The United States is facing increasing rates of immigration and increasing numbers of undocumented immigrants. Immigration reform is a current legislative topic and many different approaches have been proposed. Government officials face challenging decisions regarding immigration regulation and public benefits for undocumented immigrants, particularly health care. Most undocumented immigrants are of Mexican descent and many are women with children. Undocumented immigrants demonstrate poorer health than the general population of the United States, and they access the health care system less frequently, with the exception of childbirth-related hospitalizations. Undocumented immigrants have very little access to preventive care, and are frequently afraid of seeking services for which they are eligible because of the threat of deportation.
A number of recent policies have limited undocumented immigrant access to social services such as health care and have resulted in greater cost for more costly emergency procedures, instead of less costly primary care. Future policies should focus on expanding preventive health care coverage for undocumented immigrants, especially prenatal care for women, since it saves money and prevents severe illnesses that can pose public health risks.
The United States is a large and diverse nation, and it is a challenge for policies to keep up with the needs of the people. Policy regarding the regulation of immigration into the United States has been particularly poor in recent decades, and there has been a lack of a coherent strategy to provide resources for recent immigrants, particularly undocumented immigrants. In the case of immigrant health care, the interaction between policy, access and use of the health care system, and health outcomes is dynamic and complex.
In several settings, public policy has mandated that providers and institutions limit health care services to undocumented immigrants. These regulations have influenced use of health care and health status, which have in turn influenced policy. Immigrants have responded to policy changes that limit their access with fear and have thus delayed accessing services they need, thereby suffering negative health outcomes (Berk, Schur, Chavez, & Frankel, 2000; Marshall, Urrutia-Rojas, Mas, & Coggin, 2005; McGuire & Georges, 2003; Stati, Hurley, & Katz, 2006; Trossman, 2004). These negative health outcomes are perceived in vastly different ways by policy makers and are used to establish or strengthen issue positions. The interplay between these factors is important to understanding what regulations and resources should be instituted, but it is equally important to find information that accurately portrays the status of immigrants and health care in the United States. It has been unclear for decades whether or not undocumented immigrants are draining resources from the health care system and to what extent.
People interested in addressing the problems of immigrant health care are found in many levels of government and in public and private organizations, but it has been uncertain whose responsibility it is to develop a solution. Immigration, a nation-to-nation migration, has been a federal issue, but state and local governments have also
created and advocated a variety of policies in recent years in response to the seeming inability of the federal government to embrace a uniform plan. The uncertain climate leaves undocumented immigrants unsure about their rights to health care and often afraid of using even the resources for which they are eligible. Ambiguous jurisdiction has also created a complex ethical and legal environment for health care providers.
At a time when immigration law is undergoing major reform, politicians and public health officials can obtain a sense of successful strategies in managing health care problems related to undocumented immigrant access by analyzing the policies of the past twelve years. Both qualitative and quantitative studies of these policies have
demonstrated undocumented immigrant access to health care is minimal, that such immigrants are using less health care than U.S. citizens and documented immigrants, and that policies that further limit their access to health care result in negative health outcomes (Berk, Schur, Chavez, & Frankel, 2000; Loue, Cooper, & Lloyd, 2005). Policies that expand undocumented immigrant access to preventive care save money by preventing the need for more costly emergency care, and produce more positive health outcomes (Lu, Lin, Prietto, & Garite, 2000; Marshall, Urrutia-Rojas, Mas, & Coggin, 2005).
Introduction to the Problem of Undocumented Immigration
Composition of United States immigrant population
The United States has always been a country of immigrants, but responding to the needs of increasingly large numbers of new residents has never been more demanding than now. The population of the United States is growing by foreign immigration alone by about 2.8% each year (Weis et al., 2001), and the number of undocumented immigrants coming into the United States is sharply increasing (Rehm, 2003). An immigrant who comes to the United States without documents is an illegal alien resident, dwelling within the country illicitly, and this creates administration and record-keeping problems. About 57% of the 10 million undocumented immigrants that currently reside in the United States are from Mexico (Passel, Capps, & Fix, 2004). Immigration policy has thus been directed toward addressing the influx of crossings of the U.S./Mexican border into the United States. These policies have focused on border patrol efforts and stiffer penalties for border crossers, but they have not been successful at slowing the steadily increasing rate of undocumented immigrants who enter the country each year.
