Emergency Medicaid Policies Enabling Equitable Access to Healthcare Coverage for Undocumented Individuals with Hematologic Malignancies across the United States

INTRODUCTION: Limitations on healthcare coverage for undocumented individuals with hematologic malignancies in the United States often preclude receipt of necessary cancer-directed therapies, including stem cell transplant (SCT). Consequently, many undocumented individuals—up to 50% of whom are uninsured—frequently rely on emergency departments as their usual source of care, as the federal Emergency Medical Treatment and Active Labor Act (EMTALA) mandates that patients with serious medical conditions receive stabilizing treatment, regardless of ability to pay. Emergency Medicaid (EM)—a state-run, federally mandated program—provides coverage for this life-saving care, but policy implementation varies widely between states, ranging from coverage equivalent to that of U.S. citizens to no care outside of immediate stabilization. Furthermore, EMTALA explicitly prohibits the use of federal funds to cover services related to “organ transplant,” which state Medicaid policies commonly interpret to also exclude SCT. Several states have enacted policy changes to address this healthcare disparity, but as there is no central record of these policies or coordinated advocacy efforts to facilitate this expansion, the impact is limited, and many patients continue to lack access to equitable care.

METHODS: To guide healthcare advocacy efforts to expand equitable care for hematologic malignancies, healthcare policy documents from each state and D.C. were manually reviewed by multiple independent reviewers between February 2024 and July 2024. Policy documents were identified as documents appearing on government websites (including Medicaid policy manuals, provider handbooks, and legislation) that outlined eligibility criteria and healthcare coverage of services for undocumented immigrants with hematologic malignancies or any cancer. If coverage options remained unclear, state Medicaid agencies were called for confirmation.

RESULTS: We identified states that have addressed inequitable healthcare coverage policies for undocumented immigrants with hematologic malignancies and how this was achieved. The two most prevalent mechanisms that states utilize to provide coverage for undocumented immigrants with hematologic malignancy are 1) inclusion of cancer as an emergency medical condition under EM and 2) provision of full coverage for all undocumented individuals through Medicaid-equivalent (MEq) plans. Three states (CA, OR, WA), as well as D.C. provide full coverage for all undocumented individuals through MEq plans. MN will provide full coverage through a MEq plan effective January 2025. IL and NY provide full MEq coverage for undocumented individuals ages ≥42 and ≥65 years old, respectively. Five additional states (MA, MD, NM, NY, PA) provide some duration or service-limited coverage for hematologic malignancies. Iowa provides full Medicaid coverage for undocumented immigrants with breast and cervical cancer, but not for those with hematologic or other cancers. Two states (CO and MD) allow undocumented individuals to purchase Marketplace insurance coverage. Undocumented patients can receive SCT in states with full MEq coverage (CA, DC, IL, OR, MN in 2025, WA), states with policies allocating state-only funds for this purpose (NM, NY), and states whereby the definition of “organ transplant” expressly excludes SCT (PA). We also assessed how states expanded cancer coverage. Access to cancer care was expanded by three primary mechanisms: 1) Inclusion of a cancer diagnosis as a covered condition under EM (MD, MN in 2025, PA, WA); 2) Waiving citizenship requirements from Medicaid eligibility criteria (CA, IL, MN, OR, WA); 3) Other state-level programs (D.C., MA, NM, NY) which provide coverage via non-Medicaid or service-limited programs. Method of coverage expansion changed over time: full Medicaid coverage became more common in the 2020s (CA, IL, OR), often through stepwise expansion by age group (CA, IL, NY).

CONCLUSION: We identify examples of successful policy change expanding healthcare coverage for undocumented patients with hematologic malignancies in twelve states and D.C. However, most states continue to limit equitable healthcare delivery compromising outcomes. This work serves to build a network of advocacy-oriented hematologists to establish coordinated efforts to eliminate disparities in care of hematologic malignancies.