key: cord-0925048-m4hqxna2
authors: Beck, Teresa L.; Le, Thien-Kim; Henry-Okafor, Queen; Shah, Megha K.
title: Medical Care for Undocumented Immigrants: National and International Issues
date: 2018-11-16
journal: Physician Assist Clin
DOI: 10.1016/j.cpha.2018.08.002
sha: 70fb71351caca2ce4100b806ac9d99fa094f8453
doc_id: 925048
cord_uid: m4hqxna2

The number of undocumented immigrants (UIs) varies worldwide, and most reside in the United States. With more than 12 million UIs in the United States, addressing the health care needs of this population presents unique challenges and opportunities. Most UIs are uninsured and rely on the safety-net health system for their care. Because of young age, this population is often considered to be healthier than the overall US population, but they have specific health conditions and risks. Adequate coverage is lacking; however, there are examples of how to better address the health care needs of UIs.

Family Foundation, Health Coverage of Immirgants: https://www.kff.org/disparitiespolicy/fact-sheet/health-coverage-of-immigrants/) and 90% are adults between the ages of 18 and 40 years. More than 4 million people in the United States are the US-born children of UIs. About half of UIs are of Mexican origin; however, these numbers have declined over the last 5 years, from more than 6 million to 5.6 million as of 2014. California, Texas, and Florida have the largest numbers of UIs, and Nevada has the largest share, making up 8% of the state's population. [2] [3] [4] [5] The issue of UIs is not unique to the United States. Internationally, the United Nations Population Division estimates that there are 30 million to 40 million unauthorized immigrants worldwide, and although most are in the United States, proportionally continental Europe has a larger share. 6 Although UIs have a variety of reasons to migrate, from safety concerns to economic incentives, addressing the health needs of these populations come with unique challenges and solutions. This article provides an overview of challenges in addressing their health needs, existing methods for accessing care, health conditions specific to this population, and potential solutions to consider in both the national and international contexts, specifically in Europe.

Despite the better health status of the younger UI population, this advantage deteriorates over increasing time spent in the United States. 7 Various factors from socioeconomic status to fear of deportation affect the UI population's health both domestically and internationally and deter UIs from seeking care. The UI population is often of lower socioeconomic status, which adds to the difficulties accessing health care. Given that most of the federal insurance plans are unavailable to the UI population, UIs are susceptible to higher out-of-pocket costs for care. In addition, because of undocumented status, they may not have sick leave days and may have difficulty negotiating time off from work to seek care. 8 Decreased proficiency in the language of the host country and fear of deportation may also present barriers to health care for UIs. Studies have shown that patients with limited English language proficiency (LEP) are at higher risk of poor health and have decreased access to health care. Patients who have LEP had increased difficulty in understanding their health status as well as accessing preventive services. 9 Fear of deportation may lead to the avoidance of seeking care and risk of severe health complications, 8 and this also affects health care for US-born children of UIs. In addition, shame and discrimination are common feelings experienced by the UI population and contribute to poor access to health care globally. 8 Many of these issues in health care are not unique to the United States. In a study by Chauvin and colleagues, 10 22% of the UI population in Europe had access to health coverage, and, of those, only about 36% had true access because of barriers such as administrative difficulties, limited language proficiency, and lack of awareness of available services. Of the main reasons for lack of access, administrative difficulties in obtaining health care and finances were cited as the most common. France and Belgium were found to have the most complicated systems for obtaining health care and, for those who had access, the fear of deportation or imprisonment was prevalent.

The Patient Protection and Affordable Care Act (ACA), passed in 2010, required most US citizens and legal residents to have health insurance, and resulted in the expansion of Medicaid in 32 states. UIs are not eligible for Medicaid or state-based exchanges under this law. 11 Thus, although the number of overall uninsured in the United States has decreased, it is mostly US citizens and legal residents who have gained access to health insurance. 12 In 1986, Congress approved the Emergency Medical Treatment and Labor Act (EMTALA), requiring hospitals to provide services for active labor and emergency care regardless of insurance and immigration status. In addition to EMTALA, there is emergency care under Medicaid, which is currently the only federal insurance that is available to UIs. Emergency Medicaid covers patients in active labor and those with acute medical emergencies. 13 It may only be used to stabilize patients and may not cover patients for services after the patient has been stabilized.

