Illinois Immigrant Health Coverage improved Hospital Financial Stability

Illinois programs providing state-funded health insurance to undocumented and noncitizen adults were associated with lower hospital bad debt, while evidence for reductions in charity care was less consistent, according to a cohort study published in JAMA Network Open.

Investigators analyzed hospital financial data from January 1, 2017, through December 31, 2023, for 161 Illinois hospitals and 1,902 hospitals in comparison states. A 2-way fixed-effects difference-in-differences design compared changes after Illinois implemented Health Benefits for Immigrant Seniors in 2020 and Health Benefits for Immigrant Adults in 2022 with contemporaneous changes in control hospitals. Entropy-balanced models were also used to improve covariate comparability.

In covariate-adjusted models, the programs were associated with a 7.5% decline in bad debt (estimate, −0.08; 95% CI, −0.11 to −0.04) and a 19.4% decline in charity care (estimate, −0.19; 95% CI, −0.26 to −0.13). Results were generally similar for cost-adjusted outcomes and in entropy-balanced analyses.

Bad-debt reductions were larger in counties with higher concentrations of non–US-born noncitizen residents. In the full sample, hospitals in high-concentration counties had a 35.0% greater estimated reduction in bad debt and a 25.5% greater reduction in cost-adjusted bad debt than hospitals in low-concentration counties, relative to corresponding differences in comparison states.

The authors noted that charity-care estimates were more sensitive than bad-debt estimates to departures from the parallel trends assumption. Wild bootstrap randomization inference P values for the 6 full-sample outcomes ranged from .15 to .40 and did not meet the study’s .05 threshold for statistical significance. Limitations included possible unobserved differences between Illinois and comparison hospitals, implementation in only 1 state, and potential measurement error in hospital cost reports. Investigators said the most robust evidence concerned reductions in hospital bad debt.

Source: Martinez-Cardoso A, Yu B, Nayak A, Kaestner R, Bustamante AV. State-funded health insurance expansion for noncitizen immigrants and hospital uncompensated care. JAMA Netw Open. 2026;9(9):e2631331. doi:10.1001/jamanetworkopen.2026.31331