More undocumented immigrants are between ages 18-29 compared to the entire Latino population in the United States (Reed, Westfall, Bublitz, Battaglia, & Fickenscher, 2005). They live in higher rates of poverty and have lower levels of education compared to other Latinos and the general population of the United States (Marshall, Urrutia-Rojas, Mas, & Coggin, 2005). Forty-four percent of noncitizen immigrants are uninsured compared with nineteen percent of immigrants who are U.S. citizens (Prentice, Pebley, & Sastry, 2005).
Description of Undocumented Immigrants
In 1993, Governor Pete Wilson of California stated his opposition to public health care funding for undocumented immigrants, even before the introduction of Proposition 187, which he strongly supported. Governor Wilson called for federal legislation to “limit or eliminate the giant magnet of federal incentives that draw foreigners into the county illegally” (Governor Goes Public, 1993). A survey of 972 undocumented Latino immigrants in Fresno, Los Angeles, Houston, and El Paso in 1996-1997 did not support the claim that immigrants come to the United States for free health care and social services. More than half of surveyed immigrants cited jobs/work opportunities as the most important reason they immigrated. The next most common response was to be with family. Less than one percent of respondents considered attaining social services as their primary reason for immigrating. It is unlikely that the respondents would lie about this fact, as they were willing to reveal to interviewers that they were in the country illegally (Berk, Schur, Chavez, & Frankel, 2000).
Undocumented immigrant health status
Minorities, immigrants, and people with low incomes are populations more at risk for “poor physical, psychological, and social health” than other populations, according to the United States Department of Health and Human Services (Marshall, Urrutia-Rojas, Mas, & Coggin, 2005). It has been shown that undocumented immigrants are the U.S. population group with the worst health status, a fact that is generally attributed to their high poverty rates and low levels of education (Marshall et al.). Among the diseases affecting undocumented immigrants are communicable infections such as tuberculosis, incidences of which are higher among recent immigrants to the United States than any other population group (Carvalho et al., 2004; Chin et al., 1998).
Undocumented immigrants also face a variety of conditions harmful to mental health, although there has been little research to show whether or not undocumented immigrants are at higher risk for psychiatric disorders than other people. In a 2005 qualitative study, Sullivan and Rehm identified ten themes of mental health stresses affecting undocumented immigrants: failure to succeed in country of origin; dangerous border crossings; limited resources; restricted mobility; marginalization and isolation; blame/stigmatization; vulnerability/exploitability; fear and fear-based behaviors; stress and depression; and poor health.
Health care usage of undocumented immigrants
According to data from the National Health Interview Survey in 1999, 73 percent of Mexican American children are considered by a parent to be in good health by a parent, compared with 85 percent of non-Hispanic White children (Rehm, 2003). Despite the lower perceived health status, Mexican American children are less likely than any other subgroup to have seen a physician in the last year (Rehm). Rehm argues that these data can be generalized to include both documented and undocumented immigrants. Compared with the entire U.S. population, undocumented immigrants visit physicians less frequently and have lower rates of hospital admission (Berk, Schur, Chavez, & Frankel, 2000). Despite poor health, undocumented immigrants are using the health care system less frequently than most American residents—a fact that refutes the claim that illegal aliens abuse health care privileges. The one exception to the lower rates of health care usage among undocumented immigrants is hospitalizations for childbirth. In the Berk et al. study, 3.4 percent to 6.4 percent of undocumented immigrant women had a childbirth-related hospital visit in the study year. This percentage was far higher than that of the total population (1.7 percent). High rates of childbirth among undocumented immigrants have been attributed to the younger age of undocumented immigrants with respect to the total population and to the fact that children born in the United States will become citizens.