Federal provisions available to UIs include prenatal care and care for children funded by Maternal and Child Health Block grants and the Supplemental Food Program for Women, Infants and Children. In 2009, the Children's Health Insurance Program (CHIP) was expanded under the CHIP Reauthorization Act (CHIPRA). In 2015, federal funding for CHIP was expanded to states, which included the standard Medicaid benefit package such as the Early and Periodic Screening, Diagnostic, and Treatment services for medically necessary mental health and dental services, vaccinations and prescription drugs, and access to medical specialists and hospital care and services. Although these resources are available for a vulnerable subset of UIs, there are few resources that exist for sick, nonpregnant adults. 12 Federally Qualified Health Centers (FQHCs) are community health centers that receive federal grant funding to support care to the uninsured without regard for immigration status. There are approximately 1200 health centers operating around the country, providing primary health care, dental, mental health, and pharmacy services on a sliding-scale basis. In addition, there are many low-cost and free community clinics that rely on private donations and volunteers to provide services to those who cannot afford to pay. 14 

Europe faces similar challenges regarding access to health care for its UI population. The Platform for International Cooperation on Undocumented Migrants (PICUM) reported that Italy and Spain provided the widest coverage for UI with universal access to health care. 10 Germany, Greece, Sweden, and Switzerland only cover emergency care for UIs. 10 Table 1 provides an overview of access to care for UIs in Europe. 15 

There is ongoing political debate in the United States regarding health care services for UIs. Those in opposition maintain that using taxpayer-funded services to support individuals who enter and remain in the United States illegally undermines the legal system. However, some scholars and legislators have argued that it is both unethical and impractical to deny access to health care services for illegal immigrants living in the United States. 16 They view health care as a basic human right and an obligation of a just society to provide health care for everyone. Leading medical professional societies such as the American Medical Association (AMA), American College of Physicians (ACP), the American Academy of Family Physicians (AAFP), and the American Nurses Association (ANA) reaffirm the position that all individuals living in the United States, regardless of their immigration status, should have access to quality health care, including the opportunity to purchase insurance. These leaders maintain that providing this population with access to health insurance is an evidence-based way to reduce health care costs. [17] [18] [19] Another argument, from a cost perspective, is that many UIs will benefit from preventive care and early treatment of chronic diseases before they advance to lifethreatening and costly complications. 20, 21 Proponents of this strategy advocate for improving health literacy and vaccination rates, and offering health screenings to the UI population to try to prevent long-term adverse health outcomes and control cost. Moreover, UIs may harbor infections such as tuberculosis (TB), which, when undetected, can easily be transmitted to the general public, thus posing a public health risk. 22 In contrast, some have argued that treating UIs creates more expenditures for the United States while saving their countries of origin the costs of providing health care. 23 Furthermore, they argue that sharing inadequate health care resources with UIs will reduce the availability of those scarce resources for US citizens. In the last 2 decades, several states have attempted to advance legislation designed to deny UIs access to publicly funded health services. One such initiative was California's Proposition 187. This law, later deemed unconstitutional, required health care professionals to verify immigration status and report UIs to authorities. 24 In addition, some believe that continued unabated treatment of UIs is an incentive for persistent violation of the immigration laws and threatens national security in the post-9/11 era. 25 Proponents of this argument suggest that denying health care to UIs will discourage others from attempting to immigrate without proper documentation. 24 

