Immigrant health care in the United States

Overview

Though termed "immigrants," this group includes a large body of noncitizens, such as foreign students, migrant workers, permanent legal residents, and those without legal documentation. Data indicates that the United States’ immigrant population was 28.4 million in 2000, although the Population Reference Bureau has since reported an increase to roughly 40 million in 2010. Furthermore, the Census Bureau projects that this number will continue to increase in the next decade, with the country’s Southeastern and Mountain regions' immigrant populations growing especially fast. In addition to its impact on the country’s demographics and labor market, this rise in the immigrant population has had a disparate impact on the United States' health care system and its surrounding dialogue.

Health care providers

The health care system in the United States is made up of both public and private insurers, with the private sphere generally dominating in providing coverage. Despite this, the federal government remains important given its role in determining public health benefits—for instance, Medicaid, the United States health program for families and individuals of low income. Although Medicaid previously serviced immigrants, welfare reform policies such as the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) in 1996 implemented stricter conditions for eligibility. This legislative move largely shifted responsibility for immigrant health care from the federal government to the state and local levels; as such, its impact varies across states. Generally, the provisions of PRWORA prevent immigrants from accessing federal benefits like the State Children’s Health Insurance Program (SCHIP) until after they have held lawful permanent residency for five years (except in cases of emergency). In response, some states have implemented their own programs expanding health coverage to immigrants and other low-income groups; among these include states of Illinois, New York, the District of Columbia, and some counties in California. These services differ accordingly, with some providing the same coverage as Medicaid or SCHIP, while others limit coverage to specific categories of immigrants. Conversely, other states like Arizona, Colorado, Georgia, and Virginia, have implemented laws that further restrict noncitizens' access to health care. Legislation of similar nature include the Deficit Reduction Act of 2005, which requires proof of identity and U.S. citizenship from all those applying for/renewing Medicaid coverage.

In contrast to PRWORA, the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1985 provides emergency medical care to all, without any requirements of proof of citizenship or residency. It declares that hospitals must screen and treat individuals until they are fit for release or stabilized for transfer.

In some areas like Washington D.C., uninsured immigrants receive outpatient care from public clinics and community health centers. However, the services offered by this type of health care tends to be uneven; for example, specialty services like Pap smears may be offered but not blood pressure tests or follow-up treatments.

Several municipalities in the United States offer health care coverage for undocumented immigrants, including Los Angeles County's My Health LA program, and San Francisco's Healthy San Francisco.

Findings and statistics

Since the enactment of PRWORA in 1996, the gap in health coverage between immigrants and citizens has grown considerably. In addition to the context of welfare policy, however, immigrant access to health care is also governed by several other factors: socioeconomic background (e.g. educational attainment and occupation), language skills, immigration status, geographic location, and stigma. With two or more of these factors compounded together, health outcomes can vary substantially across individual families but regardless, they are considerably disadvantaged compared to U.S.-born citizens.

Immigrants, on average, use less than half the dollar amount of health care services that American-born citizens use, receiving about $1,797 per capita compared to their U.S.-born counterparts' $3,702. Moreover, low-income immigrants are over two times more likely to lack health insurance than low-income citizens. In general, they have less interaction with the health care system, though incidences in which they do tend more likely to be through emergency departments. Interestingly, collected data indicates lower levels of heart disease, arthritis, depression, hypertension, asthma, and cancer among immigrants than U.S.-born citizens. Speculation behind this phenomena looks towards the fact that the immigrant population is generally younger than the native-born population as a whole; others believe that these medical conditions simply have not yet been detected given the immigrants' lower rates of health coverage.

Overall, analyses indicate that after factors such as health status, income, and race/ethnicity are controlled for, citizenship status plays a significant role in determining one's medical care access. Noncitizen immigrants and their children are less likely to be insured, and the lack of insurance consequently reduces their ability to receive care. Naturalized citizens, on the other hand, generally receive the same level of health care access as U.S.-born citizens, implying that health care usage becomes more available with acculturation.

