Stuck between Health and Immigration Reform — Care for Undocumented Immigrants (New Eng Jour Med)

Stuck between Health and Immigration Reform — Care for Undocumented Immigrants

Benjamin D. Sommers, M.D., Ph.D.
July 24, 2013

It is a time of immense change in U.S. health care and immigration policy. On the cusp of major insurance expansions under the Affordable Care Act (ACA), Congress is now debating a path to citizenship for millions of undocumented immigrants. Understanding what will (and won't) change under the ACA and immigration reform is critical to crafting sensible health policy in this realm. Despite a flurry of political activity, health care for undocumented immigrants remains a patchwork with gaping holes, and that reality is unlikely to change much over the coming decade.

Approximately 25 million noncitizens live in the United States, 11 million to 12 million of them undocumented. Though more than 75% of undocumented residents are Latin American, U.S. immigrants are more diverse than generally recognized, with substantial numbers from South and East Asia, Europe, Canada, and Africa.1 Regardless of its origins, this population's health care options remain limited.

For most undocumented immigrants, the primary sources of U.S. health insurance are unavailable. Although approximately 80% of adult undocumented immigrants are in the labor force, most are in low-income fields that rarely offer health insurance, such as farming, building maintenance, and food preparation.1 Meanwhile, undocumented immigrants are expressly excluded from Medicaid, the primary coverage option for many low-income citizens, and undocumented elderly adults are ineligible for Medicare. The only federal health program available to some undocumented immigrants is Emergency Medicaid, which covers acute care in inpatient settings and emergency departments for persons who, aside from their immigration status, meet their state's Medicaid-eligibility criteria. Given the small numbers of people who are eligible and the limited scope of services covered, Emergency Medicaid does little to facilitate meaningful access to care for most immigrants.

The cumulative effects of these systematic limitations on insurance for undocumented immigrants, combined with low household incomes, are major disparities in health care access between this population — particularly Latino immigrants — and U.S. citizens. Whereas approximately 15% of the overall U.S. population lacks health insurance, nearly two thirds of undocumented Latino immigrants are uninsured. Less than 60% of undocumented Latinos report having a regular medical provider, and they receive recommended preventive care at far lower rates than citizens.2 When they arrive in this country, most immigrants are healthier than the U.S.-born population — the so-called immigrant paradox — but within one or two generations, they have become on average less healthy than nonimmigrants, probably because of the adoption of unhealthy American lifestyles combined with systematic access disparities that prevent appropriate care for this population's growing burden of chronic diseases.3

http://www.nejm.org/doi/full/10.1056/NEJMp1306636?query=TOC