There are significant gaps in the literature on the health status of the UI population. Immigrants in general, and the undocumented in particular, report lower levels of cancer, heart disease, arthritis, depression, hypertension, and asthma than do the native born. 26 Factors thought to contribute to lower rates of reported chronic diseases include the young immigrant population and the process of migration, which, especially in cases of undocumented individuals, positively selects for those healthy enough to make the often arduous journey (ie, the so-called healthy immigrant effect). 7, 26 In addition, little is known about the long-term health of the children of UIs, particularly related to the adverse effects of inadequate prenatal care and the stressors related to undocumented status, which has been shown to negatively affect children regardless of their own legal status. 12 Most of the emergency health care services used by UIs are for childbirth. A study of emergency Medicaid expenditures for undocumented and recent immigrants in North Carolina between 2001 and 2004 found that more than 82% of health care spending was related to childbirth and complications of pregnancy. Of the remaining health care expenditures, one-third was spent on the treatment of acute injuries and poisoning, possibly related to exposure to pesticides or other toxins in the workplace. 27 These uses of health care services reflect not only the young age of most UIs but also the type of work that they perform. 28 Beyond pregnancy and acute injury, chronic renal failure, cerebrovascular disease, and heart disease were major contributors to emergency Medicaid use. 27 Various factors associated with undocumented status are thought to erode the health advantage of the undocumented at a faster rate than their documented counterparts. Specifically, limited access to quality health care; increased vulnerability caused by low income and occupational status; and the stressors associated with undocumented status, such as fear of deportation, have been implicated. 29 In addition, UIs with chronic and infectious medical conditions are negatively affected because of poor access to care. [30] [31] [32] Perinatal health of undocumented women and their US-born children is a specific area of concern. Consistent with much of the health literature, several studies have found that undocumented women engage in few health risk behaviors while pregnant and seem to have low rates of low-birth-weight or preterm babies. [33] [34] [35] [36] However, the beneficial effects of better health behaviors during pregnancy are counteracted by the effects of lower rates of prenatal care among UIs. Poor (and late) prenatal care has been associated with higher risk for adverse perinatal outcomes. 36, 37 In addition, stressors related to undocumented status, such as fear of deportation or experiences of discrimination and stigma, may adversely affect the physical and emotional health of UIs, with potential consequences for their US-born children. 38, 39 Findings from a qualitative study of 85 immigrant families experiencing the arrest of at least 1 parent by immigration authorities, showed an increase in the children's behavioral problems, speech and developmental concerns, and declines in school performance. 40 There is a public health concern over UIs bringing infectious diseases into the United States. Legal immigrants and refugees are required to have a medical examination for migration to the United States, while they are still overseas. This examination is the responsibility of the Centers for Disease Control and Prevention (CDC), which provide instructions to the panel physicians who conduct the medical examinations. The procedure consists of a physical examination, an evaluation (skin test/chest radiograph examination) for TB, and a serologic evaluation for syphilis. Requirements for vaccination are based on recommendations from the Advisory Committee on Immunization Practices. 41 Individuals who fail the examination because of certain health-related conditions are not admitted to the United States. Such conditions include drug addiction or communicable diseases of public health significance, such as TB, syphilis, gonorrhea, leprosy, and a changing list of current threats such as polio, cholera, diphtheria, smallpox, or severe acute respiratory syndromes. 42 There is a growing concern that UIs crossing into the United States illegally could bring any of these threats. The most prevalent infectious diseases are hepatitis B, latent and active TB, filariasis, intestinal helminth infections, malaria, intestinal protozoa infections, hepatitis C, other nonparasitic infections, sexually transmitted diseases, and human immunodeficiency virus. 43 Little is known about the mental health issues of UIs. However, the literature suggests that UIs have a unique risk profile that may contribute to different mental health outcomes compared with their documented counterparts. Themes specific to UIs include failure in the country of origin, dangerous border crossings, limited resources, restricted mobility, marginalization/isolation, stigma/blame and guilt/shame, vulnerability/exploitability, fear and fear-based behaviors, and stress and depression. 44 One study compared the diagnoses and mental health care use of undocumented Latin American immigrants (15%) with those of documented (73%) and US-born Latin Americans (12%) treated in this clinical setting. The undocumented Latin Americans were more likely to have a diagnosis of anxiety, adjustment, and alcohol abuse disorders. The UIs also had a significantly greater mean number of concurrent psychosocial stressors compared with documented immigrants and US-born groups, and they were more likely to have psychosocial problems related to occupation, access to health care, and the legal system. 45 Other studies have shown increasing rates of substance abuse, binge-eating, and conduct disorders among UIs residing longer in the United States. 7

