The debate leading to the Patient Protection and Affordable Care Act (ACA) of 2010 resulted in excluding from coverage all undocumented immigrants and legal immigrants of less than five years. Already ineligible for Medicaid, undocumented immigrants were additionally barred from purchasing federally subsidized insurance through the new state-level exchanges.[1]

Even young undocumented immigrants eligible to apply for work permits after the Deferred Action on Childhood Arrivals (DACA) program of 2012 are ineligible for the exchanges, Medicaid, or the Child Health Insurance Program (CHIP).

Immigration reform proposals outlining a "path to citizenship" include steps such as registration, background checks, and payment of fines and back taxes, and would require undocumented immigrants to "go to the back of the line of prospective immigrants."[2] This means that those who are currently undocumented will remain reliant on safety-net health care for years, even after some become lawful, permanent residents.

With immigration reform and health reform proceeding along different tracks, health-care access is limited for adult undocumented immigrants and their children, citizens or not.

Demographics

An estimated 11.2 million undocumented immigrants live in the United States.[3] About 80 percent emigrated from Latin American countries, more than half from Mexico.[4] Forty-seven percent of undocumented immigrant households consist of a couple with children, 4 million of whom are U.S. citizens.[5]

Undocumented immigrants come here to work, often taking unskilled, physically demanding jobs.[6] They make up 25 percent of U.S. farmworkers, 19 percent of building, groundskeeping, and maintenance workers, 17 percent of construction workers, and 12 percent of food-service workers.[7] They pay sales taxes and may even pay into Medicare although ineligible for benefits.[8] Contrary to popular belief, health expenditures are about 39 percent lower for undocumented men and 54 percent lower for undocumented women than for those born in the United States.[9] One study comparing uninsured immigrant children with uninsured children born in the United States found that health expenditures were 86 percent lower among immigrant children.[10]

Disparities in Care

Unless undocumented immigrants find an opening in charity care, they have little access to hospice or dialysis. Their ineligibility for such programs as Medicare, Medicaid, or CHIP-the major sources of reimbursement for the providers-puts such services out of reach.[11]

Undocumented immigrants' most significant sources of care are safety-net facilities-public and not-for-profit hospitals, and community health centers. Patients who otherwise lack access to primary care often turn to federally qualified health centers (FQHCs) and migrant health centers-two types of not-for-profit organizations that the federal Health Resources and Services Administration funds.

Organized around family care, community health centers aim to fill a gap for undocumented patients. But although the ACA includes an $11 billion increase for FQHCs-and expansion of Medicaid may provide them with additional revenue-Medicaid reimbursements cannot support care to undocumented patients.

In 1986, with costs for the care of uninsured patients having shifted from private to public hospitals, Congress enacted the Emergency Medical Treatment and Active Labor Act (EMTALA).[12] Under the law, "any patient arriving at an Emergency Department in a hospital that participates in the Medicare program must be given an initial screening, and if found to be in need of emergency treatment (or in active labor), must be treated until stable." Although EMTALA is not a funding mechanism, the emergency medical treatment of uninsured patients is sometimes covered under emergency Medicaid reimbursements.

Many observers worry that ACA will undermine public support for safety-net care because those who remain uninsured will be largely the undocumented.[13] Meanwhile, chronically ill patients ineligible for public insurance already stretch the safety net with their reliance on costly emergency departments.[14]

Research shows that citizen children born of undocumented immigrant parents lack reliable access to health care even when insurance and care are available.[15] Although emergency departments are often the only option, undocumented adults and their children are less likely than citizens to use them. They also are less likely to visit providers as outpatients or to use mental-health or dental services.[16] When they do use health services, they tend to pay out of pocket. Moreover, their misunderstanding of eligibility, difficulty obtaining information in their language, and fear of authorities keep parents from enrolling children in programs.[17]

According to the Agency for Healthcare Research and Quality 2011 National Healthcare Disparities Report, Hispanics have less access to health care than non-Hispanic whites, receive poorer care, and are twice as likely to report financial and insurance reasons for not having care. Hispanics who are undocumented are less likely than citizens to have a usual source of care (58 percent vs. 79 percent) or to get annual checks of their blood pressure (67 percent vs. 87 percent) and cholesterol (56 percent vs. 83 percent).[18]

The nation's long-standing public interest in the health and welfare of children requires us to think in terms of whole families and whole populations, rather than immigration status. After all, immigrants contribute to the health-care system but collect little, and the ACA may remove the few services available to them.

Public debate about immigration reform should recognize that existing health-care policies and piecemeal remedies can hurt children, and that hurts society.

Michael K. Gusmano is a research scholar at the Hastings Center in Garrison, New York, and a New York Medical College associate professor of health policy. Nancy Berlinger is a research scholar at the Hastings Center and a lecturer at Yale University School of Nursing. Contact them at gusmanom@thehastingscenter.org and berlingern@thehastingscenter.org. And visit www.undocumentedpatients.org.

