Health Care Costs and Immigration Status Among US Adults
- 1Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio
Abstract
Importance: The Affordable Care Act (ACA) expanded insurance coverage, while the 2018 Public Charge Rule Proposal (PCRP) raised concerns about immigration-related barriers to health care access.
Objective: To evaluate changes in insurance coverage, health care use, and medical expenditures among immigrant and US-born adults across ACA expansion and post-PCRP eras, stratified by poverty status.
Design, Setting, and Participants: This cross-sectional study used nationally representative Medical Expenditure Panel Survey (2010-2023) data for US adults aged 19 to 64 years with available data on nativity, family income, insurance coverage, use, and expenditures. Income less than 138% of the federal poverty level was considered low income; 138% or higher was considered not low. Data were analyzed from April 1, 2026, to April 15, 2026.
Exposures: Policy era, categorized as pre–ACA expansion (2010-2013), post–ACA expansion (2014-2018), and post-PCRP (2019-2023), and nativity, categorized as immigrant or US-born.
Main Outcomes and Measures: Primary outcomes were person-year measures of insurance coverage, health care use, and annual medical expenditures adjusted to constant 2023 US dollars. Survey-weighted multivariable models estimated adjusted changes across eras and tested differences by nativity.
Results: Complete-case adjusted analyses included 237 175 person-year observations from 126 724 unique adults, including 67 076 female adults (50.8%) and 59 648 male adults (49.2%), with a survey-weighted mean (SD) age of 40.8 (13.2) years; the analytic sample included 56 561 low-income and 180 614 non–low-income person-year observations. Among adults with low income, post-PCRP insurance coverage was higher among US-born adults (adjusted odds ratio [AOR], 2.84; 95% CI, 2.55-3.17) and immigrants (AOR, 2.29; 95% CI, 1.98-2.65), with smaller relative gains for immigrants. Post-PCRP total expenditures increased among US-born adults with low income (β = $1684.60; 95% CI, 883.10−2486.20) but not among immigrants with low income (β = $220.20; 95% CI, −680.10−1120.50). Among adults without low income, post-PCRP total expenditures increased among US-born adults (β = $1788.60; 95% CI, 1487.70−2089.50) and immigrants (β = $974.10; 95% CI, 517.50−1430.70).
Conclusions and Relevance: In this serial cross-sectional study of US adults aged 19 to 64 years, immigrants had lower insurance coverage, health care use, and medical expenditures than US-born adults. Coverage was higher in later eras, but coverage gains and expenditure growth were smaller among immigrants with low income, suggesting that insurance expansion alone may be insufficient to address nativity-related differences in health care access and spending.
Related
- A retrospective analysis of health care utilization and costs by body mass index category among adults with, or at risk of, cardiovascular disease
- A comparison of health care utilization among insured working-age adults in the state of Virginia, U.S. by long COVID and disabling condition status in 2022.
- Cross-sectional dataset on human papillomavirus (HPV) awareness, vaccination status, and health information sources among adults in five states of Nigeria
- The status quo and influencing factors of the utilization of Traditional Chinese Medicine (TCM) health services among older adults in China: a nationwide cross-sectional study.
- Healthcare utilization and medical costs among adults with selected psychiatric disorders: a nationwide retrospective cohort study
BibTeX
@article{alizai2026health,
title = {{Health Care Costs and Immigration Status Among US Adults}},
author = {Qaidar Alizai and Lorenza Arena and Areesh Mevawalla and Rida Ejaz and Jethro Wang Zih-shou and Meher Angez and Abdulaziz Elemosho and Charalampos M. Charalampous and Timothy M. Pawlik},
journal = {JAMA Network Open},
year = {2026},
month = oct,
doi = {10.1001/jamanetworkopen.2026.40261},
url = {https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2855778},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - Health Care Costs and Immigration Status Among US Adults
AU - Qaidar Alizai
AU - Lorenza Arena
AU - Areesh Mevawalla
AU - Rida Ejaz
AU - Jethro Wang Zih-shou
AU - Meher Angez
AU - Abdulaziz Elemosho
AU - Charalampos M. Charalampous
AU - Timothy M. Pawlik
PY - 2026
DA - 2026/10/01
JO - JAMA Network Open
DO - 10.1001/jamanetworkopen.2026.40261
UR - https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2855778
AB - Importance: The Affordable Care Act (ACA) expanded insurance coverage, while the 2018 Public Charge Rule Proposal (PCRP) raised concerns about immigration-related barriers to health care access. Objective: To evaluate changes in insurance coverage, health care use, and medical expenditures among immigrant and US-born adults across ACA expansion and post-PCRP eras, stratified by poverty status. Design, Setting, and Participants: This cross-sectional study used nationally representative Medical Expenditure Panel Survey (2010-2023) data for US adults aged 19 to 64 years with available data on nativity, family income, insurance coverage, use, and expenditures. Income less than 138% of the federal poverty level was considered low income; 138% or higher was considered not low. Data were analyzed from April 1, 2026, to April 15, 2026. Exposures: Policy era, categorized as pre–ACA expansion (2010-2013), post–ACA expansion (2014-2018), and post-PCRP (2019-2023), and nativity, categorized as immigrant or US-born. Main Outcomes and Measures: Primary outcomes were person-year measures of insurance coverage, health care use, and annual medical expenditures adjusted to constant 2023 US dollars. Survey-weighted multivariable models estimated adjusted changes across eras and tested differences by nativity. Results: Complete-case adjusted analyses included 237 175 person-year observations from 126 724 unique adults, including 67 076 female adults (50.8%) and 59 648 male adults (49.2%), with a survey-weighted mean (SD) age of 40.8 (13.2) years; the analytic sample included 56 561 low-income and 180 614 non–low-income person-year observations. Among adults with low income, post-PCRP insurance coverage was higher among US-born adults (adjusted odds ratio [AOR], 2.84; 95% CI, 2.55-3.17) and immigrants (AOR, 2.29; 95% CI, 1.98-2.65), with smaller relative gains for immigrants. Post-PCRP total expenditures increased among US-born adults with low income (β = $1684.60; 95% CI, 883.10−2486.20) but not among immigrants with low income (β = $220.20; 95% CI, −680.10−1120.50). Among adults without low income, post-PCRP total expenditures increased among US-born adults (β = $1788.60; 95% CI, 1487.70−2089.50) and immigrants (β = $974.10; 95% CI, 517.50−1430.70). Conclusions and Relevance: In this serial cross-sectional study of US adults aged 19 to 64 years, immigrants had lower insurance coverage, health care use, and medical expenditures than US-born adults. Coverage was higher in later eras, but coverage gains and expenditure growth were smaller among immigrants with low income, suggesting that insurance expansion alone may be insufficient to address nativity-related differences in health care access and spending.
SN - 2574-3805
ER -