Undocumented immigrants use less health care because they have less access to it, and because they fear deportation. Illegal aliens have less access to health care because of their basic demographic factors: they live in poorer areas and are less educated than other population subgroups (Prentice, Pebley, & Sestry, 2005). They are also ineligible for many services or are bogged down by paperwork that they may not understand to determine eligibility when they attempt to access health care. Undocumented immigrants usually have limited ability to communicate in English, which makes accessing the health care system a daunting task. Many immigrants avoid using services other than emergency benefits, even if the state they live in provides preventive care through Medicaid (Prentice, Pebley, & Sestry, 2005). These immigrants are afraid that use of state resources will make them appear as public burdens and increase their chance of being reported to law-enforcement authorities (Prentice, Pebley, & Sestry, 2005). Changes in federal and state policies about provision of health care services to undocumented immigrants have made it unclear whether immigration status will be required of patients seeking preventive care, and have made illegal aliens reluctant to utilize benefits. One undocumented immigrant said of her fear, “I’m afraid to go out and only go when it’s necessary. If it’s not necessary, I don’t go. I feel impotent, like I can’t do anything.” (McGuire & Georges, 2003).
Impacts of Restricted Health Care Access for Undocumented Immigrants
Prior to 1996, immigrant eligibility for Medicaid services was determined by individual states. States were providing a range of Medicaid services to both documented and undocumented immigrants who qualified for Medicaid based on low income requirements (Loue, Cooper, & Lloyd, 2005). There was a range of preventive care options available in some states, though the policies were certainly not coherent or easy to understand. Many health care providers did not even know what services they were allowed to provide. Under the federal Emergency Medicaid program, emergency services were covered, as long as the immigrants met income-eligibility guidelines (Trossman, 2004). In the early 1990s, the state of California was spending large portions of its state Medicaid funding on services, including Emergency Medicaid services, for undocumented immigrants. With no unified federal policy and little federal funding to address the issue, members of the state government attempted to create their own policy solution. In November 1994, Proposition 187, an initiative to restrict access of undocumented immigrants to any health care funding by Medicaid, was passed by California voters by a narrow margin. The proposition was never enforced, due to multiple court challenges, but it enlivened the national debate as to which health policies would adequately address the problem (Ziv & Lo, 1995).
Proposition 187 was eventually overturned as unconstitutional: states were deemed to have no power to regulate immigration, as it violates the due process clause of the Fourteenth Amendment that guarantees all people equal protection of the laws (Loue, Cooper, & Lloyd, 2005). Opponents of the proposition noted that it was unfeasible to ask physicians and nursing staff to enforce immigration policies in clinics and hospitals. Physicians also contended that requiring them to deny health care to patients in need was against their code of ethics. Proposition 187 also led to fear among immigrants who normally access public health care. In 1995, Ziv and Lo noted that a recent survey of 313 patients with active tuberculosis found that more than one fifth of the patients had no immigration documents. Hesitancy of these illegal immigrants to seek care could have created a serious epidemic of tuberculosis. Laws such as Proposition 187 endanger physician ethics, the health of undocumented immigrants, and public health in general.
Personal Responsibility and Work Opportunity Reform Act
The issue of undocumented immigrant social service use made its way into national Welfare reform legislation in The Personal Responsibility and Work Opportunity Reform Act of 1996 was passed by the United States Congress and became effective on July 1, 1997 (Reed, Westfall, Bublitz, Battaglia, & Fickenscher, 2005). The law regulated cash assistance through the newly named Temporary Aid for Needy Families program and placed more restrictions on eligibility for such assistance. It also introduced a new federal policy regarding Medicaid coverage for immigrants who were not U.S. citizens. Undocumented immigrants were no longer considered eligible for federally funded non-emergency health care services through Medicaid. Documented immigrant eligibility was limited as well. Legal immigrants were only considered federally eligible after five years of residence from the time they received legal status. The legislation included a provision that allowed states to provide non-emergency Medicaid services to immigrants who were federally ineligible if they first passed new state legislation providing the state funding for this purpose. State responses to the Personal Responsibility and Work Opportunity Reform Act (PRWORA) varied. Some cut coverage according to the federal plan, and others, including California, continued Medicaid access, partially in response to the backlash from the plan introduced by Proposition 187.