The European immigrant population comes from many different countries, with a heavy concentration from countries in Africa, the Middle East, and the former Soviet Union. The most commonly reported health care problems in this undocumented migrant population include mental health, infectious and sexually transmitted diseases, and reproductive health. Concerns about human trafficking, particularly of women and children, for commercial sexual exploitation or forced labor or slavery are more prominent in Europe. 15 

Despite the contentious debate over the ACA, a consensus has emerged that strengthening primary care will improve health outcomes and restrain the growth of health care spending. Supporting evidence comes from studies of primary care as an orientation of health systems and as a set of functions delivered by a usual source of care. 46 Although methodological concerns exist, many observational studies in the United States have found that regions with higher primary care physician-to-specialist ratios have better health outcomes, including lower mortality; fewer emergency department visits, hospitalizations, and procedures per capita; and lower costs. 46 International comparisons between industrialized countries also suggest that countries with higher ratings of primary care orientation experience better health care outcomes and incur lower health care costs than countries with lower degrees of primary care orientation. 46 These finding suggest that reducing barriers to primary care for UIs may ultimately improve the quality and cost of delivering health care for all countries struggling to manage their growing immigrant populations.

Several US cities and states with large immigrant populations have attempted to address their health care needs by providing access to primary care. New York City has the nation's largest public health system, composed of the Health and Hospitals Corporation (HHC) and Community Health Care Association of New York State, whose members include FQHCs and migrant health programs. These organizations provide much of the health care for uninsured and undocumented patients. Both systems rely on Medicaid (and, to a lesser extent, Medicare) reimbursements. They also depend on federal Disproportionate Share Hospital funding and other sources of state Indigent Care Pool funding. In addition to primary and preventive health care, HHC ambulatory centers offer uninsured patients access to on-site pharmacies and referrals to medical specialists and diagnostic and other services located in HHC medical centers. 47 California offers a Medi-Cal health insurance plan that provides a full range of lowcost health care options for uninsured Californians, with some benefits provided regardless of immigration status. In addition, Kaiser Permanente offers a Child Health Program for uninsured California children younger than 19 years who do not have access to Medi-Cal or other coverage, regardless of immigration status. My Health LA (MHLA) is a no-cost health care program that offers comprehensive health care for low-income, uninsured Los Angeles county residents, regardless of immigration status or medical condition. It offers care through 164 community clinic medical home sites, where patients receive primary and preventive health care services and some diagnostic services. Los Angeles County Department of Health Services facilities also provide county clinic medical home sites, plus emergency, diagnostic, specialty, inpatient services, and pharmacy services. Healthy San Francisco (HSF) is a low-income program for San Francisco County residents regardless of employment status, immigration status, or medical condition. Unlike MHLA, HSF charges a participation fee and point-of-service fee to all patients except for those at less than 100% of the federal poverty level and those who are homeless. 47 The Harris County Health System, which includes the city of Houston, Texas, offers Access Care, a financial assistance program open to uninsured and undocumented Harris County residents, and provides access to discounted health care at more than 20 community clinics, a dental clinic, and surgical and other subspecialty clinics. The Harris Health System has a dialysis clinic as well as a long-term care facility. 47 In Massachusetts, all immigrants are eligible for some form of health coverage. There is 1 application for all available programs, including the insurance marketplace. Mass Health Limited is the state version of emergency Medicaid. It is available to UIs and some immigrants who are PRUCOL (Permanent Residence Under Color of Law), defined as aliens who are living in the United States with the knowledge and permission of the federal government, and whose departure the agency does not contemplate enforcing. 47 In Nevada, the nonprofit Access to Healthcare Network (AHN) offers medical discount programs, specialty care coordination, a health insurance program, nonemergency medical transportation services, a pediatric hematology/oncology practice, and a toll-free statewide call center. AHN has 35,000 members, more than half of whom are presumed to be undocumented. 47 

A study by Hacker and colleagues 8 identified 5 areas to address barriers to care for UIs: advocacy for policy, insurance options, expansion of the safety net, training of providers, and education of UIs on navigating the system ( Table 2) . 

Nearly all industrialized countries provide some form of government-supported health care to all of its residents, including those who are undocumented (see Table 1 ).