Children

Studies on the disparities between immigrants and citizens’ health care show an especially pronounced impact on children. Even if born in the United States, children of noncitizens tend to have poorer health. Not only are they more likely to be uninsured, but they also have less access to both medical and dental care. Children of immigrants are also less likely to have received proper immunizations than U.S.-born children.

Furthermore, data collected from the National Health Interview Survey in a 1999 study indicates that foreign-born children are five times more likely than American-born children to lack a constant source of health care. Additional findings show that foreign-born children make less ambulatory and emergency visits to hospitals; however, they have considerably higher costs on average when they do, suggesting that immigrant children are sicker or more severely affected during emergencies. This inference is drawn from their lower rates of outpatient/office-based visits.

Hispanics and Latinos

Though no precise data on the undocumented immigrant population is available, estimates in 2009 suggest that 70% are from either Mexico or Central America. Because Hispanics comprise a major proportion of the U.S.'s immigrant and noncitizen population, a more extensive body of research has been collected about their status in obtaining and receiving health care services. Data indicates that they have the highest rate of uninsurance among all ethnic groups—33% compared to the national average of 15%. Compared to citizens with similar wages, hours, or occupations, Hispanic non-citizens were half to two-thirds less likely to be offered health coverage in the workplace. Moreover, further studies even show that regardless of immigration status, Hispanics have less access to health care services than white citizens overall. Yet interestingly enough, findings indicate that a large body of Hispanic and Latino Americans have similar or better outcomes than the average population—a phenomenon that has been labeled the “Hispanic paradox”. Further research indicates that this paradox exists only on some health measures; for example, Hispanic immigrants are healthier in terms of blood pressure and heart disease than non-immigrant non-Hispanic whites, but are more likely to be overweight or obese and have diabetes.

Asians

The Asian immigrant population encompasses many subgroups, though extensive information on any specific one is fairly limited. Contrary to findings on Hispanic immigrants, they generally tend to have household incomes similar to or higher than European immigrants. Their coverage rates vary however; some Asian subgroups match European immigrants but others like Vietnamese and Koreans had rates of over 30% of uninsurance. Additional research indicates that compared to other ethnic groups, Asian children receive the poorest quality of primary care. Despite the tendency for less health care access than non-Hispanic white citizens, Asian ethnicity and immigrant status are correlated with better health and higher school attendance among children. However, this observation of "better health" may be due to less diagnosis as a result of less health care utilization. Others also suggest that the higher rates of school attendance among Asian children may result from cultural values that prioritize education.

Because Asian immigrants often continue to practice alternative medicine after migration, cultural health beliefs contribute to disparities in medical care access. For instance, the practice of gua sha, or coin rubbing, to treat various physical ailments exists in Vietnamese, Chinese, Indonesian, and other cultures. Similarly, other healing techniques like fire cupping are used. Consequently, Asian immigrants’ perceived need of formal health care services is often lower, as some believe their alternative healing methods are more effective than prescription medicines.

Different expectations of the consumer/provider relationship also derail Asian immigrants from seeking U.S. health care providers’ services. In addition to language barriers, some Asian subgroups emphasize a higher level of trust between health care practitioners and patients, and as a result, may feel alienated using the more formalized American health care system.

Challenges

Restrictions based on immigration status are not the only obstacles to obtaining health care; the challenges that impede immigrants from accessing services are both structural and social. Even immigrants who are eligible for health benefits are less likely to receive them than U.S. citizens.

Structural barriers

The lack of health insurance is a major reason behind immigrants’ low usage of the United States health care services. The Survey of Income and Program Participation (SIPP) indicated that in 2002, 13.4% of native-born citizens were not insured compared to 43.8% of foreign-born adults. Reasons for uninsurance vary, but the findings of a 2005 study suggest that personal characteristics as well as the types of jobs immigrants have factor largely into the lack of coverage. For instance, there is a high concentration of immigrants in low-paying jobs and other jobs that do not offer health insurance. Personal characteristics that stem from structural obstacles include education; both immigrants and native-born citizens who have lower levels of education tend to be uninsured.