One of the greatest indicators of the effects of PRWORA is the decreased use of the services for which undocumented immigrants access health care most, namely services related to childbearing, such as prenatal and neonatal care. After the passage of PRWORA, Florida implemented the eligibility restrictions for Medicaid, and thus restricted access to prenatal care, while California did not. In 1999-2001, Fuentes-Afflick et al. interviewed 1,799 postpartum women in California and Florida to compare the effects of the varied implementations of the policy. Three-fourths of undocumented women from California in the study received prenatal care beginning in the first trimester of their pregnancy, whereas only 57% of undocumented women in Florida did. Three times as many undocumented women in Florida received fewer than six prenatal visits, compared to the recommended ten to fifteen. The study demonstrated that the implementation of PRWORA led to decreased use of health care services by undocumented immigrants. It also led to more negative health outcomes for the mothers and infants, including higher rates of low birth weight and premature newborns (Fuentes-Afflick et al.). Prenatal care is a classic example of preventive care that decreases future health problems and the need for more costly secondary care. The United States Department of Health and Human Services notes that, “Adequate access to health care services can improve health outcomes” (Marshall, Urrutia-Rojas, Mas, & Coggin, 2005).
Illegal Immigration Reform and Immigrant Responsibility Act
Attempts by the federal government to limit health care and other public benefits for immigrants were made again in 1996. The Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRAIRA) was enacted on September 30, 1996 (Loue, Cooper, & Lloyd, 2005). In addition to stiffer penalties for fraudulent documents and smuggling persons across the Mexican border, the act placed restrictions on immigrant eligibility for Social Security, Food Stamps, and education, and reiterated the restrictions to health care already in place from PRWORA. Though health care access could be expanded per state determination, the federal government provided block grants for Emergency Medicaid services only. IIRAIRA also required public hospitals to verify patient immigration status, even for emergency services, with the United States Citizenship and Immigration Services (USCIS, formerly the INS) prior to Medicaid reimbursement for such services (Rehm, 2003).
With the implementation of IIRAIRA, the sharing of information between the United States Citizenship and Immigration Services (USCIS) and public hospitals became more prominent. California was no exception to this pattern. Illegal aliens who were accessing emergency health care were thus identified and known by USCIS. Immigrants were frightened by the possibility this created for their personal information to be used in enforcing immigration law against them. A critical care nurse in a hospital that sees large volumes of undocumented immigrants relates:
Undocumented workers often change their names every time they visit the
hospital out of fear. I remember one man was being treated for a seizure that the ER staff initially thought was an isolated event. After talking with him more, I learned that he had come in with a seizure just the month before but had used another name. I’m always telling people that we are hospital workers and here to take care of them, and not immigration (Trossman, 2004).
Loue, Cooper, & Lloyd (2005) examined the accessibility of prenatal care to 157 women of Mexican ethnicity, including 56 women who were undocumented, after the implementation of PRWPRA and IIRAIRA. The illegal aliens were more likely to delay seeking care than their legal resident and citizen counterparts. Fear and confusion about program eligibility requirements for Medicaid services were cited by participants as a reason for being less likely to seek prenatal care.
