In Thailand, All People Have Access to Health Coverage, Even Undocumented Migrants

While the Affordable Care Act (ACA) has made significant strides in providing health coverage to more Americans, there is still no federal policy that allows people entering the United States without legal status — known as undocumented migrants — to enroll in federally funded health insurance programs.

Without access to coverage through Medicaid, the Children’s Health Insurance Program, Medicare, or private plans sold in the ACA marketplaces, roughly 10.5 million undocumented people, or 3 percent of the U.S. population, lack an affordable pathway for receiving health care.[1] In the U.S., health care costs can be prohibitive without insurance — nearly three of four adults without coverage at any point within the past year are forced to skip or delay needed care because of the cost.

Some countries allow undocumented migrants access to health care benefits in limited circumstances. But Thailand is one of only two countries, alongside Spain, to give undocumented migrants the same health benefits as its citizens, and therefore lay claim to having a truly universal health coverage system. Thailand’s experience demonstrates that when undocumented people are given health coverage, the entire population can benefit.

Thailand’s Efforts to Bring Undocumented Migrants into the Health Care System

In 2005, Thailand became home to people escaping economic and political crises in Myanmar, Laos, Cambodia, and Vietnam, as well as many others seeking economic stability and work opportunities. At the time, these migrants accounted for roughly 5 percent of Thailand’s labor force and contributed roughly 6 percent of the country’s GDP.

The Thai Ministry of Public Health started allowing undocumented migrants to enroll in public health insurance and receive limited health services at contracted public facilities in 2001. By 2014, benefits were expanded to allow undocumented migrants to receive a wider range of health services in public health facilities, and they were able to add their dependents and spouses to their health plans.

The Thai health system is made up of multiple parallel health insurance schemes, and which one a person falls under depends on their immigration and job status. So-called low-skilled migrants in the informal sector — including undocumented migrants —can enroll in the Health Insurance Card Scheme (HICS). Enrollment requires migrants to undergo national verification to obtain a work permit and a health screening and pay a small annual premium. Once they’ve been approved, the benefits are fairly comprehensive, though treatments for some surgeries, fertility services, and other major interventions are excluded. Undocumented migrants who do not enroll in HICS are still able to receive health services, but they must pay out of pocket.

Roughly a third of migrants are enrolled in the country’s health insurance system. While the government is making an effort to encourage more people to enroll, the impact of extending coverage to undocumented migrants has already been significant: Thailand has minimized the spread of infectious diseases, improved access to health services, reduced the incidence of catastrophic health spending, and created a healthier workforce.

But barriers to access remain. Most undocumented migrants are not enrolled in the country's health insurance system, owing to barriers like cost, language, and the national verification process. In addition, hospitals often have to wait months for reimbursement by the government, especially for care given to undocumented migrants, which can cause them to turn high-cost patients away. And hospitals in remote regions, where many undocumented migrants reside to undertake agricultural work, can often lack the proper medical and financial resources to provide comprehensive care.

The Case for Extending Health Coverage to Undocumented People in the U.S.

In the U.S., undocumented immigrants contribute roughly $1.6 trillion to the economy and billions of dollars annually towards taxes. Nearly three-quarters undertake work classified as essential, including jobs in the agricultural, construction, and transportation sectors. In short, undocumented immigrants are a critical part of the U.S. economy, and they drive economic growth.

Nevertheless, half of undocumented immigrants have no insurance, and they tend to experience poorer health outcomes. From an economic perspective, these poor outcomes lead to a less productive workforce. From a public health perspective, lack of coverage means less access to preventive screenings and vaccinations, which leads to the spread of infectious diseases like tuberculosis and HIV. Beyond the economic and public health benefits, undocumented immigrants’ access to coverage upholds the United Nations Declaration of Human Rights principle that every person has the right to health care.

Starting in November 2024, the Biden administration will allow those in the Deferred Action for Childhood Arrivals (DACA) program to be eligible for insurance coverage through the ACA marketplaces and the Basic Health Program, a state ACA coverage option in Minnesota, New York, and Oregon. An estimated 100,000 previously uninsured DACA recipients will gain coverage as a result. For the remaining undocumented population, some states have extended affordable coverage. For example:

• California and Oregon are providing full Medicaid benefits to undocumented immigrants whose income makes them eligible for Medicaid.
• New York expanded Medicaid eligibility to undocumented immigrants over age 65.
• Colorado and Washington State are providing financial support for low-income undocumented immigrants to purchase coverage through the marketplaces.

Climate-fueled natural disasters, global conflict, and economic opportunities will continue to drive people out of their home countries and across borders. Other high-income countries like the United States will inevitably see their undocumented migrant populations grow. As Thailand shows, expanding health coverage to people entering the country in irregular ways can promote a healthier and more prosperous population overall.

The author would like to thank Watinee Kunpeuk, Researcher at the International Health Policy Program in Bangkok, Thailand for their review of this Insight.

[1] A recent rule from the Biden administration will allow those in the Deferred Action for Childhood Arrivals program to be eligible for insurance coverage through the Affordable Care Act marketplaces and Basic Health Programs with financial assistance.