Immigrants and Health Care -- At the Intersection of Two Broken Systems
Immigrants and Health Care -- At the Intersection of Two Broken Systems
At a primary care clinic in
For recent immigrants -- especially the estimated 12 million who are here illegally -- seeking health care often involves daunting encounters with a fragmented, bewildering, and hostile system. The reason most immigrants come here is to work and earn money; on average, they are younger and healthier than native-born Americans, and they tend to avoid going to the doctor. Many work for employers who don't offer health insurance, and they can't afford insurance premiums or medical care. They face language and cultural barriers, and many illegal immigrants fear that visiting a hospital or clinic may draw the attention of immigration officials. Although anti-immigrant sentiment is fueled by the belief that immigrants can obtain federal benefits, 1996 welfare-reform legislation greatly restricted immigrants' access to programs such as Medicaid, shifting most health care responsibility to state and local governments. The law requires that immigrants wait 5 years after obtaining lawful permanent residency (a "green card") to apply for federal benefits. In response, some states and localities -- for instance,
Whether or not they have health insurance, immigrants overall have much lower per capita health care expenditures than native-born Americans,1 and recent analyses indicate that they contribute more to the economy in taxes than they receive in public benefits. In a study from the RAND Corporation, researchers estimated that undocumented adult immigrants, who make up about 3.2% of the population, account for only about 1.5% of U.S. medical costs.2 Many immigrants do not seek medical treatment unless they are injured or acutely ill; at our clinic, patients with type 2 diabetes often have florid symptoms and even incipient renal damage by the time their disease is diagnosed.
One study found that annual per capita expenses for health care were 86% lower for uninsured immigrant children than for uninsured U.S.-born children -- but emergency department expenditures were more than three times as high.1 Although U.S. hospitals must provide emergency care without first asking about income, insurance, or citizenship, early diagnosis and treatment in a primary care setting are both medically preferable and a better use of resources. "If people keep postponing medical care because they're so concerned about being sent back over the border," noted Elizabeth Benson Forer, executive director of the Venice Family Clinic, a venerable free clinic in
Immigrants live, work, and attend school in communities throughout the country; laws and bureaucratic barriers that reduce their use of key preventive health services, such as immunizations and screenings for infectious disease, make for bad public health policy, and denying immigrants primary care ultimately increases health care costs for everyone. For example, labor and delivery costs for undocumented immigrant women are covered under the federal and state emergency Medicaid program, but most states do not cover prenatal care, and there is no coverage for family planning. Some of my patients say they would like to use oral contraceptives or an intrauterine device or undergo a tubal ligation, but they can't afford it. And immigrants, like native-born Americans, are vulnerable to chronic diseases; as my colleague, nurse practitioner Lois Wessel, notes, "Even the 25-year-old day laborers are eventually going to become 45-year-olds, probably still undocumented, with hypertension and diabetes. . . . Life in
Recently, a bipartisan group of
Noncitizens make up about 20% of the 46 million uninsured people in the
A recent study found that although emergency Medicaid spending for immigrants in
The chief sources of outpatient care for uninsured immigrants are public clinics and community health centers. Such clinics are often sparse in suburban and rural areas that have recently faced an influx of immigrants. Even in cities with strong community-clinic networks and a long history of serving immigrants, access to care is uneven. For example, at the Venice Family Clinic, a bilingual nurse educator runs health and exercise classes in Spanish and English for patients with diabetes, pregnant women receive
In states seeking to expand insurance coverage, the question of including undocumented immigrants is a thorny one. About 1 million of California's 4.8 million uninsured residents are undocumented adults, and about 136,000 are undocumented children.4 As part of a proposal for comprehensive health care reform, Governor Arnold Schwarzenegger is seeking to provide health insurance coverage (through Medicaid and the State Children's Health Insurance Program, or SCHIP) to all children with family incomes at or below 300% of the federal poverty level, regardless of immigration status. Although there is considerable public support for insuring undocumented immigrant children, Republican state legislators "do not believe that state general fund revenues should be invested in people who are here illegally," said health secretary Belsh -- "and that extends to children."
The federal Medicaid program has always been restricted to
In Georgia, which last year passed a law requiring immigrants to show proof of legal residency in many situations, "we've started seeing a lot of kids not going to the doctor," said Flavia Mercado, a pediatrician who runs the International Medical Center at Atlanta's Grady Memorial Hospital. "A lot of my clients are leaving and going to other states, and a couple are even going back to their country. Everyone is very fearful." She said that Atlanta organizations are scaling back health services for Hispanics and have stopped sponsoring Hispanic health fairs, fearing that they will be raided by police or immigration officials. Meanwhile, faced with rising health care costs and increasing numbers of uninsured persons, the state's Medicaid program has sharply reduced benefits: it recently stopped paying for prenatal care for high-risk women and for nonemergency hemodialysis. Although immigrants make up a minority of the uninsured, Mercado said media reports regularly blame illegal immigrants for the worsening problems of the state's health care system. Anger over high medical costs and reduced access to care no doubt contributes to anti-immigrant sentiment; the remedy, however, is not immigrant bashing, but health care reform.
"As an American citizen, I understand that you want to make sure the resources are there for the right people," Mercado said. "Yet how can you deny someone health access? If we don't treat and prevent illness . . . our whole community is going to suffer."
Dr. Okie is a contributing editor of the Journal.
1. Mohanty SA, Woolhandler S, Himmelstein DU, Pati S, Carrasquillo O, Bor DH. Health care expenditures of immigrants in the United States: a nationally representative analysis. Am J Public Health 2005;95:1431-1438. [Free Full Text]
2. Goldman DP, Smith JP, Sood N. Immigrants and the cost of medical care. Health Aff (Millwood) 2006;25:1700-1711. [Free Full Text]
3. DuBard CA, Massing MW. Trends in emergency Medicaid expenditures for recent and undocumented immigrants. JAMA 2007;297:1085-1092. [Erratum, JAMA 2007;297:1774.] [Free Full Text]
4. Brown ER, Pourat N, Wallace SP. Undocumented residents make up small share of California's uninsured population. Los Angeles: UCLA Center for Health Policy Research, March 2007.
5. Pear R. Lacking papers, citizens are cut from Medicaid. New York Times. March 12, 2007:A1.