Sep, 05, 2025

How H.R.1 Impacts Coverage for Non-Citizens

Patti Boozang, Elizabeth Dervan, and Tara Straw, Manatt Health

Overview

On July 4, President Trump signed into law H.R.1, making dramatic changes to the Medicaid and Marketplace coverage landscape nationwide. As part of these changes, H.R.1 included major provisions scaling back access to health coverage for many lawfully residing non-citizens beginning next year. These changes are estimated to leave 1.3 million more immigrants uninsured, undermining their access to healthcare and putting their financial security at risk.   

Immigrants have historically faced significant barriers to health coverage and safety-net programs, in part due to complex eligibility rules and processes that limit access to non-citizens, language access challenges, and changing definitions of public charge, creating fears about how accessing services or programs might impact immigration status. Additionally, non-citizen immigrants are disproportionately employed by low-wage jobs and industries that are less likely to offer employer-sponsored coverage. Today, immigrants are less likely to be insured compared to U.S. citizens, despite evidence that suggests immigrants, including those who are undocumented, may subsidize the U.S. healthcare financing system.

The Affordable Care Act (ACA) significantly improved access to affordable healthcare for immigrants by extending Marketplace subsidies to lawfully present non-citizens, helping to lower the uninsurance rate and improving access to care. Medicaid has also served as a crucial program for immigrant families, with many lawfully residing non-citizens eligible for Medicaid and the Children’s Health Insurance Program (CHIP) for decades. Together, the Marketplaces, Medicaid, and CHIP have helped to provide many lawfully residing non-citizens across the country with pathways to coverage and affordable healthcare.  

In a sharp reversal, H.R.1 severely limits lawfully residing non-citizens’ ability to access coverage through these programs. As described below, the law eliminates the availability of premium tax credits (PTCs) and federally-funded Medicaid and CHIP coverage for many non-citizens who have been eligible for these programs for years, and eliminates PTCs for the lowest income, lawfully present non-citizens who are subject to a waiting period before they qualify for Medicaid or CHIP.[1] In doing so, H.R.1 ends the availability of any affordable coverage option for many lawfully residing individuals in the country. While states may be able to provide coverage through Medicaid/CHIP state options or state-funded health programs, states will face major challenges in doing so as they absorb historic funding cuts enacted under H.R.1. Overall, H.R.1 will profoundly impact immigrants’ ability to access healthcare across the country going forward.  

How Medicaid/CHIP and the Marketplaces Cover Non-Citizens Today

Today, Medicaid/CHIP and the Marketplaces serve as critical sources of health coverage to many lawfully residing non-citizens.

With respect to Medicaid/CHIP, states are able (and sometimes required) to provide coverage to “qualified” non-citizens (QNCs) specified under the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 and certain other lawfully residing non-citizens who meet the other eligibility criteria of the state. QNCs include, for example, lawful permanent residents (LPRs), refugees, asylees, certain humanitarian parolees (such as certain Afghans who aided U.S. operations in Afghanistan or people fleeing violence in the Ukrainian war), victims of human trafficking, individuals residing under the Compacts of Free Association (often referred to as COFA migrants), Cuban-Haitian entrants, among others. Importantly, some QNCs—such as LPRs—are subject to a five-year waiting period (meaning they have held a “qualified” immigration status for five years) before qualifying for Medicaid or CHIP.[2]

In addition to QNCs, states can provide Medicaid or CHIP coverage to lawfully residing children or pregnant individuals through the so-called “CHIPRA 214” state option, authorized under the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009. Under this option, states can provide coverage to QNCs without regard to the five-year waiting period, and to lawfully residing individuals beyond QNCs. Roughly three-quarters of states use the CHIPRA 214 option today. Some states also provide health coverage to non-citizens through CHIP Health Services Initiatives (HSIs), the From Coverage to End of Pregnancy (FCEP) option (allowing states to provide CHIP coverage to children from conception to birth, regardless of the pregnant individual’s immigration status), and state-funded programs.

