	Introduction

The 111 th Congress has made health reform a priority. As health reform is debated, one possible issue that may surface is the rights and requirements of noncitizens (aliens) under health reform. Because some of the proposals to address health reform in the United States would create a mechanism to provide health insurance to the overwhelming majority of individuals in the nation, this report explores the health insurance coverage of noncitizens in the United States, as well as noncitizen usage of selected safety-net providers and the impact of unauthorized aliens on the health care system. Overview of Noncitizen Eligibility for Health Insurance

Noncitizens are not barred from having health insurance or from paying for health care on their own. Indeed, due to the quality of health care in the United States, some noncitizens come to the United States to receive health care from world-renowned doctors and hospitals. Furthermore, U.S. law mandates that Medicare-participating hospitals provide emergency medical services for all patients who seek care, regardless of their ability to pay; this includes services to all noncitizens, regardless of their immigration status. Nonetheless, the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) established comprehensive new restrictions on the eligibility of noncitizens for federal, state, and local public benefits—with significant exceptions for those with a substantial U.S. work history or military connection—setting specific eligibility requirements and exceptions for many health care services. In summary, noncitizens have specific eligibility requirements under law for public benefits, including means-tested public benefits such as Medicaid and CHIP, which can, however, pay for emergency medical services of certain noncitizens who are otherwise eligible. In addition, due to the exemptions and the fact that under regulation federally funded health centers are not defined as federal public benefits, there does not appear to be specified eligibility requirements or prohibitions related to noncitizens' use of Federally Qualified Health Centers, including community health centers and migrant health centers. Analysis: Overview

			Overview of Health Insurance Coverage

As shown in Figure 1 , noncitizens are more than three times as likely as native-born U.S. citizens, and more than two times as likely as naturalized U.S. citizens, to be uninsured: 43.8% of noncitizens lacked any type of health insurance, compared with 12.7% of native-born and 17.6% of naturalized populations. Similarly, noncitizens have a lower rate of private insurance coverage, while native-born and naturalized U.S. citizens have similar rates of private health insurance. The noncitizen population also has the lowest rate of Medicare coverage, while naturalized citizens, who tend to be older than native-born citizens and noncitizens, have the highest rate of Medicare coverage. Lastly, the noncitizen population has much lower rates of military/veterans coverage than the naturalized and native-born populations. The rates and types of health insurance coverage are affected by variables such as occupation, industry, education, and region of birth; however, other socio-economic variables, such as age, do not seem to have an effect. During that time period, the percentage of noncitizens in the uninsured population increased from 19.6% in 2000 to a high of 21.5% in 2006, and then decreased slightly to 21.1% in 2007 (see Table 9 ). Conversely, in 2000, native-born citizens comprised their largest percentage of the uninsured population (75.5%) and the percentage decreased, though not uniformly, to a low of 73.1% in 2007. As with the noncitizen population, the percentage of naturalized citizens in the uninsured population increased from a low of 4.6% in 2000 to a high of 5.8% in 2007, but the increase was not steady during the period. In FY2006, $2.6 billion was spent on emergency Medicaid, which constituted 1.1% of the total Medicaid spending. Ascertaining the cost of unauthorized aliens to the health care system presents complex fiscal questions.
The 111th Congress has made health reform a priority. As health reform is debated, one possible issue that may surface is the rights and requirements of noncitizens (aliens) under health reform. Because some of the proposals to address health reform in the United States would create a mechanism to provide health insurance to the overwhelming majority of individuals in the nation, this report explores the health insurance coverage of noncitizens, as well as noncitizen use of selected safety-net providers and the impact of unauthorized aliens on the health care system.
Noncitizens are not barred from having health insurance or from paying for health care on their own. Indeed, due to the quality of health care in the United States, some noncitizens come to the United States to receive health care from world-renowned doctors and hospitals. Furthermore, U.S. law mandates that Medicare-participating hospitals provide emergency medical services for all patients who seek care, regardless of their ability to pay, including services to noncitizens, regardless of their immigration status.
Nonetheless, the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (P.L. 104-193) established comprehensive new restrictions on the eligibility of noncitizens for federal, state, and local public benefits, setting specific eligibility requirements and exceptions for many health care services. In general, noncitizens have specific eligibility requirements under law for public benefits, including means-tested public benefits such as Medicaid and the State Children's Health Insurance Program, but are eligible for emergency medical services. In addition, due to the exemptions and the fact that federally funded health centers are not defined as federal public benefits under regulation, there do not appear to be specified eligibility requirements related to noncitizens' use of Federally Qualified Health Centers (FQHCs).
In terms of insurance coverage, noncitizens are more than three times as likely as native-born U.S. citizens and more than two times as likely as naturalized U.S. citizens to be uninsured. Similarly, noncitizens have a lower rate of private insurance coverage, while native-born and naturalized U.S. citizens have similar rates of private health insurance. The noncitizen population also has the lowest rate of Medicare coverage, while naturalized citizens, who tend to be older than native-born citizens and noncitizens, have the highest rate of Medicare coverage. Lastly, the noncitizen population has much lower rates of military/veterans coverage than the naturalized and native-born citizen populations. The rates and types of health insurance coverage are affected by variables such as occupation, industry, education, and region of birth; however, other socio-economic variables, such as age, do not seem to have an effect.
Between 2000 and 2006, the percentage of noncitizens in the uninsured population increased from 19.6% to 21.5% and then decreased slightly (to 21.1%) in 2007. Conversely, in 2000, native-born citizens made up the largest percentage of the uninsured population (75.5%), and the percentage decreased, though not uniformly, to a low of 73.1% in 2007. As with the noncitizen population, the naturalized citizens percentage of the uninsured population increased from a low of 4.6% in 2000 to a high of 5.8% in 2007. In FY2006, 1.5% of the total Medicaid recipients received emergency Medicaid, and $2.6 billion was spent on emergency Medicaid, constituting 1.1% of the total Medicaid spending. The impact of noncitizen usage on emergency departments and FQHCs is unclear. Finally, several studies have attempted to quantify the health care costs of unauthorized aliens to certain states or geographic areas. The studies do not tend to be comparable because of differences in timeframes, methodology, and the types of costs studied. This report will not be updated.