Robert P. Marlin, MD, PhD, MPH


Chief, Metta Health Center, Lowell Community Health Center, Lowell, MA

Dr. Marlin has advocated for the health and healthcare needs of vulnerable populations for the past twenty years. Over the past decade he has focused on the development of multidisciplinary and coordinated models of care for refugee and immigrant populations. Since 2006, he has directed the Coordinated Care Program for Political Violence Survivors at the Cambridge Health Alliance, where he also provides primary care services to a diverse, largely immigrant patient population. Dr. Marlin received his medical degree from the State University of New York at Stony Brook School of Medicine in 2003 and his Ph.D. in Anthropology from Rutgers, the State University of New Jersey in 2001.  Dr. Marlin completed his internal medicine residency at Cambridge Health Alliance in 2006. He completed the Mongan Commonwealth Fund Fellowship in Minority Health Policy and received his M.P.H. in Health Policy from the Harvard School of Public Health in 2013.

Health Care Reform, Immigration Reform, and Access to Care for Unauthorized Immigrants


The goal of this project was to understand the changes in access to care and coverage for unauthorized immigrants that will be implemented under the Patient Protection and Affordable Care Act of 2010, the implications of potential federal immigration reform for access and coverage, and how safety net institutions can most effectively respond to both in order to continue to provide care for this population.


During the past two decades, the unauthorized immigrant population in the U.S.
has expanded significantly. During this same period there have also been significant restrictions placed on unauthorized immigrant access to health care. Unauthorized immigrants currently comprise a disproportionate share of the uninsured population in the U.S. and this will increase following the full implementation of the Patient Protection and Affordable Care Act of 2010. At the same time, federal safety net funding to states that had previously been used to pay for uninsured patient care, including that of unauthorized immigrants, will be reduced. Following the 2012 elections, Congress is also likely to put forward immigration reform legislation. In this context, safety net institutions must consider how they can continue to provide services to this vulnerable population.


A review of the health policy and immigration policy literature, including proposed Congressional immigration reform legislation, was performed, allowing for identification of the current state of unauthorized immigrant health care access and coverage. Findings from the literature review were used to structure interviews with key informants, including health policy and immigration experts. Data and insights from both the literature review and key informant interviews were used to formulate final recommendations to safety net institutions on the preservation of unauthorized immigrant access to care.


Restrictions on unauthorized immigrant health care coverage currently outlined in the Patient Protection and Affordable Care Act of 2010 will severely limit the ability of safety net institutions to provide care to this population, even at current levels. If successful, the immigration reform elements most likely adopted by Congress will further limit this access to coverage and care. Findings from the key informant interviews and the literature review support the need to look for solutions to this situation in both modification of the current legislation and in the development of state, county, municipal, and institution-specific responses.

Future Directions:     

While the Patient Protection and Affordable Care Act of 2010 will be largely implemented by 2014, the extent to which individual states will accept expanded Medicaid coverage is still not clear. The specific provisions affecting the support of safety net institutions in providing coverage to unauthorized immigrants will continue to be rolled out for another seven years after that. The specific provisions of likely immigration reform will be adopted no earlier than one to two years from now and will also have a lengthy timeline for full implementation. Therefore, national and state-specific recommendations for providing this population with coverage and access to care will need to be reevaluated on a regular basis.


Bruce Siegel, MD, MPH, President and CEO, National Association of Public Hospitals and Health Systems