The Marketplaces are also important sources of affordable coverage for lawfully residing individuals. Marketplace subsidies that help individuals enroll in and use health coverage—PTCs and cost-sharing reductions—are available to a broader group of lawfully present immigrants (not just QNCs) compared to Medicaid/CHIP. Thus, the Marketplaces help fill the gaps for non-citizens who are ineligible for Medicaid/CHIP, including during the five-year waiting period where applicable. Marketplace subsidies are also available to lawfully present non-citizens with incomes under 100% of the federal poverty level (FPL) as a statutory exception from what is otherwise the lower-bound income level for PTC eligibility.

H.R.1’s Changes to Affordable Coverage for Non-Citizens

H.R.1 ends the availability of federally-funded Medicaid/CHIP coverage and Marketplace subsidies for many groups of lawfully residing individuals, with certain changes starting as soon as next year.  

For Medicaid/CHIP, beginning October 1, 2026, only the following non-citizens will remain eligible for federally-funded Medicaid/CHIP coverage:

  • LPRs (after the five-year waiting period);
  • Cuban/Haitian entrants;
  • COFA migrants; and
  • Lawfully residing children and pregnant individuals under CHIPRA 214 (at state option).

 

H.R.1 explicitly notes that these changes do not apply to CHIP HSIs, allowing states to continue serving a broad group of children through these initiatives.[3]

For the Marketplaces, there will be two important changes limiting non-citizens’ access to affordable health coverage. First, beginning January 1, 2026, PTCs will no longer be available to non-citizens with incomes under 100% of the FPL who are ineligible for Medicaid due to their immigration status (including LPRs and others who are subject to their five-year waiting period for Medicaid)–effectively creating a coverage gap under the poverty level for the lowest income lawfully present non-citizens.   

Following that, beginning January 1, 2027, PTCs will only be available to the following non-citizens with incomes at or above 100% of the FPL:

  • LPRs;
  • Cuban-Haitian entrants; and
  • COFA migrants.

 

Lawfully residing non-citizens who do not qualify for PTCs would still be able to enroll in unsubsidized Marketplace plans. 

Overall, the impact on coverage across both programs will be severe. The provisions in H.R.1 end coverage options that have been available to many lawfully residing individuals for decades—including refugees, asylees, victims of human trafficking, and others. As a result, more immigrants will go without health coverage, leading them to face higher barriers to healthcare, take on more medical costs, or forgo care altogether. The nonpartisan Congressional Budget Office (CBO) estimated that 1.3 million people would go without health coverage due to these changes, with most of this impact due to changes to Marketplace subsidies.[4] Overall, given these coverage losses, CBO projects these changes will reduce federal spending by $120 billion over 10 years.[5]

Together, these changes to Marketplace subsidies and Medicaid/CHIP effectively end the availability of any affordable coverage option for many lawfully residing non-citizens in the country. While lawfully present non-citizens remain eligible to enroll in Marketplace plans, individuals will be required to pay the full, unsubsidized premium. This is likely to prove cost prohibitive for most, severely limiting enrollment and access to coverage—both for people currently receiving Marketplace coverage and for low-income immigrant families newly barred from Medicaid or CHIP who would otherwise turn to the Marketplaces for affordable coverage options. This is made worse by H.R.1’s elimination of PTCs for individuals below 100% of the FPL, leaving the lowest income lawfully residing individuals, including LPRs, without affordable coverage.

As an example, Figure 1 below describes how these provisions would interact to eliminate coverage options for low-income non-citizens in a Medicaid expansion state. While LPRs will continue to be eligible for PTCs above 100% of the FPL and Medicaid/CHIP after a five-year waiting period, the elimination of PTCs for individuals with incomes below 100% of the FPL beginning January 1, 2026 means lower-income LPRs would have essentially no coverage option while waiting to qualify for Medicaid/CHIP. Refugees and asylees (and other lawfully residing individuals no longer eligible for federally funded Medicaid/CHIP or PTCs under H.R.1) would first lose Medicaid/CHIP beginning October 1, 2026, but be able to briefly seek out subsidized coverage in the Marketplaces through the calendar year. Beginning January 1, 2027, these individuals would also lose access to PTCs in the Marketplaces, likely leaving them without affordable coverage options and without health insurance.

