California policymakers continue to weigh strategies for making health insurance universal and health care accessible to all—including for undocumented immigrant residents. The state expanded Medi-Cal to undocumented children and young adults using mostly state funds, and budget negotiations are underway to expand coverage to older undocumented adults. While coverage for all undocumented immigrants has been on the legislative agenda for several years, COVID-19 has underscored how gaps in health insurance coverage for immigrants, fear and avoidance of health care systems, and lack of access to vaccines can have consequences for entire communities.

This report updates PPIC’s past work on health care and insurance coverage for undocumented immigrants, from presenting updated uninsured rates among immigrant groups to unpacking systematic differences in health care access by documentation status. We also examine aspects of how children in mixed-status families—where at least one member is undocumented—engage with the health care system. Situating these topics amid the shifting federal and state contexts of the past five years, including the pandemic, we find that:

• Uninsured rates are high for low-income undocumented immigrants. Uninsured rates for those older than 50 are especially concerning given higher levels of health care need.
• The health care safety net serving undocumented immigrants is uneven across geography, by age group, and in some cases by health needs.
• Undocumented immigrants and their family members do not use more emergency department services than other immigrants; lack of connections to the health care system is a greater concern.
• Children in families with at least one undocumented member are almost 11 percent less likely to have a usual source of care compared to children in other immigrant families, although they get health care at similar rates.

Questions remain around how to improve access to health insurance coverage and medical care for undocumented immigrants and their families. Current legislation proposes further expansion to cover all low-income adults regardless of immigration status. Expanding affordable insurance options—such as Medi-Cal expansion for older adults and the option to buy health insurance through Covered California—could begin to fill in the gaps for this group.

In addition to coverage expansions, incentivizing all counties to serve undocumented immigrants in their programs for the medically indigent and increasing supports for safety net providers could improve equity in accessing medical care. Finally, outreach to immigrant communities through community-based organizations and other trusted messengers would begin to alleviate some of the fear many undocumented immigrants and their family members have surrounding government programs. These efforts would be consistent with the changing sentiments of state residents. In California, public support for inclusive health care coverage is growing—66 percent of adults supported health care coverage for undocumented immigrants in 2021, up from 54 percent in 2015 (Baldassare et al. 2021).