Although countries in the European Union have significantly fewer UIs, their models may offer insights on the options and challenges of addressing this health care dilemma facing the United States.

Medical care for UIs is a complex area involving challenges for accessing care, barriers in financing care, and unique medical conditions. Fear, stigma, cost, and cultural barriers often prevent UIs from seeking medical care. UIs make up a small but substantial portion of the population in the United States and internationally, and there is an emerging interest in finding solutions to address their health care needs. In the United States, cities with large numbers of immigrants have models that provide health care to their uninsured regardless of immigration status, and could potentially be expanded to other areas of the country experiencing increasing growth of their immigrant populations. International approaches may also inform on policies to address the health care needs of UIs.

Immigration terms and definitions involving aliens

Unauthorized migrants: numbers and characteristics. Background briefing prepared for Task Force on Immigration and America's Future

Health coverage and care for immigrants

Estimates of the unauthorized immigration population residing in the United States

5 facts about illegal immigration in the U.S

PI-CUM submission to the UN Committee on the Protection of the Rights of All Migrant Workers and Members of Their Families: day of general discussion on the role of migration statistics for treaty reporting and migration policies

The immigrant and Hispanic paradoxes: a systematic review of their predictions and effects

Barriers to health care for undocumented immigrants: a literature review

Low health literacy, limited English proficiency, and health status in Asians, Latinos, and other racial/ethnic groups in California

Access to healthcare for undocumented migrants in 11 European countries

Affordable Care Act

Undocumented immigrants and health care reform. Final report to The Commonwealth Fund

The impact of unauthorized immigrants on the budgets of state and local governments

CMS issues proposed changes in conditions of participation requirements and payment provisions for rural health clinics and federally qualified health centers

Health care for undocumented migrants: European approaches

Providing primary health care to immigrants and refugees: the North Hamilton experience

National immigration policy and access to health care: American College of Physicians -a position paper

American Academy of Family Physicians: STRONG MEDICINE for America

Nursing beyond borders: access to health care for documented and undocumented immigrants living in the US

Health care for undocumented immigrants in Texas: past, present, and future

Care of undocumented-uninsured immigrants in a large urban dialysis unit

Diagnostic evaluation of newly arrived asymptomatic refugees with eosinophilia

Better primary health care for refugees -catch up immunisation

The message of 187: facing up to illegal immigration

Do the right thing. it will gratify some people and astonish the rest

Immigrant health care in the United States: what ails our system?

Trends in emergency Medicaid expenditures for recent and undocumented immigrants

Undocumented immigrants in the United States: use of health care

Healthcare access and barriers for unauthorized immigrants in El Paso County

The initiation of dialysis in undocumented aliens: the impact on a public hospital system

Differences in clinical presentation among persons with pulmonary tuberculosis: a comparison of documented and undocumented foreign-born versus US-born persons

Sociocultural and structural barriers to care among undocumented Latino immigrants with HIV infection

Birth outcomes among low-income women-documented and undocumented

Differences in low-birthweight among documented and undocumented foreign-born and US-born Latinas

Prenatal care among immigrant and racial-ethnic minority women in a new immigrant destination: exploring the impact of immigrant legal status

Birth outcomes in Colorado's undocumented immigrant population

Elimination of public funding of prenatal care for undocumented immigrants in California: a cost/benefit analysis

Depression and anxiety among first-generation immigrant Latino youth: key correlates and implications for future research

Growing up in the shadows: the developmental implications of unauthorized status

Facing our future: children in the aftermath of immigration enforcement

Immigrant and refugee health: technical instructions for medical examination of aliens

Immigrant and refugee health: frequently asked questions about the final rule for the medical examination of aliens -revisions to medical screening process

Infectious diseases in immigrants from the perspective of a tropical medicine referral unit

Mental health of undocumented Mexican immigrants: a review of the literature

Psychosocial stressors, psychiatric diagnoses, and utilization of mental health services among undocumented immigrant Latinos

Primary care: a critical review of the evidence on quality and costs of health care

Undocumented immigrants and access to health care in New York City: identifying fair, effective, and sustainable local policy solutions: report and recommendations to the Office of the Mayor of