Immigrants with undocumented status are almost five times more likely to be uninsured than U.S. citizens. This prevents them from receiving needed health care and imposes an estimated cost of $17 billion per year on U.S. taxpayers, mostly due to uncompensated care. Immigrants with undocumented status have limited access to coverage because they do not qualify for Medicaid, Medicare, or federal Marketplace subsidies. Given the lack of options on the federal level, some states have decided to offer insurance coverage to some immigrants with undocumented status, such as children and pregnant people. Colorado is the first state to provide subsidized health insurance coverage to undocumented immigrants with low income statewide. Mathematica recently conducted an independent evaluation of this initiative, called the Colorado Health Insurance Affordability Enterprise (HIAE).
Colorado’s legislature established the HIAE through Senate Bill 20-215 in 2020 to address the affordability of health insurance on the individual market and reduce uninsurance in populations with limited insurance options. The HIAE’s governing board created OmniSalud as a component of the HIAE to provide health insurance for Colorado residents who are not eligible for federal subsidies. Coloradans with income below 150 percent of the federal poverty line, regardless of immigration status, can enroll in subsidized health plans with zero premiums and low cost sharing. Although about 36,000 immigrants with undocumented status were estimated to be eligible for this subsidized coverage, OmniSalud had the budget to cover only 10,000 enrollees for plan year 2023. Colorado used the existing state-based marketplace platform, Connect for Health Colorado, to set up Colorado Connect as a new platform for OmniSalud enrollees and implemented the program for the 2023 open enrollment period.
Advocates and policymakers interested in extending health insurance coverage to populations with undocumented immigration status in other states should consider the following lessons from Colorado’s experience:
- Understand your state’s political circumstances and structures.
Colorado’s legislation had support from legislators of both parties and from the state’s strong health care advocacy community. Once authorized, the HIAE benefited from well-established partnerships across government and nongovernmental entities, including the state-based marketplace, Connect for Health Colorado. Other states might be able to make the case for a coverage expansion that appeals to both the initiative’s natural allies and a wider net of potential supporters. States should also begin any prospective expansion with a realistic appraisal of the strength and depth of their relationships with key entities, as well as a strategy for robust collaboration and troubleshooting, particularly when technology and other operational challenges arise. - Partner with trusted messengers and engage them through each step of the process.
Colorado recognized that the OmniSalud population would be difficult to reach given shifting immigration policies, its past experiences being denied affordable health insurance coverage, and its general mistrust of the government. Faced with these challenges, the state relied on trusted community partners in spreading the word about coverage expansion and in informing its ongoing policymaking efforts. States should connect with people and organizations that have built trust within their communities and share key outreach and enrollment messages with them early, often, and in languages spoken by the state’s immigrant populations. States should also intentionally build authentic and meaningful engagement with communities into their governance and decision making processes and structures. - Expect high demand for health coverage initiatives that expand coverage to immigrants without documentation.
OmniSalud’s 10,000-enrollee subsidy cap was reached in the first five weeks of open enrollment—well before the December 15 deadline for January 1 coverage. State policymakers did not expect this high level of demand for coverage, and enrollment assisters needed more preparation to effectively communicate with potential enrollees about the limited availability of the subsidies. Colorado plans to expand the enrollment cap in future years as the HIAE budget grows. States should consider how to ensure that enrollment assisters, partners, and consumers are aware of any enrollment limit and provide next steps for those who want to enroll but cannot afford to without subsidies.
Colorado’s experience in implementing OmniSalud has imparted important lessons that will contribute to the success of the HIAE in the future. These lessons could inform similar efforts in other states, such as California and Washington, as well as the broader policy discussion on how to best ensure that those with undocumented status have affordable and accessible options for health care coverage. Without affordable health insurance options, this population will continue to experience poorer health outcomes and impose a burden on taxpayers.