The impact of decreased access to prenatal care is devastating from a public health and fiscal perspective. Undocumented immigrants who do not receive prenatal care are four times more likely to have low birth weight and preterm infants than those who receive adequate care (Lu, Lin, Prietto, & Garite, 2000). Their infants are also more likely to suffer from abnormal birth conditions such as infant anemia, birth injury, fetal alcohol syndrome, hyaline membrane disease, seizures, and need for assisted ventilation (Lu et al.; Reed, Westfall, Bublitz, Battaglia, & Fickenscher, 2005). California researchers (Lu et al.) calculated that the cost of neonatal care for undocumented immigrants who did not receive adequate prenatal care was $2,341 more than that for an infant whose mother received prenatal care. This cost, as part of labor and delivery services, was covered by the state’s Emergency Medicaid program. The average cost of prenatal care for women in the sample who received it was $702 each. Investigators calculated that, on average, every dollar spent on prenatal care saved $3.33 in neonatal care costs. In addition, care for children who lacked prenatal care continues beyond initial neonatal services. Long-term care for low birth weight babies was $3,247 more for those who had not received prenatal care than for those who had. For every dollar spent on prenatal care, $4.63 in long-term care costs was saved for low birth weight babies. These data argue for expanded coverage of less expensive preventive care rather than denial of services and dependency on more expensive emergency care.
Need for Expanded Health Care Access for Undocumented Immigrants
It has become a public health priority of the last several decades to expand access to preventive care in order to reduce negative health outcomes. Undocumented immigrants suffer from delay in seeking access to medical care at a higher rate than any other population subgroup (Berk, Schur, Chavez, & Frankel, 2000). They have very
little access to primary care, including dental care. A Missouri Nurses Association member states:
A lot of our patients who are undocumented workers tend to be young-to-middleaged males. For the most part, they are pretty healthy. We tend to see them for episodic illnesses. But dental care is always a problem. There are just not enough dental providers for our clients. And it may take up to six months to get into the dental clinic, so preventive care is virtually non-existent (Trossman, 2004).
Because they lack such access, undocumented immigrants experience more negative health outcomes and utilize expensive emergency services as a temporary fix.
Insurance for undocumented children
Undocumented children remain the most vulnerable subgroup of the immigrant population in the United States. Sixteen percent of undocumented children have not seen a physician in the past two years, compared with seven percent of uninsured white children (Frates, Diringer, & Hogan, 2003). The California Endowment developed a model for providing health insurance for undocumented immigrant children in 2000. The program enrolled thousands of children, and demonstrated increased use of primary care services by such children and their families (Frates et al.), a marker toward future positive health outcomes. This model serves as an example of the direction policy initiatives on immigrant health care should take. Expanded undocumented immigrant health insurance programs would actually save health care money. While some opponents of such an expansion may argue that it would draw more immigrants across the U.S./Mexican border illegally, there are no data to support such a claim. Very few immigrants currently immigrate for the primary purpose of accessing social services, and to assume that their motivations would suddenly change with expanded access to primary health care relies on unfounded logic.
There is no easy solution to the problem of dealing with undocumented immigrants in the United States. In order to create a cohesive policy that meets the needs of the government, health care community, and undocumented immigrants, legislators and public health officials must first understand the nature of the population they are regulating. They need to know what factors truly draw illegal aliens into the United States, specifically whether or not they are seeking public services and particularly free health care above other resources. Policy makers should recognize the demographics and descriptions of the population who are accessing these resources and understand exactly what resources they are using. It is important that public administrators know more about the health and health care usage of illegal immigrants in order to make policy decisions that limit or expand access to care. Finally, it is necessary that policy makers understand the immediate and long-term effects of previous policies. A comprehensive analysis of these historical efforts is an important first step in creating more successful future policy.
The health care system pays a tremendous price to address the needs of this population. The costs of not addressing health care needs, especially with regard to primary and preventive care, are even more significant.Public health efforts to develop primary care access and encourage public use of preventive care should be expanded to undocumented immigrant populations. Instead of making policies that create fear and hesitancy in accessing services, government officials should focus on persuading illegal aliens to use those services that keep them in better health and save money on long-term care.
It is ethically, fiscally, and socially responsible to expand federal coverage of health care for undocumented immigrants. Years of limiting and denying access to health care have led to poorer health outcomes and increased cost. Government officials should look toward program models that fully insure low-income residents of the United States without regard to their immigration status. It is the only policy strategy that works. The best way to ensure the health of all Americans is to see that the issue of health care benefits is addressed in terms of prevention of public health problems, rather than with focus on enforcing immigration laws through the health care system.
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