For undocumented immigrants in the United States, obtaining health insurance through the government is next to impossible, with both the Affordable Care Act and a recent executive immigration order explicitly declaring them ineligible for health care coverage. That means many are forced to put off preventative care measures and eventually turn to expensive, overstressed emergency rooms once they become severely ill. 

Now, state officials are trying to find ways around the federal government's prohibition and provide various kinds of coverage to immigrants who don't qualify for Obamacare. Using state funds, California and New York are pioneering ways to offer comprehensive coverage for undocumented immigrants and others with temporary work visas. A handful of other states offer limited insurance coverage to subsets of immigrant populations. But experts warn such programs remain in the minority, and that the overall lack of health care coverage for immigrants in the United States could result in much higher medical bills in the future.

By 2016, 5.1 million undocumented immigrants in the U.S. will be uninsured, a group of UCLA researchers has estimated. In 2012, there were an estimated 11.2 million unauthorized immigrants in the U.S. Under the 1986 policy EMTALA, hospitals cannot turn away a person in need of care, regardless of immigration status or ability to pay. Emergency treatment costs to Medicaid amounts to about $2 billion a year, mostly for illegal immigrants, according to a 2013 report by Kaiser Health News. In 2009, research by the Center for Immigration Studies estimated the cost of treating uninsured and undocumented immigrants at $4.3 billion per year at safety-net facilities like emergency rooms and community health clinics.

Advocates for immigrant health coverage say these sums might be less exorbitant if undocumented immigrants had regular primary care, which would be more accessible if they had insurance. “Those bills could’ve been drastically reduced,” Frank Rodriguez, president of the Latino Health Care Forum, which offers health care outreach and enrollment assistance to the uninsured and underinsured in Texas, said. “There are no preventative health measures, so they [undocumented, uninsured immigrants] end up having to use emergency care.”

Critics, however, argue that providing health care to illegal immigrants will encourage more illegal immigration and that taxpayers shouldn't have to pay for social services for those in the country without legal status. "County hospitals are overwhelmed with uninsured people, and they've been forced to come up with more money to accommodate these people — largely because they've encouraged them to come in," Ira Mehlman, media director for the Federation for American Immigration Reform, has told the Los Angeles Times.

Unauthorized immigrants could theoretically buy private health insurance, but that option is usually prohibitively expensive. “Unauthorized immigrants are not eligible for almost any of the federal, state and local health care programs, and they tend to work in jobs that don’t carry employer coverage,” Randy Capps, director of research for U.S. programs at the Migration Policy Institute, said. 

The other health care option for undocumented immigrants is federally qualified health centers, which are reimbursed by and receive other funding from the government and do not ask questions about immigration status. But “federally qualified health centers don’t do much primary health care because they’re not reimbursed [for it],” Rodriguez said. If a person sought primary medical services at such centers, they would likely have to pay out of pocket, albeit on a sliding fee scale. “The undocumented immigrants won’t go,” he said. 

Alvaro Huerta, a staff attorney at the National Immigration Law Center, called it "shortsighted" not to give undocumented and deferred action immigrants access to primary care, given how cost-effective such care be. “Every principle of health reform, [for the] documented or undocumented, says, put your money into preventative care, because you’re going to be spending 100 times the investment in preventative care when people wind up sick in emergency rooms or hospitals," he said.

On Jun. 15, 2012, the Obama administration issued an executive order granting certain undocumented immigrants immunity from deportation and making them eligible for work permits. A few months later, the administration explicitly restricted its policy so that these immigrants were not eligible for health insurance under the Affordable Care Act.

California has long been the vanguard for ensuring that immigrants have access to health care and insurance. It allows deferred action grantees under Obama's policies to enroll in Medi-Cal or a parallel public health insurance program, and lawmakers have also proposed legislation to grant all undocumented immigrants eligibility for the same two programs. Most recently, in December 2014, State Senator Ricardo Lara of California introduced SB 4,  a bill that tries to make all undocumented immigrants eligible for Medi-Cal.

Some counties in California also offer coverage to all undocumented immigrants. My Health LA, for instance, is a program in Los Angeles County specifically for the undocumented population. According to Steven Abramson, director of development and marketing for ChapCare, about 10 percent of the clinics’ patients are covered under that program. In order to qualify, they have to prove that they live in the county and that their income level is below 138 percent of the federal poverty level. “It’s obviously not perfect, but it’s definitely better than the alternative, which is having nothing,” he said. 

In New York, undocumented immigrants are not eligible for coverage through the state’s health care exchange. Nor are they eligible for Medicaid, unless a woman is pregnant. But unlike in other states, an immigrant who has received a work visa under Obama's immigration policies is eligible for Medicaid or another form of public health insurance, depending on income.

“It’s absolute common sense," said Robert Hayes, the CEO of Community Healthcare Network NYC, which runs 11 federally qualified health centers plus a mobile van in New York City and serves undocumented immigrants.

While immigrants tend to be younger and thus healthier than the general population, if they develop chronic illnesses like diabetes that go undetected or untreated because of a lack of health insurance, the cost of treatment would be far higher down the road.

"These are usually young, healthy people now, that we could keep healthy, but like all of us will need medical care at some point in their lives," Huerta said. "It’s critical to get these people, who are American in everything but a piece of paper, access to care they need now before it becomes something we’re paying for in the long run."