Additionally, citizenship status is significant in determining one’s health care access, especially that of children. Health benefits are largely contingent on immigrant parents in that although a child may be born in the U.S., the naturalization process for adults can take between 5 and 10 years. Since welfare reform initiatives like the Personal Responsibility and Work Opportunity Reconciliation Act have been enacted, states have seen an overall decline in the number of children being vaccinated.

Finally, the financial costs of health coverage may also explain uninsurance. Studies have shown a connection between the lack of coverage and higher poverty rates.

Social barriers

Access to and usage of health care depends in part on immigrants’ level of acculturation. Linguistic difficulties can prevent immigrants from accessing health care in two major ways. First, English proficiency is necessary to complete health insurance forms and to effectively communicate medical problems with physicians; as such, difficulty in obtaining language assistance or translated private/public health insurance forms makes the process of getting coverage a more intimidating and discouraging ordeal. Second, language skills impact one’s available job opportunities. Without an adequate level of English proficiency, immigrants are constrained to certain jobs, often those that are less likely to provide job-based insurance.

There is also a climate of fear and distrust that prevents immigrants, especially those without documentation, from actively seeking out health services. Fear arises largely from the idea of risking deportation or becoming ineligible for citizenship. Although the Immigration and Naturalization Service has stated that receiving Medicaid or SCHIP benefits (with the exception of long-term care) does not jeopardize residency status, many immigrants are still unaware and perceive otherwise. This misunderstanding of policies may also be subsequently compounded with the lack of knowledge about what health services are available.

Finally, some research indicates that barriers may exist according to a group’s cultural beliefs. For example, Southeast Asians tend to be less forthcoming in seeking health care because their cultural norms describe pain and sickness as an inevitable part of life. Additionally, their value of stoicism and differences in etiology (e.g. beliefs in yin and yang, chi, etc.) may further undermine their perceived practicality of Western health care. As such, different immigrant groups vary in whether or not they actively seek out health services.

Public opinion

Disparities in health care coverage between immigrants and native-born residents have risen in part from policy changes such as PRWORA in determining eligibility for Medicaid and other public benefits. They have subsequently contributed to much debate over whether reform is necessary to address these inequalities and the state of immigrant health outreach, resulting in immigration’s emergence as a hot-button issue.

Support for immigrant health care benefits

The case for addressing problems in immigrant health care includes a large body of both moral and economic reasoning. Proponents of immigrant health care reform contend that children of immigrant families are like native-born children in their need for security in health and nutrition. Given their role in the nation’s future—e.g. in the workforce, military, etc.—they argue that the current state of health care access does not appropriately reflect national interest. Because immigrants will directly impact health care as a part of the health sector’s work force, their inclusion in receiving benefits is necessary in servicing the expanding population. Additionally, because general health care is underutilized, emergency medical care becomes the priority. This ultimately results in delays in major diagnoses until the later stages of an affliction, thereby increasing a community’s level of disease. Moreover, others argue that it is unfair that immigrants have contributed a number of tax dollars to fund public benefits, yet are not taking advantage of them.

A fact report published by the Immigration Policy Center in 2009 also suggests that increased immigrant participation in the United States’ health care system yields monetary benefits. Due to the nation’s baby boom phenomena, a greater proportion of the population is aging, thus demanding more health care. A change in eligibility requirements to include immigrants and noncitizens in the health care system would spread the costs of sustaining public benefits; more tax dollars would be available to alleviate the financial strain of Social Security and Medicare.

Opposition to immigrant health care benefits

Conversely, others argue that immigrants to the United States intend to take advantage of public benefits and therefore favor legislation that implements more restrictions. Alternatively, some believe that health care benefits should be limited given their burden on the federal budget. There is some concern from this side that legislative acts like EMTALA, in ensuring emergency medical care to all, lack clarity in defining what constitutes an “emergency.” As such, minor health issues such as migraines—as opposed to emergencies like gunshot wounds and cardiac arrest—are included and hurt hospitals due to the lack of additional government compensation.

