Half of WA’s undocumented immigrants are uninsured. For the first time, the state marketplace is open to them

Almost 30 years ago, Javier was in his mid-40s and had just moved to the U.S. from Mexico when he had a heart attack.

Javier asked KUOW not to publish his last name because he’s undocumented.

Someone called an ambulance, and he woke up in a hospital, he said. They stabilized him and sent him home.

The hospital was asking for tens of thousands of dollars — money Javier didn’t have.

“I got bill, after bill, after bill” for that trip to the emergency room, he said in Spanish. “I didn’t pay attention to them. I didn’t pay them.”

Javier is one of the roughly 50% of undocumented immigrants without health insurance in Washington state and nationwide. But this month, Washington became the first state to open its insurance marketplace to all residents, including all undocumented immigrants. And those below a certain income will even be able to get state subsidies to help pay the insurance premiums.

From their inception, state health insurance exchanges explicitly excluded undocumented immigrants — and to change that, states have to get a special waiver from the federal government. Washington is the first state to get that waiver.

Because Javier didn’t have health insurance or extra cash, when he got home from the hospital, he didn’t get any follow-up care: no tests, scans, or ongoing medication. For years, he didn’t know why he’d had a heart attack, or if he could have another.

“When people have access to health insurance, it can often be the difference between life and death,” said Wynne McHale, chief of staff at the Washington Health Benefit Exchange.

McHale said that people often delay getting care — like in Javier’s case — when they don’t have access to health insurance.

“That can mean showing up in the ER with cancer that has developed to a much later stage,” McHale said.

Sasha Wasserstrom, policy director for the Washington Immigrant Solidarity Network, said uninsured, undocumented immigrants not only suffer from untreated chronic conditions; they also often avoid seeking care for acute injuries, like severe burns from working in kitchens. Wasserstrom said that can mean they suffer from ongoing pain or lose the ability to use parts of their body, like one of their hands or arms.

In about a dozen states, including Washington, undocumented children can qualify for state Medicaid or other state-funded coverage. A handful of those states have also extended coverage to some undocumented adults, depending on their health conditions, incomes, or ages.

For example, in several states, pregnant people, those on dialysis, or those with cancer can get state Medicaid regardless of their immigration status. Colorado extends state-subsidized plans to low-income undocumented residents through a system separate from the state marketplace. And California has increasingly expanded the state’s Medicaid to include many low-income undocumented residents.

But Washington is the first to open its marketplace to all undocumented residents.

“We are really excited that Washington state is joining just a handful of states in trying to figure out: How do we make coverage available for all of our community members, regardless of immigration status?” McHale said.

They said that’s the “right thing to do,” but also, they added, “Thinking about what it means for the workforce and for our economy for all of our community members to have access to health care, it means that people are healthier, and people are able to show up to work.”

McHale expects only a small percentage of the state’s approximately 100,000 newly eligible residents to sign up for insurance this year.

One issue is cost: The premiums — even subsidized premiums — are still too expensive for many.

Also, though the state has worked with many community-based organizations to try to get the word out, lots of undocumented immigrants don’t yet know about the change or don’t trust the state with their information.

“It’s a very hard population to get access to,” said Adrienne Sabety, a health care economist at Stanford University in California. She has researched ways to increase undocumented immigrants’ access to and use of primary care.

Sabety said she suspects that most of those who purchase health insurance for the first time this November will be people with chronic conditions, like hypertension or diabetes. That could lead to cost savings, she said, since regular management of those conditions is usually cheaper than caring for them only on an emergency basis.

Still, she said, access to insurance is only a first step toward actually getting regular health care.

“My guess is that [just because] you expand insurance, you don’t suddenly see millions of people making a primary care appointment immediately,” she said.

Sabety explained that it can be so hard to get a doctor’s appointment in the U.S. — especially if English isn’t your first language or you don’t know how to navigate the country’s decentralized health system — that it remains to be seen how much of a difference insurance alone can make.

“This is going to add individuals who may have never interacted with the formal health care system before,” Sabety said. “It might require hospitals and providers to create or expand the existing service base for English as a second language.”

Critics of Washington’s policy change say it could make the state a magnet for undocumented immigrants with medical needs.

But overall, the pushback has been muted.

“This particular issue doesn’t rank high,” said Jim Walsh, a state lawmaker and chair of the state’s Republican Party.

Walsh said his main problem is with the U.S. health care system as a whole.

“I’m totally against spending tax subsidies on this rotten system,” he said. “But whether they’re documented or undocumented doesn’t matter.”

But in many other states and nationally, giving undocumented immigrants more access to health care remains a tough sell.

Leading up to the 2020 presidential election, Democratic candidates were asked whether they’d support opening up Medicaid or subsidized health insurance to undocumented immigrants. All said yes.

Then-President Donald Trump opposed the idea, and a CNN poll after the debate found most respondents were also opposed.