The safety nets of Medicare and Medicaid don’t catch everyone. One group excluded from the programs are older undocumented people, points out Jose Figueroa, associate professor of health policy and management at Harvard T.H. Chan School of Public Health. In a recent perspective article published in the New England Journal of Medicine, Figueroa puts forth policy solutions that can help deliver health care to “dual noneligibles,” the growing population left behind by public insurance. He shares more below.
Q: Who are “dual noneligibles” and what challenges do they face in the U.S. health system?
A: “Dual noneligibles” are older undocumented people in the U.S. who, because of their immigration status, are ineligible for both Medicare and Medicaid. By 2030, an estimated 1.1 million seniors may fall into this category. This population faces significant health challenges due to aging, high chronic disease burdens, and socioeconomic vulnerabilities. Unlike dually eligible individuals who can rely on both Medicare and Medicaid, dual noneligibles often lack health insurance and access to affordable, consistent health care. Instead, they must navigate a patchwork of state and community-based safety net programs, which vary in availability and comprehensiveness. Many avoid seeking care altogether due to cost, fear of deportation, and other access barriers, despite the fact that dual noneligibles (and other undocumented immigrants) contribute billions of dollars in taxes, including to Medicare and Social Security.
Q: What are some policy changes that could help deliver health care to dual noneligibles?
A: While not exhaustive, my co-author, David Velasquez, and I propose three potential strategies. First, increased funding for community health centers (CHCs) is critical. CHCs are a vital resource, offering primary care, some specialty care, and social services to patients regardless of immigration status. While federal support for CHCs will likely be limited under the Trump administration, states and private insurers could step in with targeted grants. This kind of supplemental support is already being provided in Massachusetts and California.
Second, we can expand financial assistance and so-called charity care—free or discounted health services for patients unable to pay. For example, states can require nonprofit hospitals to extend charity care to dual noneligibles, similar to New York’s financial assistance mandate that requires hospitals to offer assistance to low-income patients regardless of their immigration status. Nonprofit hospitals currently receive $37 billion in tax breaks in exchange for providing community benefits, including subsidized care for underinsured populations. States could enforce more equitable distribution of these tax subsidies to ensure more of the funds reach hospitals where dual noneligibles are a significant portion of the patient population.
Finally, states can consider implementing Medicaid-like programs that serve dual noneligibles. Currently, some states, like California, Illinois, and Minnesota, are pioneering programs that provide health benefits to undocumented immigrants. In conservative-led states, like Texas and Florida, this will likely be politically challenging. In those states, employer-sponsored health plans could offer an alternative route to care for dual noneligibles whose family members are legal residents.
Q: Why is it important for public health officials and policymakers to embrace, rather than neglect, health care access for dual noneligibles?
A: Dual noneligibles are and have been integral to the U.S. economy, working in essential industries like agriculture, construction, and caregiving. Excluding them from national discussions of health care access undermines our country’s public health goals. Finding solutions to provide health care access for all people in our country, irrespective of immigration status, can ensure we all have an opportunity to lead dignified lives as we age.