Figure 1. How H.R.1 Will Impact Non-Citizen Coverage in a Medicaid Expansion State

For illustrative purposes, this graphic looks at someone who is eligible under the Medicaid expansion for adults with income under 138% of the FPL. The coverage implications would be different for non-citizens in non-expansion states or if a non-citizen qualifies for coverage through another eligibility category. This graphic does not account for eligibility under the CHIPRA 214 option.

Looking Ahead

There are important steps that states can take to provide coverage options for non-citizens impacted by these provisions. As noted above, states can continue providing federally funded Medicaid/CHIP coverage to any lawfully residing children and pregnant individuals under the CHIPRA 214 option (without regard to a five-year waiting period), including refugees, asylees, and others. States can also provide coverage to individuals regardless of immigration status through state-funded programs, though those programs will be increasingly stressed by heightened demand from newly eligible non-citizens.[6] Additionally, in recent months, states have proposed or started to roll back the use of state dollars for programs that expand health coverage to non-citizens, due to state budget deficits. On top of this, states will be absorbing the historic federal funding cuts enacted in H.R.1—putting major financial pressure on their budgets as they consider whether and how to take up Medicaid/CHIP options or to expand (or even maintain) their state-funded programs for non-citizens.

Overall, H.R.1’s changes will have major consequences for lawfully residing non-citizens across the country and will leave more people uninsured, threatening to widen existing coverage and health disparities for non-citizens going forward. These changes build on other recent and major federal efforts to restrict immigrants’ use of healthcare and other programs, including the expansion of eligibility restrictions under PRWORA to new federal health, nutrition, and other programs,[7] the end of Deferred Action for Childhood Arrivals (DACA) recipients’ ability to access the Marketplaces, and similar eligibility restrictions enacted in H.R.1 for the Supplemental Nutrition Assistance Program (SNAP). Combined with recent revelations that the administration had used Medicaid data for immigration enforcement, these upcoming changes to Medicaid and Marketplace coverage will likely also contribute to confusion and chilling effects that prevent immigrants, including eligible individuals, from seeking and finding the coverage and health services they need. As implementation dates approach, state Medicaid, CHIP, and Marketplace programs will need to work together to prepare for the operational and human impacts of these restrictions, including by engaging with impacted communities, Navigators and assisters, and community-based organizations to help connect people to coverage and healthcare options.

[1] The law also imposes the same restrictions in Medicare. This means that some additional older non-citizens who are not lawfully permanent residents, Cuban/Haitian entrants, or Compacts of Free Association migrants will become uninsured.

[2] States can also receive federal funding for emergency Medicaid provided to individuals who do not qualify on the basis of their immigration status. Under H.R.1, beginning October 1, 2026, states will only receive their regular federal Medicaid match for such services, including for individuals who, but for their immigration status, would have qualified for Medicaid expansion.

[3] States can also continue adopting the FCEP option to provide coverage to targeted low-income children from conception to birth.

[4] Over the next decade, CBO estimates that H.R.1’s narrowing of the scope of lawfully present individuals eligible for PTCs would lead to 900,000 individuals going without coverage; that sunsetting the availability of PTCs for lawfully present individuals under 100% FPL would lead 300,000 individuals to become uninsured; and that changes to Medicaid/CHIP eligibility would lead 100,000 people to go without health insurance.

[5] See CBO, Estimated Budgetary Effects of Public Law 119-21, to Provide for Reconciliation Pursuant to Title II of H. Con. Res. 14, Relative to CBO’s January 2025 Baseline (July 21, 2025).

[6] As of April 2025, 14 states plus the District of Columbia provide fully state-funded coverage for income-eligible children regardless of immigration status, and seven states plus the District of Columbia provide fully state-funded coverage to some income-eligible adults regardless of status.

[7] Federal enforcement of these changes has been temporarily suspended through September 10, 2025.