Access To Health Care Needs To Be Addressed In Immigration Reform

Main Category: Public Health
Article Date: 21 Mar 2013 - 1:00 PDT


Amid grow­ing bipar­ti­san and pub­lic sup­port for com­pre­hen­sive immi­gra­tion reform, there is a need and an oppor­tu­nity to under­stand how immi­gra­tion reform will meet health care reform dur­ing the imple­men­ta­tion of the Afford­able Care Act. If as a nation we are begin­ning to think about offer­ing 11 mil­lion undoc­u­mented immi­grants legal sta­tus and a path to cit­i­zen­ship, how should undoc­u­mented immi­grants, new immi­grants, and future immi­grants be inte­grated into our health care sys­tem at a time of change? Lack of progress on immi­gra­tion reform has placed finan­cial pres­sures on safety-net health care orga­ni­za­tions and cre­ated eth­i­cal chal­lenges for health care pro­fes­sion­als seek­ing to pro­vide good care to their undoc­u­mented patients: how should we act now to pre­vent these prob­lems going forward?

Begin­ning in June 2011, inves­ti­ga­tors at The Hast­ings Cen­ter, an inde­pen­dent, non­par­ti­san, and non­profit bioethics research insti­tute, have explored eth­i­cal, legal, and pol­i­cy­mak­ing chal­lenges in access to health care for the nation's undoc­u­mented immi­grants and their fam­i­lies. This report sum­ma­rizes key project find­ings for stake­hold­ers, includ­ing health care pro­fes­sion­als, health pol­i­cy­mak­ers, immi­grants' rights orga­ni­za­tions, grant mak­ers, and journalists.

Key Facts

• An esti­mated 11.2 mil­lion undoc­u­mented immi­grants live in the U.S. Most are eco­nomic migrants con­cen­trated near labor mar­kets. Typ­i­cal jobs include food pro­duc­tion, con­struc­tion, main­te­nance, and other unskilled, phys­i­cally demand­ing, low-wage jobs.
• An esti­mated 4 mil­lion U.S.-born "cit­i­zen chil­dren" have undoc­u­mented par­ents. Most undoc­u­m
• ented immi­grants live in "mixed-status" families. Due to increased bor­der secu­rity and the eco­nomic down­turn in the U.S., undoc­u­mented immi­gra­tion has greatly decreased since 2006 (to net zero from Mexico).
• Cal­i­for­nia, Texas, Florida, New York, and Illi­nois are home to 55.5% of undoc­u­mented immi­grants liv­ing in the U.S., with grow­ing com­mu­ni­ties in many other states.

Health Care Access

Undoc­u­mented immi­grants are cur­rently inel­i­gi­ble for the major fed­er­ally funded pub­lic insur­ance pro­grams: Med­ic­aid, Medicare, and the Child Health Insur­ance Pro­gram (CHIP) because they are not "law­fully present" in the U.S., as required by the Per­sonal Respon­si­bil­ity and Work Oppor­tu­nity Rec­on­cil­i­a­tion Act of 1996. Some states (notably New York) have granted lim­ited exemp­tions allow­ing some undoc­u­mented immi­grants to enroll in Med­ic­aid or CHIP. Undoc­u­mented immi­grants were excluded from the insur­ance pro­vi­sions of the ACA. Per­ma­nent legal immi­grants have to wait five years to become eli­gi­ble for Med­ic­aid and the ACA. The pub­licly funded safety-net pro­vides some access to health care for undoc­u­mented immi­grants, through state-level Emer­gency Med­ic­aid to cover hos­pi­tal­iza­tion for emer­gency med­ical treat­ment and Fed­er­ally Qual­i­fied Health Cen­ters for pri­mary care. Access to med­ically appro­pri­ate diag­nos­tics, treat­ment, and care beyond the scope of these emer­gency treat­ment and pri­mary care pro­vi­sions is severely lim­ited. While health care pro­fes­sion­als may resort to using emer­gency treat­ment pro­vi­sions to help patients man­age health prob­lems, this is rec­og­nized as an expen­sive and med­ically prob­lem­atic way to treat chronic disease.

Young undoc­u­mented immi­grants (the "dream­ers") eli­gi­ble for work per­mits under the Deferred Action on Child­hood Arrivals (DACA) pro­gram are cur­rently excluded from Med­ic­aid and CHIP and from ACA insur­ance benefits.

Health Con­se­quences of Undoc­u­mented Status

Eighty per­cent of undoc­u­mented immi­grants in the U.S. are His­panic. The Depart­ment of Health and Human Ser­vices (HHS) reported in 2012 that His­pan­ics are more likely to be unin­sured, more likely to have chronic dis­eases, and less likely to receive pre­ven­tive care, com­pared with the gen­eral pop­u­la­tion. Efforts to improve the health of the U.S. His­panic pop­u­la­tion are likely to be stymied if undoc­u­mented immi­grants are unable or reluc­tant to be included in these initiatives.

Cit­i­zen chil­dren of undoc­u­mented par­ents lag both in health insur­ance enroll­ment and in access to health care despite their eli­gi­bil­ity for CHIP. Pub­lic health research sug­gests that anti-immigrant poli­cies (such as Ari­zona S.B. 1070) have devel­op­men­tal con­se­quences for chil­dren with undoc­u­mented par­ents. Even when these poli­cies do not explic­itly restrict access to health care, undoc­u­mented par­ents may be reluc­tant to par­tic­i­pate in preventive-health and other activ­i­ties in which their sta­tus could be revealed or ques­tioned. Sim­i­lar find­ings have been reported in edu­ca­tion research.

