1111/phn.12524 [DOI] [PubMed] [Google Scholar]
- 34.Swartz JJ, Hainmueller J, Lawrence D, Rodriguez MI. Oregon’s expansion of prenatal care improved utilization among immigrant women. Matern Child Health J. 2019;23(2):173–182. 10.1007/s10995-018-2611-1 [DOI] [PubMed] [Google Scholar]
- 35.Rodriguez MI, Kaufman M, Lindner S, Caughey AB, DeFede AL, McConnell KJ. Association of expanded prenatal care coverage for immigrant women with postpartum contraception and short interpregnancy interval births. JAMA Netw Open. 2021;4(8):e2118912. 10.1001/jamanetworkopen.2021.18912 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990‒2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9947): 980–1004. 10.1016/S0140-6736(14)60696-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.US Department of Health and Human Services. Implementing Nurse-Family Partnership (NFP). Home visiting evidence of effectiveness. 2019. Available at: https://homvee.acf.hhs.gov/implementation/Nurse-Family%20Partnership%20(NFP)%C2%AE/Model%20Overview#Intendedpopulation-M. Accessed April 18, 2024.
- 38. National Center for Medical Legal Partnership. Available at: https://medical-legalpartnership.org . Accessed April 18, 2024. .
- 39.Gramlich J, Scheller A. What’s happening at the US-Mexico border in 7 charts. Pew Research Center. November 9, 2021. Available at: https://www.pewresearch.org/short-reads/2021/11/09/whats-happening-at-the-u-s-mexico-border-in-7-charts. Accessed July 3, 2024. [Google Scholar]