Everyone deserves health care, no matter their skin color, ability, income, or immigration status. Apple Health Expansion (AHE) is a program that expands access to life-saving medical care to thousands of Washingtonians who do not have health coverage due to their immigration status. However, Washington’s legislature has only partially funded the program, leaving the majority of people who are eligible for AHE still struggling to meet their medical needs. Additionally, the federal administration is exacerbating the need for health coverage: they are attacking immigrants and have recently stripped away health care from many lawfully present residents, including refugees and asylees, who will lose coverage this October. While the Washington legislature faces its third straight year of revenue shortfalls, there are compelling economic benefits for both individuals and the state to protect healthcare for immigrants and the AHE program.

What is Apple Health Expansion?

The state legislature created AHE in 2022 in recognition of the need for affordable health care for immigrants excluded from both federal Medicaid and federal Advanced Premium Tax Credits (APTCs), which help people pay for their health care premiums. There were an estimated 35,000 residents in Washington eligible for AHE in 2021. When AHE enrollment began on July 1, 2024, nearly all 12,000 available slots in the program were filled in less than two days, providing health coverage to only a third of eligible Washingtonians. The short time that it took to reach capacity demonstrated both the great need for and interest in health coverage.

As of this July, there are almost 34,000 Washingtonians who are eligible for AHE¹ who have been denied due to limited funding. Additionally, in the coming months, tens of thousands more Washington residents will lose health coverage, as lawfully present immigrants are stripped of Apple Health coverage as a result of congressional H.R. 1, the congressional Republican megabill that was passed in 2025.² This means demand will only increase for healthcare access through AHE. The AHE program is vital to meeting the needs of Washington’s immigrant communities, as well as the needs of our work force and state economy.

Investing in Apple Health Expansion saves lives and money

All Washington residents, no matter their immigration status, benefit when more people have health coverage. When more people have health coverage, our work force, economy, and state budget are all stronger. Immigrants in Washington pay taxes, strengthen our state economy, and contribute to our local workforce, but they need medical coverage to live healthy lives and contribute.

• Immigrants are major tax contributors: Immigrants in WA paid $6.5 billion in state and local taxes in 2023; within this community, undocumented Washingtonians paid over $1 billion in state and local taxes.
• Immigrants are an essential part of our workforce: One in five workers in our state are immigrants. Studies have shown that affordable health care can improve an individual’s workforce participation.
• Access to healthcare boosts our economy: People with adequate medical care also have greater spending power and are able to work, which increases state revenue through sales taxes and payroll taxes.

Ensuring more Washington residents have access to health care also decreases the cost to hospitals and the state because improved health coverage lowers the number of uninsured visits that are uncompensated. When hospitals cover the cost of patients who are uninsured, they are less able to pay for new equipment and technologies that improve patient care, maintain staffing and patient capacity, and keep their doors open. Many uncompensated uninsured hospital visits are a result of a patient’s inability to pay the high cost of out of pocket care. Early estimates indicate that if the WA State Legislature fully funded AHE and the entire eligible population enrolled in the program, health care providers could save an estimated $111 million in 2034 alone in uncompensated care costs.³ When immigrants have medical coverage, all Washingtonians seeking care, hospitals, and the state also benefit.

AHE not only strengthens the economy and our medical system, it also allows immigrant Washingtonians to access physical and mental health care, which supports the financial well-being of their families and the people who rely on them. Affordable health coverage has a financial multiplier effect. In addition to improving an individual’s work force participation, health coverage also allows individuals to reduce their medical debt by an average of $1,200. AHE helps ensure that Washington residents can work and provide care for their loved ones. Most importantly, health coverage saves lives.

Effective and cost saving health coverage must include a full range of care

In large part due to our state’s upside down tax code – which has resulted in year over year revenue shortfalls, and relies on those with the least to pay the most – the Washington legislature continues to face difficult budget decisions. Many critical services have been cut in the last few years. However, limiting the kind of care people insured through AHE can access would be shortsighted and result in further costs to our state and healthcare system down the line.