Some opponents also raise caution at increasing immigrant health care benefits due to the conception of immigrants/ noncitizens and their role in criminal violence. Though this view generalizes a large body of individuals, reports of cities with large illegal immigrant populations and high crime rates—e.g. Los Angeles—indicate a connection between immigrant gangs and emergency medical care cases. Because EMTALA obligates treatment, these incidents are taken care of but ultimately result in substantial financial loss. Opponents on this basis not only argue against increased immigrant health care benefits but also generally believe that U.S. immigration law should be more stringent.

Policy challenges and proposed solutions

Efforts at reforming the health care system in regards to immigrants have varied in terms of success in the past decade. In 2003, the federal government proposed funding hospitals over a four-year period to cover emergency treatment for uninsured and undocumented immigrants, but required asking for patients’ citizenship statuses. It was ultimately withdrawn due to the belief that such a policy would delay immigrants from actively seeking care unless in extreme need, thereby contributing to overall higher incidences of medical problems in a community. In 2005 and 2006, proposed Senate and House of Representatives bills sought to decrease illegal immigration but additionally made it a felony for health care providers to service undocumented immigrants. Though the bills did not pass, much discourse erupted from health care organizations in response to them. The American Medical Association notably passed a policy called “Opposition to Criminalization of Medical Care Provided to Undocumented Immigrant Patients” in response.

Other policy solutions focus on allocating more funds to community health centers and to SCHIP and/or state programs. Similarly, another proposal specifically targets increased funding for prenatal care, with studies showing that this kind of preventative care acts as a cost-effective solution to overall health care costs. Greater public funding for prenatal care of immigrants and noncitizens would decrease low-birth-weight babies, prematurity, and other related costs, thereby lowering health care expenditures. Finally, policies making insurance more affordable for workers could potentially reduce coverage disparities, given that a large proportion of immigrants are less likely to be covered than native-born citizens.

In addition to proposed reform bills, alternative routes to improving health coverage rates have been sought, namely via the means of direct immigrant outreach initiatives. Studies indicate the overall effectiveness of state-funded coverage programs in reducing the immigrant-citizen health care disparities, but other efforts have been suggested for further results. For instance, states can encourage and promoter greater use of health services by reducing enrollment barriers—e.g. dispersing more information about eligibility, reducing language difficulties, etc. To address specific cultural impediments, others purport that health care providers should receive more education about communication patterns, others’ perceptions of health and fatality, and traditional folk medicines. Overall, continued outreach efforts are necessary to overcome immigrant skepticism of Western technology and diagnostic methods.

Recent legislation

On March 23, 2010, the Patient Protection and Affordable Care Act (PPACA) was signed into law by President Barack Obama. This legislation, joined with the Health Care and Education Reconciliation Act of 2010, seeks to expand coverage and improve access to the health care system while simultaneously managing its costs. Among PPACA’s provisions are: the requirement that all U.S. citizens and legal residents possess health insurance; the creation of refundable tax credits for households between 100% and 400% of the federal poverty line; the expansion of Medicaid eligibility; the provision of free preventative services; the extension of dependent coverage to age 26; new funding to support community health centers; and more. Although not all of the act’s reforms are slated for immediate implementation, the changes, needless to say, have many implications for the immigrant and noncitizen population.

PPACA’s creation of subsidies to make insurance more affordable notably benefits legal immigrants, given that they comprise a large number of the uninsured population. In contrast, undocumented immigrants are denied these subsidies and further prohibited from participating in federal or state health insurance exchanges, though their lawfully present children will be eligible. Regardless of citizenship status, however, PPACA’s funding for the development of new community health centers has the potential to help both legal and undocumented immigrants who lack coverage.

Views on the act’s contributions to the immigrant and noncitizen population vary. Some argue that the reform has immense benefits by addressing coverage gaps and extending more benefits to naturalized citizens. Others argue that substantial disparities still exist, with an estimated 3.7 million adults remaining uninsured due to their undocumented status. Furthermore, because the act does not address the five-year waiting period placed by PRWORA, more recent low-income legal immigrants may not seek insurance “for want of resources to pay their share of the costs.”