Immi­gra­tion Reform, Health insur­ance, and the Safety-Net

Undoc­u­mented immi­grants are likely to con­tinue to rely on safety-net health care for years to come. Immi­gra­tion reform pro­pos­als cur­rently under dis­cus­sion describe numer­ous steps that undoc­u­mented immi­grants will need to com­plete to gain pro­vi­sional legal sta­tus. As out­lined in these pro­pos­als, undoc­u­mented immi­grants with pro­vi­sional legal sta­tus will con­tinue to be inel­i­gi­ble for fed­eral ben­e­fits such as Med­ic­aid and Medicare. Their appli­ca­tions for per­ma­nent legal res­i­dence will be processed only after green card appli­ca­tions from legally present immi­grants have been reviewed; as noted, per­ma­nent legal res­i­dents cur­rently must wait five years before enrolling in Medicaid.

It is as yet unclear whether immi­gra­tion reform will expand access to ACA pro­vi­sions for new immi­grants or if the shorter path to cit­i­zen­ship for young undoc­u­mented immi­grants pro­posed in the Sen­ate plan will expand access to health care for this group. Because most undoc­u­mented immi­grants are low-income work­ers, Med­ic­aid may be their most likely future source of health insur­ance. Greater eco­nomic oppor­tu­ni­ties result­ing from legal sta­tus, includ­ing bet­ter jobs and access to credit, may even­tu­ally make afford­able pri­vate health insur­ance more avail­able to them.

Undoc­u­mented Immi­grants and the Ethics of Access: Fair­ness, Pru­dence, Beneficence

The "dirty" jobs that undoc­u­mented immi­grants and other unskilled immi­grants often fill are part of the econ­omy of devel­oped nations. Fair­ness would seem to require that undoc­u­mented immi­grants "go to the end of the line," behind cur­rent appli­cants for per­ma­nent res­i­dency. How­ever, there has been no real queue for unskilled work­ers from Mex­ico and other devel­op­ing coun­tries to join to fill a range of avail­able jobs in the U.S. The route to these jobs has instead involved unau­tho­rized entry and tacit accep­tance of this sta­tus quo. As immi­gra­tion reform attempts to fix this prob­lem, fair­ness also requires atten­tion to the health, wel­fare, and safety of all mem­bers of our soci­ety as equal per­sons and social cit­i­zens. One low-income population's access to med­ically appro­pri­ate health care should not wait on the res­o­lu­tion of the immi­gra­tion backlog.

To do so is pru­dent as well as fair. As a soci­ety, we aim to make progress on health and health care for all. Leav­ing the undoc­u­mented behind now, while health care reform is being imple­mented, may increase the suf­fer­ing of the sick, under­mine the health-related rights of cit­i­zen chil­dren whose access to health care depends on their par­ents, and work against the goals of reduc­ing health dis­par­i­ties affect­ing vul­ner­a­ble pop­u­la­tions. Think­ing about how to inte­grate undoc­u­mented immi­grants and other new immi­grants into our com­pre­hen­sive efforts to improve our health care sys­tem is a chal­leng­ing prob­lem. It requires fresh think­ing about the cost of pro­vid­ing health insur­ance to 11 mil­lion undoc­u­mented immi­grants and also to legal res­i­dents cur­rently excluded, and to the cost of exclusion.

Health care pro­fes­sion­als seek to do good (benef­i­cence) and be effec­tive advo­cates for their patients. As long as a large group of low-income patients is excluded from health insur­ance cov­er­age and from pub­lic pro­grams that cover dial­y­sis, hos­pice care, and other ser­vices, this sit­u­a­tion will con­tinue to cre­ate dis­pro­por­tion­ate dilem­mas and eco­nomic bur­dens for safety-net providers in com­mu­ni­ties and states where undoc­u­mented immi­grants find work. Tack­ling the prob­lem of access to health care as part of immi­gra­tion reform is good for the nation's health care work­force and for the integrity of our safety-net.

Rec­om­men­da­tions for inte­grat­ing access to health care into immi­gra­tion reform:

• Pol­i­cy­mak­ers and other stake­hold­ers in immi­gra­tion reform should explic­itly address access to health care for low-income immi­grants, who may include undoc­u­mented immi­grants, guest work­ers, per­ma­nent legal res­i­dents, refugees, and newly nat­u­ral­ized cit­i­zens, in the details of reform pro­pos­als. The health and health care needs of future cit­i­zens should be on the table at all lev­els of pol­i­cy­mak­ing, with atten­tion to the costs of inclu­sion and of exclu­sion. At a time of reform in immi­gra­tion and health care, it is pru­dent to assess whether exist­ing bar­ri­ers to health care (such as wait­ing peri­ods for Med­ic­aid enroll­ment within the larger immi­grant pop­u­la­tion) are appro­pri­ate, or are unduly bur­den­some to safety-net providers and to per­sons in need of med­ical treatment.
• The HHS Sec­re­tary should direct safety-net fund­ing to states with large infor­mal labor mar­kets, where undoc­u­mented immi­grants and other low-income immi­grants are likely to live and seek health care, to mit­i­gate known uncompensated-care problems.
• State pol­i­cy­mak­ers should, sim­i­larly, sup­port safety-net fund­ing for orga­ni­za­tions serv­ing undoc­u­mented immi­grants, other low-income immi­grants, and mixed-status families.
• Health pol­icy ana­lysts should study and share find­ings on local-level inno­va­tions, such as union-sponsored low-cost health insur­ance, aimed at improv­ingthe health, wel­fare, and safety of undoc­u­mented immi­grants and their inte­gra­tion into main­stream society.

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