Health Care Costs and Immigration Status Among US Adults

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.

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.

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.

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.

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.

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).

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.