Endnotes

[1] T.S. Jost, "Health Insurance Exchanges and the Affordable Care Act" (report, Commonwealth Fund, Washington, DC, September 2010). [Back to story]

[2] C.E. Schumer et al., "Bipartisan Framework for Comprehensive Immigration Reform," 2013, http://www.mccain.senate.gov/public/index.cfm?FuseAction=PressOffice.PressReleases&ContentRecord_id=87afa1c7-c0ac-6131-5e8e-9bf8904159e6. [Back to story]

[3] Pew Hispanic Center estimate based on the 2010 Current Population Survey March Supplement. [Back to story]

[4] J.S. Passel and D'V. Cohen, "Trends in Unauthorized Immigration: Undocumented Inflow Now Trails Legal Inflow" (report, Pew Hispanic Center, Washington, DC, 2008), http://pewhispanic.org/files/reports/94.pdf; and M. Hoefer, N. Rytina, and B.C. Baker, Estimates of the Unauthorized Immigrant Population Residing in the United States (Washington, DC: Office of Immigration Statistics, 2008), http://www.dhs.gov/xlibrary/assets/statistics/publications/ois_ill_pe_2007.pdf. [Back to story]

[5] J.S. Passel and D. Cohn, "A Portrait of Unauthorized Immigrants in the United States" (report, Pew Hispanic Center, Washington, DC, 2009), http://pewhispanic.org/files/reports/107.pdf. [Back to story]

[6] M.L. King, "Immigrants and the U.S. Health Care System: Five Myths that Misinform the American Public" (report, Center for American Progress, Washington, DC, June 7, 2007). [Back to story]

[7] J.S. Passel, "Unauthorized Immigrant Population: National and State Trends, 2010" (report, Pew Hispanic Center. Washington, DC, 2010), http://pewhispanic.org/files/reports/133.pdf. [Back to story]

[8] K. Solana, "Illegal Immigrants Give Billions to Medicare, Social Security with No Hope to Benefit," Medicare Newsgroup, January 7, 2013, http://medicarenewsgroup.com. [Back to story]

[9] C. DuBard and M. Massing, "Trends in Emergency Medicaid Expenditures for Recent and Undocumented Immigrants," Journal of the American Medical Association 297, no. 10 (2007): 1085-1092; and A.N. Ortega, F. Hai, V.H. Perez, et al., "Health Care Access, Use of Services, and Experiences among Undocumented Mexicans and Other Latinos," Archives of Internal Medicine 167, no. 21 (2007): 2354-2360. [Back to story]

[10] S.A. Mohanty, S. Woolhandler, D.U. Himmelstein, et al., "Health Care Expenditures of Immigrants in the United States," American Journal of Public Health 95 (2005):1431-1438. [Back to story]

[11] R. Llano, "Immigrants and Barriers to Healthcare: Comparing Policies in the United States and the United Kingdom," Stanford Journal of Public Health (June 2011). [Back to story]

[12] J. Zibulewsky, "The Emergency Medical Treatment and Active Labor Act: What It Is and What It Means for Physicians," Proceedings of the Baylor University Medical Center 14, no. 4 (October 2001): 339-346. [Back to story]

[13] N. Bernstein, "Hospitals Fear Cuts in Aid for Care to Illegal Immigrants," New York Times, July 26, 2012, http://www.nytimes.com/2012/07/27/nyregion/affordable-care-act-reduces-a-fund-for-the-uninsured.html. [Back to story]

[14] N. Berlinger and R. Raghavan, "The Ethics of Advocacy for Undocumented Patients," Hastings Center Report 43, no. 1 (2013): 14-17. [Back to story]

[15] J.E. DeVoe, C.J. Tillotson, and L.S. Wallace, "Children's Receipt of Health Care Services and Family Health Insurance Patterns," Annals of Family Medicine 7, no. 5 (2009): 406-412; G. Granados, J. Puvvula, N. Berman, and P.T. Dowling, "Health Care for Latino Children: Impact of Child and Parental Birthplace on Insurance Status and Access to Health Services," American Journal of Public Health 91, no. 11 (2001): 1806-1807; and J.E. DeVoe, C.J. Tillotson, et al., "Parent and Child Usual Source of Care and Children's Receipt of Health Care Services," Annals of Family Medicine 9, no. 6 (2011): 504-513. [Back to story]

[16] K. Derose, B.W. Pitkin, N.L. Bahney, and J.J. Escarce, "Review: Immigrants and Health Care Access, Quality, and Cost," Medical Care Research and Review 66, no. 4 (2009): 355-408. [Back to story]

[17] K.M. Ziol-Guest and A. Kalil, "Health and Medical Care among the Children of Immigrants," Child Development 83, no. 5 (2012): 1494-1500. [Back to story]

[18] M.A. Rodriguez, A.V. Bustamante, and A. Ang, "Perceived Quality of Care, Receipt of Preventive Care, and Usual Source of Health Care among Undocumented and Other Latinos," Journal of General Internal Medicine 24, supplement 3 (2009): 508-513; and A. Henderson, W. Robinson, and K. Finegold, "The Affordable Care Act and Latinos" (ASPE Research Brief, Department of Health and Human Services, Washington, DC, 2011). [Back to story]