People are healthier when they have access to the specific medical care that they need, which means that AHE must include access to critical health services, including primary, preventative, specialty, and acute care. People are also able to save costs for themselves, the state, and hospitals, when they have coverage that covers the care that they need. The Affordable Care Act (ACA) defined 10 essential health benefits which recognizes that rehabilitative and habilitative services, labs, and pediatric oral and vision care are critical services that improve quality of life for people. A full range of services, ranging from cardiology to physical therapy to dental care, saves lives and money for both individuals receiving care and the state. Some of these essential services include:

• Cardiology: Heart attacks and other heart diseases result in costly emergency room (ER) visits and are the leading cause of death in the United States. In 2021, there were over 4.5 million cardiovascular-related hospitalizations that resulted in costs surpassing $110 billion dollars that year. People on AHE must receive access to cardiologists, who play an important role in identifying and preventing heart disease.
• Physical therapy: Additionally, individuals with low- to middle-incomes disproportionately experience health conditions, especially musculoskeletal disorders that can originate from or be exacerbated by manual and repetitive work. Physical therapy (PT) cuts costs by preventing patients’ need for more expensive treatments, allowing individuals to return to work or work more efficiently, while reducing their need for pain medications. The American Physical Therapy Association assessed that there would be a $4,160 net economic benefit per episode of care for PT for acute lower back pain and $39,533 per episode of care for carpal tunnel syndrome, both of which are common workplace injuries.
• Dental care: Providing dental care to individuals with low incomes also improves the health of families and local economies. States that have provided comprehensive dental coverage to adults and have expanded Medicaid eligibility have seen a 14% reduction in emergency room visits for oral health issues. A majority of the people who skip dental care, do so because of the cost. Access to these specialty services is key to address people’s health needs and save money for people and our state.

These are just some of the essential kinds of healthcare which are currently covered by the Apple Health Expansion. If the legislature faces limited funding, we strongly encourage the legislature and the agency to consider a safety net program like Healthy San Francisco which preserves access to specialty care while still providing care at no cost to those with income up 100% FPL.

AHE advances racial equity

AHE is an important step toward advancing racial equity and health equity by providing accessible health coverage to low-income immigrants who have been excluded from the federal health care safety net. The majority of undocumented immigrants are people of color due to the long history of racist federal immigration restrictions. In Washington, 43% of undocumented community members come from Asia or the Pacific Islands and 39% are Latine. Nationally, Latine and API immigrants under 65 years old are less likely than their white counterparts to be eligible for health coverage due to restrictions by immigration status. Of people uninsured across the country, 52% of uninsured Latines, 38% of uninsured Asians, and 29% of Native Hawaiian and Pacific Islander individuals in 2023 were noncitizens. This demonstrates the correlation between uninsurance rates and noncitizenship status and emphasizes the importance of AHE to cover noncitizen populations. As the federal administration targets immigrants, Washington legislators must stay true to their values and commitment to racial justice by addressing the needs of our diverse communities across the state.

Today, affordable health care access is more important than ever

Since President Donald Trump returned to office, immigrants are experiencing negative impacts to their health and are facing additional barriers to accessing health care. Nationally, four in ten immigrant adults and almost 80% of individuals who are likely undocumented have reported negative health impacts since January 2025, including anxiety, depression, issues sleeping or eating, or worsening chronic health issues. Roughly half of Latine and Black immigrants, English learners, and individuals who earn less than $40,000 annually across the country report that they and their children disproportionately experience these negative health impacts. One in two immigrant families also report experiencing increased barriers to earning a living wage and paying for daily essentials, including health care, food, or housing costs. Immigrants need health coverage especially when our federal government is attacking them and blocking them from accessing programs they contribute taxes to.

When people have health care, families are healthier and our shared economy is stronger. Washington state legislators should choose to invest in the economic and physical well-being of all Washingtonians by providing AHE rather than pay for the many financial, social and human costs of leaving people uninsured.

Guest Author

As Northwest Health Law Advocates’ Senior Policy Advocate, Lee Che P. Leong has led immigrant health advocacy and implementation in collaboration with Washington stakeholders since 2021. She has significant non-profit experience at the local, state and national levels. In 2023, Families USA recognized Lee Che’s work on Washington’s immigrant health expansions with their Health Justice Coverage Advocate of the Year Award. She proudly served on Mt. Baker Planned Parenthood’s Board of Directors for 9 years and currently serves on the Washington Health Benefit Exchange Health Equity Technical Advisory Committee.